An Overlooked Crisis in HIV Prevention: Behavioral and Sociocultural Drivers of Premature PrEP Discontinuation

About This Grant

Summary and Abstract. This application by a New and Early Stage Investigator seeks to understand and address the drivers of premature PrEP discontinuation among men aged 18-35, with an explicit focus on both oral and injectable PrEP. The CDC has indicated that across the PrEP Care Continuum, the individuals with the highest incidence of HIV seroconversion are those who discontinue PrEP and do not restart. There is limited utility in moving forward with biomedical approaches to HIV prevention if we fail to understand how to keep those in greatest need of PrEP engaged in care. Further, current interventions that target PrEP use and uptake may not be reaching individuals who use substances. Our preliminary work found that the majority of men who seroconverted for HIV during the course of our study also reported high levels of substance use and premature PrEP discontinuation. For this application, a team of developmental, clinical, and public health scientists propose a multilevel mixed-methods longitudinal study aimed at identifying drivers of premature PrEP discontinuation, assessing who we should aim to retain in PrEP care, and better understanding what happens in the critical window of premature PrEP discontinuation. Guided by the novel integration of both the Health Behavior Model and Medication Necessity Concerns framework, the proposed study focuses on why some individuals, in particular individuals who use substances, are able to continue PrEP, while others are not. With an end goal of mapping components of future interventions that are necessary for thwarting premature PrEP discontinuation and producing immediate recommendations for end-users, we will address four Aims: (1) Comprehensively identify drivers of premature PrEP discontinuation by conducting in-depth, semi-structured interviews (N=30) with participants who previously discontinued oral or injectable PrEP. Aim 1 goals are to identify new behavioral, psychosocial, and sociocultural factors that drive premature PrEP discontinuation— specific to delivery modality—and to inform longitudinal study assessments; (2) Evaluate which factors interact over time to impact premature PrEP discontinuation. Via a prospective cohort study design, a sample of N=300 men who use PrEP and report past 3-month substance use will be recruited for a five-wave repeated measures study; (3) Among our sample of N=300 men, identify momentary substance use-related drivers of real-time actual and contemplated premature PrEP discontinuation via four rounds of 14-day event-level ecological momentary assessments and biomarker measures of substance use; and (4) Conduct Intervention Mapping and translation forums with patient, clinician, and content expert stakeholders to define intervention components and produce recommendations attune to the holistic needs of multiple stakeholders engaged in clinical practice and research related to PrEP. This project will address gaps in current interventions related to the critical window of premature PrEP discontinuation, with immediate implications for clinical practice.