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HIV Prevention Cisgender Women
Emerging Choices in HIV PrEP: Bridging HIV Prevention Gaps for Women

Released: January 21, 2025

Expiration: January 20, 2026

Yvonne Gilleece
Yvonne Gilleece, MB, BCh, BAO, FRCP
Sophie Strachan
Sophie Strachan,
Activity Information

Activity

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Key Takeaways
  • The emergence of long-acting injectable PrEP options that are highly effective at preventing HIV across a broad range of populations is an important breakthrough for many women who have not been able to benefit from previously available daily oral PrEP strategies.
  • Future PrEP innovations have the potential to continue to expand choices and opportunities for wider PrEP engagement among women. One example is dual prevention strategies that combine contraception with biomedical HIV prevention.

In this commentary, Sophie Strachan, CEO of the Sophia Forum and Sexual Health Advisor at Chelsea & Westminster Hospital, and Yvonne Gilleece, MB, BCh, BAO, FRCP, discuss how emerging and future PrEP options can serve to address ongoing unmet HIV prevention needs, with a particular focus on how new strategies can benefit women.

Emerging Choices: Long-Acting Injectable Options 

Yvonne Gilleece, MB, BCh, BAO, FRCP:
Hello Sophie. It is nice to have the opportunity to speak with you today about new HIV pre-exposure prophylaxis (PrEP) options currently emerging and what may be coming further down the road. We have had an effective once-daily pill for many years now, yet it continues to be underused by many populations who could benefit from biomedical HIV prevention. So, let’s start by considering the value of choice in HIV prevention and some of the ways it can improve PrEP access and uptake, particularly for women, a group that has demonstrated relatively low engagement with PrEP as compared with men.

Sophie Strachan:
Women have largely been left out of the conversation about PrEP. Early PrEP studies focused more on men who have sex with men, and as you and your colleagues reported in a 2023 review commissioned by Women Against Viruses in Europe, there is a concerning lack of peer-reviewed publications on PrEP among cisgender and transgender women in Europe. Now that we have strong data from the HPTN 084 and PURPOSE 1 studies focused specifically on women and demonstrating outstanding prevention effectiveness of long-acting injectables, there is greater momentum to work on bridging HIV prevention gaps, which will include substantially larger investments in targeted education focused on engaging women in PrEP discussions.

Although we know that from a biological perspective, once-daily emtricitabine (FTC)/tenofovir disoproxil fumarate (TDF) is effective at preventing HIV in women, clinical trials have shown that for a considerable number of women, having to take a daily pill for HIV prevention is not a feasible approach, with lower adherence and thus lower effectiveness.

A similar finding was recently reported in the dPEP study evaluating doxycycline postexposure prophylaxis (DoxyPEP: doxycycline taken within 72 hours after condomless sex) for the prevention of chlamydia, gonorrhea, and syphilis among cisgender women. Despite previous studies demonstrating the efficacy of DoxyPEP among cisgender men and transgender women, in dPEP the intervention was not effective for cisgender women, and this was likely the result of low adherence as shown by hair sample doxycycline testing. 

The reasons for daily pill adherence challenges among women are complex and are not the same for everyone, but one contributing factor is likely the disproportionate caregiving burden shouldered by many women that often results in their own health and personal care becoming a low priority.

Other differences in societal sex and gender architypes create stigma for women when it comes to planning for sex and attending to their sexual health. When this stigma intersects with HIV-related stigma, it can become a substantial barrier in the form of women not feeling comfortable even having a medication for HIV prevention in their home for fear that it will be found. It is notable that in the PURPOSE 1 trial, there were 3 deaths related to violence in the daily oral FTC/tenofovir alafenamide arm, which to me raises speculation about the potential role of HIV-related stigma in those deaths.

The take-home message is that we cannot simply apply the same prevention models for women that we are applying for men. For women, we need to develop a model that understands their unique needs and incorporates the types of support that will enable adherence and efficacy.

Yvonne Gilleece, MB, BCh, BAO, FRCP:
It is certainly true that the first decade or so of PrEP did not provide as much benefit for women as we had hoped. In seeing the remarkably high efficacy of long-acting injectable PrEP options in women, first with cabotegravir and then with lenacapavir, we now have proof of what we knew all along—that the fault was not in the population but in the offered modality. More options increase the opportunity for choice, and choice is essential, especially for women.

Sophie Strachan:
Community-driven research continues to highlight the need for choices in PrEP, not only in how it is administered but in where it is accessed. This is not only true for women, but it includes women. The availability of long-acting injectable options that are administered outside of the home expands options on both fronts.

Yvonne Gilleece, MB, BCh, BAO, FRCP:
The ability to receive PrEP outside of the home also has the potential to improve access for socially vulnerable populations, such as people experiencing partner violence and those with unstable housing. In an analysis of HIV-negative women participating in the Partners PrEP Study of daily oral FTC/TDF among HIV-negative partners in HIV-serodifferent couples, experiencing partner violence in the previous 3 months was associated with increased risk of low adherence.

Sophie Strachan:
Being able to provide safe access to PrEP for these individuals is critically important. We know that people experiencing partner violence are at greater risk for HIV in part because of co-occurring circumstances, and they have substantial barriers to PrEP access. 

Future Choices: Implants, Patches, Multipurpose Prevention Technologies, and More

Yvonne Gilleece, MB, BCh, BAO, FRCP:
In addition to recent breakthroughs with long-acting injectable PrEP, research efforts are continuing into PrEP strategies that could further increase available options and improve access. There is a broad range of approaches being evaluated including long-acting oral drugs, longer-acting injectables, vaginal delivery options, transdermal patches, implantable drug-eluting devices, and multipurpose prevention technologies. Having any of these options become available in the future would bring us closer to being able to provide the best option for each person who would benefit from biomedical HIV prevention.

Sophie Strachan:
When thinking about these approaches specifically in terms of what works for women, having an array of options that includes patches and implants would closely mirror what women currently have available for choosing contraception, which would likely facilitate acceptability.

Yvonne Gilleece, MB, BCh, BAO, FRCP:
Another investigational strategy that could be enormously beneficial to women—and would have the potential to overcome some of the barriers we have been discussing—is a multipurpose prevention technology that combines hormonal contraception and PrEP in a single coformulation, whether that be a daily oral pill or a long-acting delivery system.

Unprotected sex is a risk for both HIV and pregnancy, so if women are having unprotected sex, both prevention types should be discussed: contraception and HIV prevention. If they can be provided as a 2-in-1 solution, it reduces barriers for women. It allows women to receive both in the same setting rather than having to seek a separate venue for HIV preventive care. It provides a simplified 1-stop-shopping approach for both preventive care measures and reduces the stigma that some women experience when having to ask for HIV prevention.

The benefits of this approach are anticipated to go far beyond providing a convenient, additional choice for women because it would also provide increased opportunities for healthcare professionals to discuss HIV prevention alongside reproductive health, thereby bringing HIV prevention discussions fully into reproductive health and family planning settings. This could promote the normalization of HIV prevention and bridge the knowledge/awareness gap around PrEP among women.

Sophie Strachan:
Discussions between patients and healthcare professionals regarding pregnancy prevention have been widely normalized, certainly to a greater extent than discussions of HIV prevention. Having a dual prevention option would theoretically bring HIV prevention into essentially every contraception discussion. It could reduce the question to, “Do you want contraception only or contraception plus, that also includes HIV prevention?”

This could then be followed by a discussion of HIV risk, including the fact that many people do not realize the extent to which they may or may not be at risk for HIV and that sometimes unanticipated risk presents itself without time for prior planning, so having the prevention “on board” takes away the need to plan and regularly assess risk.

Yvonne Gilleece, MB, BCh, BAO, FRCP:
It has been a longstanding view in the HIV prevention field that PrEP conversations should be happening outside of HIV and sexual health settings, including in reproductive healthcare venues such as obstetrics/gynecology departments and abortion clinics. This would also likely increase the frequency of offering HIV testing to women, which is currently not widely offered outside of sexual health clinics, presenting another barrier to PrEP consideration for women.

In many regions of Europe, including the United Kingdom, sexual and reproductive health services are not integrated, and obstetricians and gynecologists are not well versed in PrEP. In the United Kingdom, there are joint sexual health and contraception services, but there are also separate specific contraception services that are reluctant to provide routine HIV testing and PrEP owing to lack of time and lack of experience with PrEP and HIV discussions. These concerns are legitimate and include lack of confidence in the ability to answer client questions. In those settings, Education is needed for healthcare professionals to expand their PrEP knowledge and confidence. Educational programs were effective for increasing HIV testing in antenatal or prenatal services and emergency departments.

Sophie Strachan:
It seems that having a dual prevention product could also go a long way toward reducing the stigma of using HIV PrEP and privacy concerns related to having the medication at home, because it would then just be part of a pregnancy prevention coformulation.

A recent issue that has been coming up in Europe because of multiple ongoing wars and other conflicts in nearby regions is the HIV prevention needs of migrant women, particularly married women for whom potential PrEP needs are very much overlooked.

One example is the case of a migrant woman whose husband or partner will be returning to his home country for several months, during which time she knows there is a high likelihood that he will have had other sexual partners, and she therefore wants to take PrEP for a period after he returns. We often discuss the barrier of women not perceiving themselves at risk for HIV, but in these situations, women are identifying their risk and wanting to take preventive measures.

Yet, even for such motivated women, there are other barriers that can make PrEP access difficult for them, including systemic barriers related to documentation status and stigma associated with HIV. In thinking about the potential of having a dual prevention product available for women in these circumstances, the acceptability of going to a contraception service may be higher than going to a sexual health service.

Yvonne Gilleece, MB, BCh, BAO, FRCP:
We certainly look forward to having an even wider range of PrEP options in the future. Continuing to expand the HIV prevention landscape will provide women with more agency and bodily autonomy both in the choice of formulation (daily pill, long-acting injections, patch, implant, etc) and preferred access location (sexual health clinic, reproductive health service, contraception service, etc). What we have learned is that we cannot simply slot women into existing models of PrEP provision and education that have predominantly served men who have sex with men. Reaching broader segments of the population who could benefit from PrEP will require tailored approaches that can adapt to the unique needs of different people.

Your Thoughts?
How do you think the availability of long-acting injectable options will affect HIV PrEP access and engagement for women? What do you hope to see in future PrEP options that will support access for people who would benefit? Get involved in the discussion by posting a comment below.