Individual pre-exposure prophylaxis (PrEP) use among commercially insured people in the United States rose more than 20-fold from 2010 through 2014, according to results of an analysis by the Centers for Disease Control and Prevention (CDC). Almost all PrEP users were urban men.
Over the past few years, the CDC reports, HIV incidence fell across the United States but remained stable in men who have sex with men (MSM), while rising among Asians and Native Americans. PrEP came into use in the early 2010s, and the U.S. Food and Drug Administration licensed daily Truvada (tenofovir [TDF]/emtricitabine [FTC]) PrEP in 2012. Understanding PrEP uptake is important to ongoing HIV prevention planning, but national HIV surveillance data do not include PrEP uptake. The CDC conducted this study to develop a method for estimating PrEP use in the United States and to apply that method to the period 2010-2014.
Participant data came from the 2009-2014 MarketScan database, which includes 43 to 53 million people each year covered by commercial employer-sponsored health insurance. The database includes de-identified participant demographics, diagnoses and prescriptions. To identify likely PrEP users, the CDC developed an algorithm that began with everyone prescribed TDF/FTC and excluded people with (1) HIV infection, (2) hepatitis B infection or (3) probable TDF/FTC use for post-exposure prophylaxis. Using national weighting variables included in the MarketScan database, the researchers generated national estimates of persons 16 years old or older who were prescribed PrEP. Then they figured PrEP prevalence per million persons for each study year.
From 2010 through 2014, TDF/FTC prescriptions respectively numbered 111, 149, 237, 497 and 2,564. Weighted national estimates for PrEP prescriptions over those years were 417, 506, 765, 1,947 and 9,375. Average age of PrEP users fell from 44.4 years in 2010 to 37.8 years in 2014. The proportion of PrEP users who were men climbed from 82.0% in 2010 to 97.5% in 2014. During every year analyzed, more than 97% of PrEP users lived in metropolitan areas.
PrEP prevalence per million commercially insured people rose slowly from 3.3 in 2010, to 4.0 in 2011 and 6.2 in 2012. The upward trend grew steeper in 2012 at 15.7 per million, then catapulted to 75.4 per million in 2014 (P < .001 for 2010-2014). Over those five years, PrEP prevalence per million men rose from 5.5 to 6.9 to 11.0 to 29.5 to 151.2 (P < .001 for trend). Over the same years, PrEP prevalence per million women increased from 1.2 to only 3.7 (P < .001). The Western U.S. accounted for 31.8% of PrEP prescriptions in 2010 and for 43.1% in 2014. The South accounted for 33.6% of prescriptions in 2010 and for 24.9% in 2014.
The authors attribute the 27-fold spike in PrEP use among men to growing awareness among providers and MSM, which "likely resulted from the widespread dissemination of the CDC's 2014 PrEP clinical guidelines and resulting social media campaigns targeting MSM." Low PrEP uptake by women, the research suggests, underlines the difficulty clinicians face in identifying women with PrEP indications. Yet, a recent study estimated that 468,000 U.S. women may benefit from PrEP, nearly the same number as the estimated 492,000 at-risk U.S. MSM.
Mark Mascolini writes about HIV infection.