HIV pre-exposure prophylaxis (PrEP) has great potential to reduce HIV incidence among young black men who have sex with men (YBMSM) but initiation and persistence for this group remain low. We sought to understand the patterns and predictors of PrEP uptake and discontinuation among YBMSM in Atlanta, Georgia.

PrEP was offered to all participants in a prospective cohort of HIV-negative YBMSM aged 18-29. For initiators, time on and off PrEP was recorded. Time to PrEP uptake, first discontinuation, and final discontinuation were assessed with the Kaplan-Meier method, with Cox proportional hazard models used to identify factors associated with uptake and discontinuation.

After 440 person-years of follow-up, 44% of YBMSM initiated PrEP through the study after a median of 122 days (IQR 44-275). Of PrEP initiators, 69% had a first discontinuation and 40% had a final discontinuation during the study period. The median time to first PrEP discontinuation was 159 days (IQR 97-237). Factors associated with PrEP uptake included higher self-efficacy, sexually transmitted infection, and condomless anal intercourse. Factors associated with discontinuation included younger age, cannabis use, STI, and fewer sex partners. HIV incidence was 5.23/100 person-years (95% CI 3.40-7.23) with lower rate among those who started PrEP (incidence rate ratio 0.39 [95% CI 0.16-0.92]).

Persistent PrEP coverage in this cohort of YBMSM was suboptimal and discontinuations common despite additional support services available through the study. Interventions to support PrEP uptake and persistence, especially for younger and substance-using YBMSM, will be necessary to achieve full PrEP effectiveness.