HIV PrEP in the U.S. Military, 2014–2016: Who Got It, and What Stands in the Way

About 350 U.S. service members are diagnosed with HIV each year, most infected within the United States. As among civilians, the highest rates are in men and Black service members, and most new diagnoses are among men who have sex with men (MSM). Preexposure prophylaxis (PrEP) is about 90% effective at preventing HIV when used properly, and use in the military health system has grown since "Don't Ask, Don't Tell" was repealed in 2011.

This report looked at who was prescribed PrEP — Truvada (emtricitabine/tenofovir disoproxil fumarate) — from February 1, 2014, to June 10, 2016, and surveyed military health care providers.

Who got PrEP

769 service members without HIV were prescribed it.

Service members starting PrEP, by month, 2014–2016. CDC

They were stationed across the U.S. and overseas, but 41% got care at one of three medical centers — in the Maryland/DC area, Portsmouth, Virginia, and San Diego.

Service members starting PrEP, by duty location and prescribing clinic, 2014–2016. CDC

Most had the right lab tests, but not all: 16% had no HIV test within 14 days of starting, 13% were never checked for hepatitis B, and 20% and 30% had no kidney function test at baseline or within 90 days — contrary to recommendations.

A seven-item MSM risk index (a score of 10 or more prioritizes someone for PrEP) was recorded for only 20%; of those, 72% scored 10 or more.

What providers said

Of 4,217 Army, Navy and Air Force primary care and infectious disease providers surveyed in 2015–2017, 1,599 (38%) replied:

The gaps

• Race. Black service members are 17% of the force but about half of military HIV diagnoses — yet only 19% of PrEP users. Whether that's a true disparity, and whether culturally appropriate outreach would help, needs study.
• Reach. With 1.3 million active-duty members, about 85% men, an estimated 4.23% of men MSM, and a quarter of those at substantially increased risk, roughly 12,000 service members could be eligible — but by February 2017 only about 2,000 service members and beneficiaries had used PrEP, mostly through major medical centers after specialist referral.
• Cost. At about $12,000 a year per user for Truvada, PrEP for all 12,000 could exceed $140 million a year in drugs alone — though generics weren't counted, and a lifetime of HIV care costs nearly $450,000 per person, and HIV-positive personnel can't deploy to combat.
• Military life. Some deployment settings and smaller facilities lack the lab tests — including the three-site gonorrhea and chlamydia testing CDC recommends for MSM on PrEP — and some pharmacies lack Truvada. Pilots and air crew were historically barred from antiretrovirals; so far only Navy aviation allows PrEP. Unpredictable schedules make 3-month follow-ups hard, and PrEP is usually stopped in combat deployments, where Truvada is considered nondeployable.
• Disclosure. The legacy of "Don't Ask, Don't Tell" and reluctance to disclose may explain why so few had a risk score recorded — so the index alone may not be a reliable guide in the military.
• Testing. Fourth-generation HIV tests have greatly reduced missed acute infections, but some providers worried that, without good test access, someone with unrecognized HIV could be put on PrEP instead of treatment.

What's changing

Several sites with infectious disease specialists now let patients self-refer for PrEP, and the Department of Defense is developing new policy to train providers, make PrEP available in primary care everywhere, and standardize pharmacy and lab services at all military treatment facilities.

Limits

Risk scores were rarely recorded; PrEP was unevenly available across the system; and only 38% of providers answered the survey.

Sources

Based on Blaylock JM, Hakre S, Okulicz JF, et al., "HIV Preexposure Prophylaxis in the U.S. Military Services — 2014–2016," MMWR volume 67, number 20, Centers for Disease Control and Prevention; a work of the United States government in the public domain.