Uptake of HIV pre-exposure prophylaxis (PrEP) in a national cohort of gay and bisexual men in the United States: The Motivational PrEP Cascade

OBJECTIVES:The HIV care cascade provides milestones to track the progress of HIV-positive people from seroconversion through viral suppression. We propose a Motivational PrEP Cascade involving five stages based upon the Transtheoretical Model of Change. METHODS:We analyzed data from 995 men in One Thousand Strong, a longitudinal study of a national panel of HIV-negative gay and bisexual men in the United States. RESULTS:Nearly all (89%) participants were sexually active in the past 3 months, and 65% met CDC criteria for PrEP candidacy. Of those identified as appropriate candidates, 53% were Precontemplative (Stage 1; unwilling to take or believing they were inappropriate candidates for PrEP) and 23% were in Contemplation (Stage 2; willing and self-identified as appropriate candidates). Only 11% were in PrEParation (Stage 3; seeing PrEP as accessible and planning to initiate PrEP) and 4% were in PrEP Action (Stage 4; prescribed PrEP). Although few of those who were identified as appropriate candidates were on PrEP, nearly all PrEP users (98%) reported adhering to 4 or more doses per week and most (72%) were returning for recommended quarterly medical visits, resulting in 9% of PrEP candidates reaching Maintenance and Adherence (Stage 5). CONCLUSIONS:A large majority of participants were appropriate candidates for PrEP, yet fewer than 1 in 10 were using and adherent to PrEP. These findings highlight the need for interventions tailored to address the unique barriers men face at each stage of the cascade, particularly at the earliest stages where the most dramatic losses were identified.