Background: Pre-exposure prophylaxis (PrEP) reduces the risk of HIV infection in those at risk for acquiring HIV. TDF/FTC was approved for PrEP in the United States (US) in 2012; 147,000 people had initiated PrEP through 2016.
Methods: We analyzed HIV diagnoses among persons ≥ 13 years old, and viral suppression, from the National HIV Surveillance System and national pharmacy data on prevalence of TDF/FTC use, for PrEP /1,000 persons with PrEP indications. We described changes in rates of HIV diagnoses and PrEP users, from 2012-2016, for 50 states and DC using estimated annual percent change (EAPC). We calculated EAPC and 95% confidence intervals (CI) for HIV diagnoses for states by quintiles of PrEP use. To evaluate the independence of the effect of PrEP uptake from the effect of treatment as prevention, we used data from a subset of 38 states and DC (39 jurisdictions) with viral suppression data (averaged for available years from 2012-2014) among those living with diagnosed HIV, and examined whether the association of PrEP uptake and HIV diagnoses changed when controlling for state-specific level of viral suppression.
Results: The overall US rate of HIV diagnoses decreased significantly from 15.7 (2012) to 14.5 (2016)/100,000 (EAPC: -1.6, CI: -1.9, -1.3). PrEP use prevalence increased from 7.0 (2012) to 68.5 (2016)/1,000 (EAPC: +78.0%, CI: +77.3%, +78.7%). The pooled unadjusted EAPC of HIV diagnoses for states in the highest quintile of PrEP use was -4.7% (CI: -5.4%, -3.9%) and for states in the lowest PrEP use quintile was +0.9% (CI: +0.2%, +1.7%) (Figure). The average prevalence of PrEP users in 2016 was 110/1,000 (11%) in the highest quintile, and 33/1000 (3.3%) in the lowest. Among the 39 jurisdictions with viral suppression data, rate of PrEP uptake remained significantly associated with declines in new HIV diagnoses after controlling for state-level viral suppression.
Conclusions: PrEP uptake was significantly associated with declines in HIV diagnoses in the US, and this association is independent of levels of viral suppression. US states should take steps to increase the coverage of PrEP among persons with indications in the current context of increasing HIV viral suppression for people living with HIV.