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Background HIV pre-exposure prophylaxis (PrEP) is 99% effective at preventing new HIV infections if taken daily. To be successful, PrEP requires concurrent efforts to optimize uptake, persistence, and adherence. In 2018, cisgender (cis) women accounted for 19% of new HIV infections in the US but comprised only 7% of all PrEP users. Studies show poor PrEP adherence amongst cis women, but there is a paucity of real-world clinical data describing PrEP adherence among cis women and gender minority people. Methods An adherence test that measures the concentration of tenofovir in urine samples using a liquid chromatography mass spectrometry (LC-MS/MS) was used to assess recent PrEP adherence at 8 clinics. Urine samples were collected during routine visits and analyzed using the LC-MS/MS assay. Test results were retrospectively paired with gender data, when available, and sex assigned at birth (SAAB) data. Adherence data were aggregated and analyzed to assess non-adherence proportions by sub-population. Results Gender data were available from 1,461 patients at 5 clinics, 1,344 (92%) of whom were cis males (Figure 1). From the 5 clinics where gender and SAAB data were available, 3,835 tests were conducted and 517 (13.5%) indicated non-adherence (Figure 2). 3 additional clinics conduct routine adherence testing and collect SAAB data (gender data not available). At these 8 clinics, SAAB data were available for 2,773 PrEP patients, totaling 5,602 urine tests (Figure 3). Among these 5,602 adherence tests, 813 (14.5%) indicated non-adherence (Figure 4). SAAB females demonstrated significantly higher non-adherence than SAAB males (22% vs 14%, p&amp;lt; 0.001). Across clinics, 89%-98% of PrEP patients are SAAB male (Figure 5). Within these 8 clinics, SAAB female demonstrated consistently higher non-adherence (17%-44%, vs 12%-17% for SAAB males) (Figure 6). Figures 1 and 2 Figures 3 and 4 Figures 5 and 6 Conclusion Real-world data align with nationwide trends in PrEP utilization and show that the majority of PrEP patients are cis men. When initiated on PrEP, cis women exhibit higher rates of non-adherence than cis men. These data underscore the need to collect gender-identity data to monitor PrEP disparities and suggest that greater efforts are needed to target PrEP access, utilization, and accompanying support services to cis women and gender minority groups. Disclosures All Authors: No reported disclosures

979. Disparities in PrEP uptake and adherence among cisgender women using a pharmacologic measure