HIV Pre-Exposure Prophylaxis Care Continuum in Outpatient Settings: A Systematic Review and Meta-Analysis

<h2>Abstract</h2><h3>Introduction</h3> <b>:</b> Pre-exposure prophylaxis (PrEP) is a prescription medication that prevents human immunodeficiency virus (HIV) infection and transmission in those at-risk for HIV infection. We examined engagement in the oral PrEP care continuum among HIV-negative individuals at-risk for HIV in outpatient settings in the United States (US) following participation in a PrEP-related intervention, to identify key gaps in the continuum where current interventions are least effective. <h3>Methods</h3> <b>:</b> This systematic review and meta-analysis included US studies published from January 2012 through August 2022 reporting at least two of seven PrEP care continuum steps from identification of HIV-negative, at-risk PrEP-eligible persons to PrEP initiation. The final two steps, PrEP adherence and retention, of the continuum's nine steps were not analyzed due to the substantial heterogeneity in how the included studies measured these steps and the limited sample sizes across the studies. Random-effects meta-analyses, which describe the distribution of effects across studies, were performed to estimate pooled proportions of each step, and subgroup analyses were conducted based on population characteristics (e.g., individuals with sexually transmitted infection [STI], men who have sex with men [MSM]) and study settings (i.e., emergency department [ED], ambulatory care, healthcare system, and other). <h3>Results</h3> <b>:</b> We included 2,510 articles in title and abstract review, 296 were retrieved for full text review, and 34 studies met the inclusion criteria and were included in the meta-analysis. The 34 studies were comprised of 71,162 individuals eligible for PrEP. Among them, 66% had increased HIV risk awareness, 55% had enhanced PrEP awareness, 49% had facilitated PrEP access, 42% were linked to PrEP care, 40% were prescribed PrEP, and 34% initiated PrEP use. Subgroup analysis indicated that individuals identified in ED settings versus all other settings and individuals with STIs versus MSM had lower PrEP initiation rates. <h3>Discussion</h3> <b>:</b> There was a progressive decline in the proportion of individuals engaged in PrEP care continuum. These findings suggest that comprehensive efforts are needed across all settings to increase perceived susceptibility to HIV among high-risk individuals and to capitalize on the opportunity of sexually transmitted infections care and emergency department visits to engage patients in the PrEP care continuum.