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EACS 2023 PrEP Inequities in Europe
Addressing PrEP Inequities Across Central and Eastern Europe: EACS 2023

Released: November 09, 2023

Milosz Parczewski
Milosz Parczewski, MD, PhD
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Key Takeaways
  • PrEP gaps persist across central and eastern Europe, directly affecting patient outcomes and global trends in the HIV epidemic.
  • EACS 2023 featured many real-world examples of how countries in this region can implement PrEP without formal access through their respective national healthcare system.
  • The European AIDS Clinical Society and European Centre for Disease Prevention and Control also are addressing this effort through development of 2 modules on standards of care in HIV testing and PrEP implementation.

Equitably providing pre-exposure prophylaxis (PrEP) as a prevention strategy in HIV remains a key challenge across central and eastern Europe. Admittedly, high levels of stigma persist in this geographic area because of the larger “PrEP gaps” (proportion of access to PrEP vs the expressed need for it) compared with other regions of the world (eg, European Union, United States, and Africa). 

During the 19th European AIDS Conference (EACS 2023) October 18-21 in Warsaw, Poland, the community further emphasized the need to address PrEP access issues in central and eastern Europe, especially because PrEP implementation is low and not always included in national healthcare efforts in many countries in this region. 

Of note, the European AIDS Clinical Society and European Centre for Disease Prevention and Control have come together to create 2 standard-of-care modules currently in development: the first covering HIV testing and the second being related to PrEP. The aim of this effort is to harmonize these 2 key HIV services across Europe using quality standards and auditable indicators. Furthermore, it will help promote equitable access to and successful implementation of PrEP in clinical practice.

Real-world Examples From EACS 2023
EACS 2023 not only featured its standard-of-care modules, but also hosted speakers from central and eastern Europe who shared real-world examples of their efforts in closing PrEP gaps. Several of these examples included implementation strategies from countries that have no formal PrEP access.

One such study featured the successful use of a private practice to informally implement PrEP for those seeking information through alternative channels. This Greek study included 91 patients, with 70 (84.3%) adhering to treatment at 9 months.

Another example comes from Croatia, where a fully reimbursable PrEP service has been available since 2018 for men who have sex with men. It is likely that Croatia is experiencing a 29% decline in the number of new HIV diagnoses from 2018-2023 because this combination PrEP prevention strategy exists.

Fortunately, the formal implementation of PrEP programs continues to be successful in 1 key eastern European country, which has the second-highest HIV incidence in the region: Ukraine. The provision of PrEP services remains a priority even in the face of war, as reported by researchers at EACS 2023. Despite the hardship many Ukrainians have faced since Russia’s invasion began in February 2022, resilience among healthcare professionals has prevailed, and patterns associated with internal migration are visible. For example, researchers saw an increase in people receiving PrEP from 5711 individuals in 2021 to 9075 in 2022. In addition, because of internal migration patterns, western Ukraine experienced the largest increases in PrEP provision (eg, +385% in Lviv and +218% in Ivano-Frankivsk regions). In eastern Ukraine, researchers noted a decrease in PrEP uptake (-51% in Donetsk and -41% in Kherson regions), and engagement with those in need of PrEP continues.

However, PrEP uptake among Ukrainians remains much lower compared with other European countries where system-funded PrEP is available, such as Germany. In a presented study of data comparing Ukraine with Germany from January to December 2021, researchers noted that, in men who have sex with men who sought care at an HIV checkpoint, only 5% were receiving PrEP in Ukraine compared with 96% of the same individuals in Germany. This is despite higher positive screenings for HIV (3% in Ukraine vs 1% in Germany) and diagnoses of syphilis (7% in Ukraine vs 2% in Germany).

As these studies highlight, targeted HIV testing and prevention strategies are critical for the health of war-affected migrants across Europe. In my own study presented at EACS 2023, my team found that 70% of migrants from Ukraine who are now in Poland were diagnosed with HIV late, with 40% having an AIDS-defining condition. Of these individuals, 40% had tuberculosis, and 26% of the newly diagnosed tuberculosis cases were drug resistant.

Although these numbers may be daunting, they show that it is vital to the health of central and eastern Europeans that access to and uptake of PrEP is greatly improved.

Addressing PrEP Inequities Through Standardization
Inequalities relating to PrEP access exist globally—not just in central and eastern Europe. For example, researchers at IDWeek 2023 reported on an analysis of the US Veterans Health Administration, an all-encompassing healthcare system dedicated to the country’s veterans. 

The study found that racial disparities improved among Black and White veterans in the West and Northeast, yet they were especially pronounced in the South (PrEP-to-need ratio: 6 for Black veterans vs 12 for White veterans).

What is the “PrEP to need ratio”?  It is one of several measures used to understand the breadth of PrEP access inequities around the world, and it measures the number of people using PrEP vs the number of new HIV diagnoses in a year. 

The scientific data allow researchers to measure inequities and access issues regarding PrEP, which provides a notable opportunity to inform politicians and national healthcare systems to advocate for government-funded PrEP implementation and a grounded HIV prevention strategy.

Your Thoughts?
Which of the above studies will most affect your clinical practice? See more studies from IDWeek and EACS 2023, and get involved by posting a comment below.