The HIV Pre-exposure Prophylaxis (PrEP) Initiation Cascade: Patient Experiences with Primary Care in a Health Care System Before Starting PrEP

Pre-exposure prophylaxis (PrEP) for HIV prevention has been available since 2012; only 36% of people in the U.S. who would benefit from PrEP have been prescribed it. Primary care is an ideal location to initiate PrEP, as many people who may benefit from PrEP are seen in primary care annually. Yet, patients and providers face barriers to accessing and prescribing PrEP. It is unclear where disengagement from PrEP initiation occurs. We have defined the PrEP Initiation Cascade to include eight timepoints: (1) discussing sexual health with a provider, (2) interest in hearing about PrEP, (3) PrEP awareness, (4) PrEP willingness, (5) PrEP intentions, (6) speaking with a provider about PrEP, (7) being prescribed PrEP, (8) using PrEP. We surveyed patients (n = 278) from primary care in a large health system to understand where they disengaged from initiating PrEP. Multivariable logistic regression models examined patients' demographic characteristics associated with disengagement during the PrEP Initiation Cascade. Over 66% of patients wanted to hear about PrEP from their provider; less than 20% had. Of patients who spoke to their provider about PrEP, 60% were prescribed it. In regression analyses, we found that patients who were raised religious (vs. never religious), regardless of current religiosity, were more likely to have discussed sexual health with their provider, wanted to hear about PrEP from their provider, and had ever heard of PrEP. People who identified as bisexual (vs. heterosexual) and people who were diagnosed with an STI in the last 6 months (vs. no STI diagnosis) were more likely to have ever spoken to a doctor about PrEP, been prescribed PrEP, and ever used PrEP. Most patients in primary care have discussed their sexual health with their provider in the past year and are interested in hearing about PrEP from their provider, yet few spoke with their provider about PrEP. Multi-level interventions for patients and providers in primary care should be developed to increase PrEP initiation. Future research should focus on keeping patients engaged with the PrEP Initiation Cascade, particularly those in demographic groups shown to disengage in the PrEP Initiation Cascade prematurely.