PrEParing for Long-acting Technologies: A Multistate Analysis of PrEP Persistence and HIV and STI Lab Coverage Among Oral PrEP Initiators in St. Louis, Missouri (2014-2021).

Background: Engagement in pre-exposure prophylaxis (PrEP) care and routine screening for HIV and sexually transmitted infections (STIs) is critical to realizing the full benefits of this HIV prevention strategy. Methods: We enrolled a cohort of individuals seeking PrEP services in two clinics in Missouri, an Ending the HIV Epidemic priority state, from June 2014 to November 2021. We used electronic health record and survey data to explore outcomes in the 2 years following linkage to care using multistate methods. We assessed transitions between eight mutually exclusive care states differentiated by receipt of a prescription, lab coverage status, and retention. We describe outcomes in the population overall and distinct sociodemographic subgroups. Results: A total of 470 individuals were included (90.3% male; median age 29 (IQR, 25-36); 52.9% White, non-Hispanic) and contributed 879.5 person-years of follow-up. One week following linkage to care, 86.8% (95% CI: 83.6-90.0) of participants had a PrEP prescription. At month 6, 35.2% (95% CI: 30.7-39.7) were in care but had a lapse in HIV/STI screening, at month 12, 48.3% (95% CI: 43.7-53.1) were disengaged from care. Of those who disengaged, 28.3% (95% CI: 23.9-32.7) were re-engaged 6 months later. Females and uninsured individuals were the most likely to disengage during the first year of follow-up. Conclusions: Lapses in clinic visits and lab screening are common among PrEP users in Missouri and most who disengage do not return. Females, uninsured individuals, and other marginalized groups may be particularly susceptible to poor persistence suggesting targeted interventions are warranted.