HIV Pre-Exposure Prophylaxis Care Continuum in Outpatient Settings: A Systematic Review and Meta-Analysis.

Introduction: Pre-exposure prophylaxis is a prescription medication that prevents HIV infection and transmission in those at risk for HIV infection. The authors examined engagement in the oral pre-exposure prophylaxis care continuum among HIV-negative individuals at risk for HIV in outpatient settings in the U.S. after participation in a pre-exposure prophylaxis-related intervention, to identify key gaps in the continuum where current interventions are least effective. Methods: This systematic review and meta-analysis included U.S. studies published from January 2012 through August 2022, reporting at least 2 of 7 pre-exposure prophylaxis care continuum steps from the identification of HIV-negative, at-risk pre-exposure prophylaxis-eligible persons to pre-exposure prophylaxis initiation. The final 2 steps-pre-exposure prophylaxis adherence and retention-of the continuum's 9 steps were not analyzed owing to the substantial heterogeneity in how the included studies measured these steps and the limited sample sizes across the studies. Random-effects meta-analyses, which describe the distribution of effects across studies, were performed to estimate pooled proportions of each step, and subgroup analyses were conducted on the basis of population characteristics (e.g., individuals with a sexually transmitted infection, men who have sex with men) and study settings (i.e., emergency department, ambulatory care, healthcare system, and other). Results: The authors included 2,510 articles in title and abstract review, 296 were retrieved for full-text review, and 34 studies met the inclusion criteria and were included in the meta-analysis. The 34 studies were comprised of 71,162 individuals eligible for pre-exposure prophylaxis. Among them, 66% had increased HIV risk awareness, 55% had enhanced pre-exposure prophylaxis awareness, 49% had facilitated pre-exposure prophylaxis access, 42% were linked to pre-exposure prophylaxis care, 40% were prescribed pre-exposure prophylaxis, and 34% initiated pre-exposure prophylaxis use. Subgroup analysis indicated that individuals identified in emergency department settings and those with sexually transmitted infections had lower pre-exposure prophylaxis initiation rates than those identified in all other settings and men who have sex with men, respectively. Discussion: There was a progressive decline in the proportion of individuals engaged in the pre-exposure prophylaxis care continuum. These findings suggest that comprehensive efforts are needed across all settings to increase perceived susceptibility to HIV among high-risk individuals and to capitalize on the opportunity of sexually transmitted infections care and emergency department visits to engage patients in the pre-exposure prophylaxis care continuum.