Use of HIV pre-exposure prophylaxis among men who have sex with men: low uptake and retention despite high-risk indications.

HIV PrEP is over 99% effective in preventing HIV when medication adherence is high. Despite this, uptake and retention in PrEP care remains less than optimal. We investigated whether gbMSM with objective risk factors for HIV who were automatically offered PrEP would have higher uptake and retention in PrEP care. For this, gbMSM with clinical evidence of HIV risk received a reflexive offer for PrEP from a nurse. The number of offers, referral acceptance, presentation to the first appointment, initiation and retention at 6 months were examined. Of 1181 gbMSM with objective HIV risk factors who were offered PrEP, only 50% accepted, 28% initiated and 16% remained on PrEP at 6 months. Loss across the cascade was more pronounced for youth. We found a notable disconnect between recent STI diagnosis and acceptance, initiation and retention in PrEP. This notwithstanding, 137 at-risk individuals were retained on PrEP because of an active offer. PrEP delivered by nurses was as effective as that delivered by infectious disease physicians. While active offer PrEP successfully brought at-risk individuals into care, more work is required to understand the perceptions of risk, the benefits and challenges of PrEP use, and how stigma and structural barriers affect retention among diverse groups affected by HIV.