Our study indicates the uptake of AZD7442 among eligible individuals in Israel was relatively low at ~ 15%. This is consistent with previous reports from the two largest Israeli HMOs, CHS and Maccabi HealthCare Services (MHS; second largest HMO in Israel), where AZD7442 uptake ranged from 9 to 16% over a similar time frame [20, 21]. The distribution of AZD7442 to all CHS districts was based on demand, and low uptake was not due to a shortage of supply. It is possible that the structure and organization of HMOs within Israel may have influenced the uptake of AZD7442. Within CHS, AZD7442 administration was managed by the community division, with eligible individuals offered AZD7442 PreP via their primary care clinics. Although eligible individuals were closely managed in the outpatient clinics of general hospitals, the IMoH had not delineated the role of hospitals in the administration of AZD7442. Additionally, only a few hospitals participated in a patient outreach effort by the CHS community division. These factors may explain the relatively low rates of AZD7442 administration to eligible individuals.

Uptake varied widely across different populations, consistent with previous studies using the CHS and MHS databases [10, 21]. High uptake in individuals with comorbidities, increased physician visits at baseline and high numbers of dispensed prescriptions suggest that AZD7442 was administered to more frail individuals. Uptake was also high in individuals who were vaccinated with ≥ 3 doses of the COVID-19 vaccine and previously hospitalized with COVID-19, which may indicate that those perceived to be at higher risk of severe COVID-19 were more likely to receive PrEP.

Sociodemographics revealed AZD7442 uptake was higher in males versus females, and lower in ultra-orthodox Jewish than Arab individuals, with uptake highest in the rest of the population. This is contrary to previous reports where AZD7442 uptake was higher in ultra-Orthodox Jewish individuals [10, 11]. Reports on non-COVID-19 vaccine uptake among children show Arab individuals are more likely to be vaccinated than ultra-orthodox Jewish individuals, although at a lower rate in both than the rest of the population, a trend also observed with COVID-19 vaccine uptake [22,23,24].

Across immunocompromising conditions, AZD7442 uptake was highest (41%) among individuals with lung transplants and lowest among individuals with lymphoma (8%), despite lymphoma being the most common IC type among the eligible population. Lower uptake of AZD7442 among individuals with lymphoma than in those with other immunocompromising conditions has been observed in another study in Israel; the reasons for this lower uptake are unclear and should be elucidated in future investigations [21]. In Israel, lung transplant recipients are almost exclusively managed in one CHS hospital, which may explain the high AZD7442 uptake among this population as these individuals were managed by the same healthcare team. Although previous studies did not report lung transplants specifically, the trend in uptake in overall SOT recipients presented here aligns with these studies [10, 21].

The results presented here highlight the low uptake of AZD7742 in eligible IC individuals, especially in certain subgroups. Understanding the factors underlying these lower-than-expected uptake rates may help inform future non-vaccine PrEP rollout strategies. This study also suggests improving the alignment between the CHS community division and the hospital clinics in managing AZD7442 distribution to eligible individuals. This may allow greater uptake, which could have implications for HMOs other than CHS, as well as for those beyond Israel.

Strengths include that this study was undertaken using a database from the largest HMO in Israel, representing > 50% of the population. This database is complete and includes a large number of individuals with immunocompromising conditions, and the results reported here align with a previous study in the second largest HMO. We therefore believe these results are a close reflection of the overall population.

Limitations of the study include that accuracy of results is dependent on the availability and accuracy of information entered into EHRs. We report only descriptive analyses, limiting conclusions on whether specific baseline factors are independently associated with AZD7442 update; further statistical analysis would be needed to investigate this.