Factors Associated With Early and Late Discontinuation of Preexposure Prophylaxis in the San Francisco Primary Care Clinics
| Factor . | Early Discontinuationa . | . | Late Discontinuationa . | . |
|---|---|---|---|---|
| . | RR (95% CI) . | aRR (95% CI) . | RR (95% CI) . | aRR (95% CI) . |
| Age per ten-year increaseb | 0.88 (.69–1.11) | 0.91 (.77–1.08) | 0.81 (.70–.92) | 0.82 (.70–.96) |
| Female birth sexb | 1.59 (.92–2.75) | 1.62 (.95–2.75) | 1.01 (.64–1.58) | 1.00 (.77–1.29) |
| Race/ethnicityb | ||||
| White | 1.00 (Reference) | 1.00 (Reference) | 1.00 (Reference) | 1.00 (Reference) |
| Black | 1.85 (.94–3.61) | 1.70 (.74–3.93) | 1.95 (1.20–3.17) | 1.76 (.94–3.28) |
| Latino | 1.11 (.58–2.13) | 1.01 (.53–1.93) | 1.19 (.82–1.74) | 1.14 (.78–1.65) |
| Asian/other | 1.29 (.68–2.42) | 1.14 (.71–1.83) | 1.26 (.90–1.77) | 1.09 (.84–1.43) |
| Insuranceb | ||||
| Private | 1.00 (Reference) | 1.00 (Reference) | 1.00 (Reference) | 1.00 (Reference) |
| Uninsured | 1.87 (.56–6.24) | 2.13 (.65–6.96) | 0.77 (.41–1.46) | 0.83 (.45–1.51) |
| Public | 1.47 (.49–4.43) | 1.61 (.57–4.54) | 0.70 (.46–1.07) | 0.73 (.40–1.33) |
| Housing instabilityc | 1.11 (.56–2.18) | 1.04 (.46–2.36) | 1.26 (.83–1.91) | 1.20 (.67–2.15) |
| Reported illicit drug usec | 1.12 (.60–2.09) | 1.01 (.53–1.93) | 1.53 (1.08–2.17) | 1.59 (1.02–2.47) |
| Mental health diagnosisc | ||||
| None | 1.00 (Reference) | 1.00 (Reference) | 1.00 (Reference) | 1.00 (Reference) |
| Anxiety/depression | 1.01 (.60–1.70) | 0.96 (.61–1.51) | 0.69 (.50–.95) | 0.71 (.50–1.02) |
| Bipolar/schizophrenia | 1.05 (.48–2.33) | 0.94 (.42–2.11) | 1.27 (.87–1.85) | 1.17 (.76–1.82) |
| PrEP patients per provider (≥5 vs <5)d | 0.83 (.52–1.33) | 0.66 (.36–1.20) | 1.54 (1.15–2.05) | 1.36 (1.11–1.66) |
| Current PrEP use year b | ||||
| 2012-2014 | 1.00 (Reference) | 1.00 (Reference) | 1.00 (Reference) | 1.00 (Reference) |
| (time-dependent) 2015 | 2.05 (.59–7.10) | 1.91 (.73–5.01) | 1.97 (1.34–2.89) | 1.92 (1.42–2.60) |
| 2016–2017 | 5.38 (1.73–16.78) | 4.80 (2.05–11.23) | 2.86 (1.95–4.20) | 2.79 (1.98–3.92) |
| PrEP indicationb | ||||
| MSM | 1.00 (Reference) | 1.00 (Reference) | 1.00 (Reference) | 1.00 (Reference) |
| TGWSM | 2.17 (1.24–3.80) | 2.16 (1.36–3.49) | 1.62 (1.00–2.62) | 1.84 (.98–3.46) |
| Othere | 1.28 (.71–2.32) | 1.15 (.60–2.17) | 0.96 (.67–1.40) | 1.00 (.71–1.42) |
| Panel management/patient navigationf | 1.65(1.01–2.70) | 1.05 (.47–2.34) | 1.68 (1.25–2.25) | 1.13 (.81–1.58) |
| Missed a visit (ie, no-show) while using PrEPg | … | … | 1.58 (1.18–2.11) | 1.52 (1.14–2.03) |
| Factor . | Early Discontinuationa . | . | Late Discontinuationa . | . |
|---|---|---|---|---|
| . | RR (95% CI) . | aRR (95% CI) . | RR (95% CI) . | aRR (95% CI) . |
| Age per ten-year increaseb | 0.88 (.69–1.11) | 0.91 (.77–1.08) | 0.81 (.70–.92) | 0.82 (.70–.96) |
| Female birth sexb | 1.59 (.92–2.75) | 1.62 (.95–2.75) | 1.01 (.64–1.58) | 1.00 (.77–1.29) |
| Race/ethnicityb | ||||
| White | 1.00 (Reference) | 1.00 (Reference) | 1.00 (Reference) | 1.00 (Reference) |
| Black | 1.85 (.94–3.61) | 1.70 (.74–3.93) | 1.95 (1.20–3.17) | 1.76 (.94–3.28) |
| Latino | 1.11 (.58–2.13) | 1.01 (.53–1.93) | 1.19 (.82–1.74) | 1.14 (.78–1.65) |
| Asian/other | 1.29 (.68–2.42) | 1.14 (.71–1.83) | 1.26 (.90–1.77) | 1.09 (.84–1.43) |
| Insuranceb | ||||
| Private | 1.00 (Reference) | 1.00 (Reference) | 1.00 (Reference) | 1.00 (Reference) |
| Uninsured | 1.87 (.56–6.24) | 2.13 (.65–6.96) | 0.77 (.41–1.46) | 0.83 (.45–1.51) |
| Public | 1.47 (.49–4.43) | 1.61 (.57–4.54) | 0.70 (.46–1.07) | 0.73 (.40–1.33) |
| Housing instabilityc | 1.11 (.56–2.18) | 1.04 (.46–2.36) | 1.26 (.83–1.91) | 1.20 (.67–2.15) |
| Reported illicit drug usec | 1.12 (.60–2.09) | 1.01 (.53–1.93) | 1.53 (1.08–2.17) | 1.59 (1.02–2.47) |
| Mental health diagnosisc | ||||
| None | 1.00 (Reference) | 1.00 (Reference) | 1.00 (Reference) | 1.00 (Reference) |
| Anxiety/depression | 1.01 (.60–1.70) | 0.96 (.61–1.51) | 0.69 (.50–.95) | 0.71 (.50–1.02) |
| Bipolar/schizophrenia | 1.05 (.48–2.33) | 0.94 (.42–2.11) | 1.27 (.87–1.85) | 1.17 (.76–1.82) |
| PrEP patients per provider (≥5 vs <5)d | 0.83 (.52–1.33) | 0.66 (.36–1.20) | 1.54 (1.15–2.05) | 1.36 (1.11–1.66) |
| Current PrEP use year b | ||||
| 2012-2014 | 1.00 (Reference) | 1.00 (Reference) | 1.00 (Reference) | 1.00 (Reference) |
| (time-dependent) 2015 | 2.05 (.59–7.10) | 1.91 (.73–5.01) | 1.97 (1.34–2.89) | 1.92 (1.42–2.60) |
| 2016–2017 | 5.38 (1.73–16.78) | 4.80 (2.05–11.23) | 2.86 (1.95–4.20) | 2.79 (1.98–3.92) |
| PrEP indicationb | ||||
| MSM | 1.00 (Reference) | 1.00 (Reference) | 1.00 (Reference) | 1.00 (Reference) |
| TGWSM | 2.17 (1.24–3.80) | 2.16 (1.36–3.49) | 1.62 (1.00–2.62) | 1.84 (.98–3.46) |
| Othere | 1.28 (.71–2.32) | 1.15 (.60–2.17) | 0.96 (.67–1.40) | 1.00 (.71–1.42) |
| Panel management/patient navigationf | 1.65(1.01–2.70) | 1.05 (.47–2.34) | 1.68 (1.25–2.25) | 1.13 (.81–1.58) |
| Missed a visit (ie, no-show) while using PrEPg | … | … | 1.58 (1.18–2.11) | 1.52 (1.14–2.03) |
Abbreviations aRR, adjusted risk ratio; CI, confidence interval; MSM, men who have sex with men; PrEP, preexposure prophylaxis; RR, risk ratio (unadjusted); TGWSM, transgender women who have sex with men.
aEach adjusted model depends on the specific variables identified as confounders from direct acyclic graph analysis, noted below in footnotes. Each analysis used Poisson regression with robust standard errors accounting for clinic-level clustering. The early discontinuation model examines individuals who discontinue PrEP within <90 days compared with those who continue PrEP. The late discontinuation model examines discontinuation only among those who continued PrEP for ≥90 days.
bControlling for the 3 main demographic variables (age, sex, and race/ethnicity).
cControlling for the 3 main demographic variables, mental health diagnosis (classified per International Classification of Diseases, Tenth Revision, code), illicit drug use (excluding cannabis), and housing status (illicit drug use and housing status as documented in the medical record).
dControlling for the 3 main demographic variables, year, and PrEP indication.
eOther PrEP indications include serodifferent couple, at-risk heterosexual, and persons with injection drug use.
fControlling for the 3 main demographic variables, higher-volume provider (≥5 PrEP patients per provider), year, PrEP indication. Program included registry of all PrEP users, access to a patient navigator by text, and visit reminders; this was analyzed as a clinic-level, time-dependent covariate.
gControlling for the 3 main demographic variables, insurance status, higher-volume provider (≥5 PrEP patients per provider). Missed visits were examined as a time-dependent covariate over 90-day periods of PrEP use in the late discontinuation model.
Factors Associated With Early and Late Discontinuation of Preexposure Prophylaxis in the San Francisco Primary Care Clinics
| Factor . | Early Discontinuationa . | . | Late Discontinuationa . | . |
|---|---|---|---|---|
| . | RR (95% CI) . | aRR (95% CI) . | RR (95% CI) . | aRR (95% CI) . |
| Age per ten-year increaseb | 0.88 (.69–1.11) | 0.91 (.77–1.08) | 0.81 (.70–.92) | 0.82 (.70–.96) |
| Female birth sexb | 1.59 (.92–2.75) | 1.62 (.95–2.75) | 1.01 (.64–1.58) | 1.00 (.77–1.29) |
| Race/ethnicityb | ||||
| White | 1.00 (Reference) | 1.00 (Reference) | 1.00 (Reference) | 1.00 (Reference) |
| Black | 1.85 (.94–3.61) | 1.70 (.74–3.93) | 1.95 (1.20–3.17) | 1.76 (.94–3.28) |
| Latino | 1.11 (.58–2.13) | 1.01 (.53–1.93) | 1.19 (.82–1.74) | 1.14 (.78–1.65) |
| Asian/other | 1.29 (.68–2.42) | 1.14 (.71–1.83) | 1.26 (.90–1.77) | 1.09 (.84–1.43) |
| Insuranceb | ||||
| Private | 1.00 (Reference) | 1.00 (Reference) | 1.00 (Reference) | 1.00 (Reference) |
| Uninsured | 1.87 (.56–6.24) | 2.13 (.65–6.96) | 0.77 (.41–1.46) | 0.83 (.45–1.51) |
| Public | 1.47 (.49–4.43) | 1.61 (.57–4.54) | 0.70 (.46–1.07) | 0.73 (.40–1.33) |
| Housing instabilityc | 1.11 (.56–2.18) | 1.04 (.46–2.36) | 1.26 (.83–1.91) | 1.20 (.67–2.15) |
| Reported illicit drug usec | 1.12 (.60–2.09) | 1.01 (.53–1.93) | 1.53 (1.08–2.17) | 1.59 (1.02–2.47) |
| Mental health diagnosisc | ||||
| None | 1.00 (Reference) | 1.00 (Reference) | 1.00 (Reference) | 1.00 (Reference) |
| Anxiety/depression | 1.01 (.60–1.70) | 0.96 (.61–1.51) | 0.69 (.50–.95) | 0.71 (.50–1.02) |
| Bipolar/schizophrenia | 1.05 (.48–2.33) | 0.94 (.42–2.11) | 1.27 (.87–1.85) | 1.17 (.76–1.82) |
| PrEP patients per provider (≥5 vs <5)d | 0.83 (.52–1.33) | 0.66 (.36–1.20) | 1.54 (1.15–2.05) | 1.36 (1.11–1.66) |
| Current PrEP use year b | ||||
| 2012-2014 | 1.00 (Reference) | 1.00 (Reference) | 1.00 (Reference) | 1.00 (Reference) |
| (time-dependent) 2015 | 2.05 (.59–7.10) | 1.91 (.73–5.01) | 1.97 (1.34–2.89) | 1.92 (1.42–2.60) |
| 2016–2017 | 5.38 (1.73–16.78) | 4.80 (2.05–11.23) | 2.86 (1.95–4.20) | 2.79 (1.98–3.92) |
| PrEP indicationb | ||||
| MSM | 1.00 (Reference) | 1.00 (Reference) | 1.00 (Reference) | 1.00 (Reference) |
| TGWSM | 2.17 (1.24–3.80) | 2.16 (1.36–3.49) | 1.62 (1.00–2.62) | 1.84 (.98–3.46) |
| Othere | 1.28 (.71–2.32) | 1.15 (.60–2.17) | 0.96 (.67–1.40) | 1.00 (.71–1.42) |
| Panel management/patient navigationf | 1.65(1.01–2.70) | 1.05 (.47–2.34) | 1.68 (1.25–2.25) | 1.13 (.81–1.58) |
| Missed a visit (ie, no-show) while using PrEPg | … | … | 1.58 (1.18–2.11) | 1.52 (1.14–2.03) |
| Factor . | Early Discontinuationa . | . | Late Discontinuationa . | . |
|---|---|---|---|---|
| . | RR (95% CI) . | aRR (95% CI) . | RR (95% CI) . | aRR (95% CI) . |
| Age per ten-year increaseb | 0.88 (.69–1.11) | 0.91 (.77–1.08) | 0.81 (.70–.92) | 0.82 (.70–.96) |
| Female birth sexb | 1.59 (.92–2.75) | 1.62 (.95–2.75) | 1.01 (.64–1.58) | 1.00 (.77–1.29) |
| Race/ethnicityb | ||||
| White | 1.00 (Reference) | 1.00 (Reference) | 1.00 (Reference) | 1.00 (Reference) |
| Black | 1.85 (.94–3.61) | 1.70 (.74–3.93) | 1.95 (1.20–3.17) | 1.76 (.94–3.28) |
| Latino | 1.11 (.58–2.13) | 1.01 (.53–1.93) | 1.19 (.82–1.74) | 1.14 (.78–1.65) |
| Asian/other | 1.29 (.68–2.42) | 1.14 (.71–1.83) | 1.26 (.90–1.77) | 1.09 (.84–1.43) |
| Insuranceb | ||||
| Private | 1.00 (Reference) | 1.00 (Reference) | 1.00 (Reference) | 1.00 (Reference) |
| Uninsured | 1.87 (.56–6.24) | 2.13 (.65–6.96) | 0.77 (.41–1.46) | 0.83 (.45–1.51) |
| Public | 1.47 (.49–4.43) | 1.61 (.57–4.54) | 0.70 (.46–1.07) | 0.73 (.40–1.33) |
| Housing instabilityc | 1.11 (.56–2.18) | 1.04 (.46–2.36) | 1.26 (.83–1.91) | 1.20 (.67–2.15) |
| Reported illicit drug usec | 1.12 (.60–2.09) | 1.01 (.53–1.93) | 1.53 (1.08–2.17) | 1.59 (1.02–2.47) |
| Mental health diagnosisc | ||||
| None | 1.00 (Reference) | 1.00 (Reference) | 1.00 (Reference) | 1.00 (Reference) |
| Anxiety/depression | 1.01 (.60–1.70) | 0.96 (.61–1.51) | 0.69 (.50–.95) | 0.71 (.50–1.02) |
| Bipolar/schizophrenia | 1.05 (.48–2.33) | 0.94 (.42–2.11) | 1.27 (.87–1.85) | 1.17 (.76–1.82) |
| PrEP patients per provider (≥5 vs <5)d | 0.83 (.52–1.33) | 0.66 (.36–1.20) | 1.54 (1.15–2.05) | 1.36 (1.11–1.66) |
| Current PrEP use year b | ||||
| 2012-2014 | 1.00 (Reference) | 1.00 (Reference) | 1.00 (Reference) | 1.00 (Reference) |
| (time-dependent) 2015 | 2.05 (.59–7.10) | 1.91 (.73–5.01) | 1.97 (1.34–2.89) | 1.92 (1.42–2.60) |
| 2016–2017 | 5.38 (1.73–16.78) | 4.80 (2.05–11.23) | 2.86 (1.95–4.20) | 2.79 (1.98–3.92) |
| PrEP indicationb | ||||
| MSM | 1.00 (Reference) | 1.00 (Reference) | 1.00 (Reference) | 1.00 (Reference) |
| TGWSM | 2.17 (1.24–3.80) | 2.16 (1.36–3.49) | 1.62 (1.00–2.62) | 1.84 (.98–3.46) |
| Othere | 1.28 (.71–2.32) | 1.15 (.60–2.17) | 0.96 (.67–1.40) | 1.00 (.71–1.42) |
| Panel management/patient navigationf | 1.65(1.01–2.70) | 1.05 (.47–2.34) | 1.68 (1.25–2.25) | 1.13 (.81–1.58) |
| Missed a visit (ie, no-show) while using PrEPg | … | … | 1.58 (1.18–2.11) | 1.52 (1.14–2.03) |
Abbreviations aRR, adjusted risk ratio; CI, confidence interval; MSM, men who have sex with men; PrEP, preexposure prophylaxis; RR, risk ratio (unadjusted); TGWSM, transgender women who have sex with men.
aEach adjusted model depends on the specific variables identified as confounders from direct acyclic graph analysis, noted below in footnotes. Each analysis used Poisson regression with robust standard errors accounting for clinic-level clustering. The early discontinuation model examines individuals who discontinue PrEP within <90 days compared with those who continue PrEP. The late discontinuation model examines discontinuation only among those who continued PrEP for ≥90 days.
bControlling for the 3 main demographic variables (age, sex, and race/ethnicity).
cControlling for the 3 main demographic variables, mental health diagnosis (classified per International Classification of Diseases, Tenth Revision, code), illicit drug use (excluding cannabis), and housing status (illicit drug use and housing status as documented in the medical record).
dControlling for the 3 main demographic variables, year, and PrEP indication.
eOther PrEP indications include serodifferent couple, at-risk heterosexual, and persons with injection drug use.
fControlling for the 3 main demographic variables, higher-volume provider (≥5 PrEP patients per provider), year, PrEP indication. Program included registry of all PrEP users, access to a patient navigator by text, and visit reminders; this was analyzed as a clinic-level, time-dependent covariate.
gControlling for the 3 main demographic variables, insurance status, higher-volume provider (≥5 PrEP patients per provider). Missed visits were examined as a time-dependent covariate over 90-day periods of PrEP use in the late discontinuation model.
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