(88) Prevalence and Correlates of AUD Diagnoses among Users of HIV Pre-Exposure Prophylaxis

Background & Introduction: Alcohol use disorder (AUD), the most common substance use disorder (SUD) globally, is characterized by the inability to limit alcohol use despite negative consequences. AUD has been linked to various HIV-related behaviors, including an increased risk of condomless sex and lower HIV testing rates [1]. Among people living with HIV, alcohol use is associated with nonadherence to antiretroviral treatment which can lead to high viral load [2].

AUD and other forms of alcohol use and misuse may potentially impact the use of preexposure prophylaxis (PrEP), a key intervention in the effort to end the HIV epidemic. Studies have found that alcohol use and misuse are associated with PrEP nonadherence and discontinuation [3]. However, other studies have found no association, suggesting that individuals using alcohol can still use PrEP effectively [4]. Understanding how alcohol use and misuse affect PrEP use is essential to improving HIV prevention strategies.

The prevalence of clinical diagnoses of AUD among PrEP users, which is the first and necessary step in the AUD treatment pathway, is not well understood. To address this gap, this study sought to estimate the prevalence and correlates of AUD diagnosis among commercially insured PrEP users in the U.S. using healthcare claims data.

Methods: This retrospective cohort study used MarketScan, a US healthcare claims and administrative database of individuals with employer-sponsored private insurance. We identified individuals aged 16-64 years who received a new prescription for Food and Drug Administration (FDA)-approved PrEP medications – tenofovir disoproxil fumarate/emtricitabine, tenofovir alafenamide/emtricitabine, or cabotegravir – between January 1, 2014, to December 31, 2021. PrEP initiation was determined through an established algorithm adopted in previous studies involving real-world data [5].

The main outcome of the study was an AUD diagnosis within 6 months before or after the date of PrEP initiation, which we identified using diagnosis codes. Among individuals with an AUD diagnosis, we determined receipt of an FDA-approved AUD pharmacotherapy (oral and injectable naltrexone, acamprosate, and disulfiram).

We included sociodemographic (patient age, sex assigned at birth, geographic location, employment status, and type of health insurance) and clinical (sexually transmitted infection [STI] diagnosis and screening, use of psychotherapy services, substance use disorders, and mental health disorders) characteristics as covariates. We conducted descriptive statistics to summarize baseline characteristics for PrEP users with and without AUD and logistic regression analyses to determine the sociodemographic and clinical characteristics associated with AUD diagnosis before and after PrEP initiation.

Results: Of the 132,737 individuals we identified with a PrEP-related claim, 43,913 met our full inclusion criteria. Among these PrEP users, 6,274 (14.29%) were diagnosed with AUD within six months of PrEP initiation. 1,245 (2.84%) had AUD diagnoses before PrEP initiation and 5,029 (11.45%) received AUD diagnoses after PrEP initiation.

PrEP users with a AUD diagnosis prior to PrEP initiation were generally younger (mean age [SD] 34.88 [11.43] vs. 35.85 [10.78]; P <0.01), less likely to be male assigned at birth (83.29% vs. 90.31%; P<0.01), employed (79.2% vs 83.45%; p <0.01), and had a higher prevalence of mental health diagnoses, such as depression (31.24% vs 5.30%; p <0.01), compared to the no AUD group. PrEP users with a prior AUD diagnosis also had a higher prevalence of SUDs, such as opioid user disorder (5.22% vs 0.24%; p <0.01), compared to those without AUD diagnoses. PrEP users who were diagnosed with AUD after PrEP initiation showed similar differences in baseline characteristics when compared to PrEP users without AUD.

PrEP users with AUD before (13.90% vs 5.54%; p<0.01) and after (10.64% vs 5.54%; p<0.01) PrEP initiation were more likely to utilize psychotherapy services compared to the no AUD group. Compared to the no AUD group, PrEP users diagnosed with AUD before initiation were less likely to receive an STI diagnosis (5.86% vs 7.32%; p = 0.05) or STI screening (4.82% vs 11.13%; p < 0.01). Similarly, those diagnosed with AUD after initiation showed lower rates of STI diagnosis (3.46% vs 7.32%; p < 0.01) and screening (2.37% vs 11.13%; p < 0.01).

Only 1,136 (18.11%) PrEP users with an AUD diagnosis received any form of FDA-approved AUD pharmacotherapy. For both AUD groups, treatment was predominantly naltrexone, followed by disulfiram and acamprosate.

In regression analysis, we found that being male assigned at birth was negatively associated with an AUD diagnosis before (aOR = 0.62, 95% CI = 0.52-0.74, p < 0.001) and after (aOR = 0.81, CI = 0.73-0.89, p < 0.001) PrEP initiation. Age was also a negative predictor of AUD diagnosis before (aOR = 0.99, CI = 0.99-1.00, p < 0.001) PrEP initiation. Any SUD diagnosis was positively associated with AUD diagnosis before (aOR = 14.68, CI = 12.61-17.08, p < 0.001) and after (aOR of 13.37, CI = 12.08-14.78, p < 0.001) PrEP initiation. Mental health diagnoses were also positively associated with AUD diagnosis before and after PrEP initiation.

Conclusion & Discussion: This cohort study found that nearly 15% of new PrEP users were diagnosed with AUD within six months of PrEP initiation. PrEP users with an AUD diagnosis were more likely to have co-occurring mental health conditions and other substance use disorders. However, less than 20% of individuals with AUD received any FDA-approved pharmacotherapy, underscoring the need for improved screening and treatment interventions to mitigate risks associated with alcohol use. The study’s limitations include reliance on healthcare claims data, which may not capture all relevant diagnoses or treatments received outside insured healthcare settings. Additionally, the use of commercial insurance data excludes uninsured populations and those under non-commercial plans, potentially skewing AUD prevalence estimates.

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