Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
J Int AIDS Soc. 2023 Dec;26(12):e26199. doi: 10.1002/jia2.26199.
Transgender women in the United States experience high HIV incidence and suboptimal Pre-exposure prophylaxis (PrEP) engagement. We sought to estimate PrEP initiation and discontinuation rates and characterize PrEP discontinuation experiences among a prospective cohort of transgender women.
Using a sequential, explanatory, mixed-methods design, 1312 transgender women at risk for HIV acquisition were enrolled from March 2018 to August 2020 and followed through July 2022 (median follow-up 24 months; interquartile range 15-36). Cox regression models assessed predictors of initiation and discontinuation. In-depth interviews were conducted among 18 participants, including life history calendars to explore key events and experiences surrounding discontinuations. Qualitative and quantitative data were integrated to generate typologies of discontinuation, inform meta-inferences and facilitate the interpretation of findings.
21.8% (n = 286) of participants reported taking PrEP at one or more study visits while under observation. We observed 139 PrEP initiations over 2127 person-years (6.5 initiations/100 person-years, 95% CI: 5.5-7.7). Predictors of initiation included identifying as Black and PrEP indication. The rate of initiation among those who were PrEP-indicated was 9.6 initiations/100 person-years (132/1372 person-years; 95% CI: 8.1-11.4). We observed 138 PrEP discontinuations over 368 person-years (37.5 discontinuations/100 person-years, 95% CI: 31.7-44.3). Predictors of discontinuation included high school education or less and initiating PrEP for the first time while under observation. Four discontinuation typologies emerged: (1) seroconversion following discontinuation; (2) ongoing HIV acquisition risk following discontinuation; (3) reassessment of HIV/STI prevention strategy following discontinuation; and (4) dynamic PrEP use coinciding with changes in HIV acquisition risk.
PrEP initiation rates were low and discontinuation rates were high. Complex motivations to stop using PrEP did not consistently correspond with HIV acquisition risk reduction. Evidence-based interventions to increase PrEP persistence among transgender women with ongoing acquisition risk and provide HIV prevention support for those who discontinue PrEP are necessary to reduce HIV incidence in this population.
美国跨性别女性的 HIV 发病率较高，且接受暴露前预防（PrEP）的情况并不理想。我们旨在评估前瞻性队列中跨性别女性的 PrEP 起始和停药率，并描述 PrEP 停药的经验。
使用顺序、解释性、混合方法设计，从 2018 年 3 月至 2020 年 8 月招募了 1312 名有 HIV 感染风险的跨性别女性，并随访至 2022 年 7 月（中位随访 24 个月；四分位距 15-36 个月）。Cox 回归模型评估了起始和停药的预测因素。对 18 名参与者进行了深入访谈，包括生活史日历，以探索停药前后的关键事件和经验。将定性和定量数据整合起来，生成停药的类型，为元推断提供信息，并有助于解释研究结果。
21.8%（n=286）的参与者在观察期间报告在一次或多次就诊时服用 PrEP。我们观察到在 2127 人年中有 139 例 PrEP 起始（6.5 例/100 人年，95%CI：5.5-7.7）。起始的预测因素包括被认定为黑人身份和 PrEP 指征。有 PrEP 指征的起始率为 9.6 例/100 人年（132/1372 人年；95%CI：8.1-11.4）。在 368 人年中观察到 138 例 PrEP 停药（37.5 例/100 人年，95%CI：31.7-44.3）。停药的预测因素包括高中及以下教育程度和首次观察时开始使用 PrEP。出现了四种停药类型：（1）停药后发生血清转换；（2）停药后仍存在 HIV 获得风险；（3）停药后重新评估 HIV/性传播感染预防策略；（4）PrEP 使用的动态变化与 HIV 获得风险的变化一致。
PrEP 起始率较低，停药率较高。停止使用 PrEP 的复杂动机并不总是与 HIV 获得风险降低相一致。需要针对持续存在 HIV 获得风险的跨性别女性增加 PrEP 持续使用的循证干预措施，并为那些停止使用 PrEP 的人提供 HIV 预防支持，以减少该人群的 HIV 发病率。
