We, however, found in a prior analysis that the relative risk of PrEP discontinuation is unfortunately increasing over time, potentially because later versus early adopters are more ambivalent about using and remaining on PrEP. In San Francisco in 2017, approximately 40% of MSM had used PrEP in the last six months, whereas 50% reported condomless anal sex over the same time period. In an analysis within another integrated health system in Northern California, barriers to PrEP use among those who were aware of PrEP prior to HIV diagnosis but never started it included: cost/insurance issues, perceived low risk for HIV acquisition and concerns about being stigmatized if they used PrEP. As the design of this analysis involved a sample of all individuals who had used PrEP at any point in our health system, we were not able to interview individuals who HIV seroconverted and had never used PrEP before. We agree with the authors that PrEP uptake is an important component of the PrEP cascade, and will be crucial towards meeting global targets to reduce HIV transmission.
Participants in this analysis did not report stigma related to being a man who has sex with men (MSM) as a factor in their PrEP gaps, but two participants discussed stigma related to the image of PrEP as a medication for people with multiple sexual partners, and at least one participant feared disclosure of her PrEP use to her partner as she felt it might imply she had outside partners. We agree that stigma related to PrEP or sexual behaviour is an important factor that may interfere with PrEP persistence (consistent use of PrEP during periods with potential HIV exposure). Anecdotally, several of our PrEP patients are considering transitioning to PrEP 2‐1‐1 dosing during ongoing shelter‐in‐place in response to the COVID‐19 epidemic, but are worried their clinicians may not support it. We are also interested to learn that there is similarly limited awareness and resources supporting PrEP 2‐1‐1/on‐demand dosing in Australia.
We are pleased to learn that our paper’s themes resonated with other contexts such as the authors’ pre‐exposure prophylaxis (PrEP) programme in Sydney, Australia.