Disparities in HIV Pre-exposure Prophylaxis Reversal and Abandonment by Race and Income: An Intersectional Approach.

Daily use of pre-exposure prophylaxis (PrEP) effectively prevents HIV, yet uptake remains uneven, particularly among lower socioeconomic and minoritized populations. Approximately 20% of newly approved PrEP prescriptions are reversed (a newly prescribed oral PrEP prescription that is not picked up at the pharmacy within 7-14 days), and most are subsequently abandoned (reversed prescription that is not picked up within a year). The roles of race and income in these outcomes are not well characterized. We analyzed Symphony HealthCare Analytics data on first-time, insurance-approved 30-day oral PrEP prescriptions for lower-income NHB, higher-income NHB, lower-income NHW, and higher-income NHW (referent group) men and women. Intersectional disparities in prescription reversal and abandonment were decomposed into joint, referent race, referent income, and excess intersectional components, stratified by gender. The total sample was 28,019, which included 2,463 women and 25,556 men. Among men, reversal and abandonment were higher among lower-income NHB men compared to higher-income NHW men. Joint disparities were 4.5% for reversal and 3.7% for abandonment, with less than half explained by race or income alone, suggesting an additional intersectional effect. Among women, reversal and abandonment were higher among higher-income NHW women compared to lower-income NHB women. Joint disparities were -11.4% and  -12.9%, respectively, and were largely explained by independent race and income effects, with attenuation of intersectional disparities. Both financial and racial factors contribute to PrEP prescription reversal and abandonment, with patterns differing by gender. Interventions addressing cost barriers and structural inequities, alongside gender-specific strategies, may improve PrEP uptake and persistence.