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Novel PrEP in Europe
Novel PrEP Modalities in Europe and Potential Barriers: Insights from HIVR4P 2024

Released: November 05, 2024

Expiration: November 04, 2025

Cristina Mussini
Cristina Mussini, MD
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Key Takeaways
  • In Europe, novel pre-exposure prophylaxis (PrEP) modalities presented at HIVR4P have the potential to reach underrepresented populations, namely women, who are not widely included in PrEP messaging and education.
  • HIVR4P also included key presentations identifying barriers and facilitators of PrEP, suggesting that improved PrEP implementation in Europe will require involvement of people from groups who are being targeted for PrEP, as well as support from healthcare professionals.

Research findings related to new pre-exposure prophylaxis (PrEP) therapies, as well as potential barriers and facilitators of their implementation, were recently discussed at HIVR4P in Lima, Peru. Below, I discuss some of these studies and their implications in Europe. 

Novel PrEP Modalities
One important study discussed was the open-label, randomized, crossover phase I IPM-054 study on the dapivirine vaginal ring (DVR). The DVR should be changed each month, and historically, in women, adherence rates to PrEP have not been high, regardless of whether the PrEP is in the form of a daily pill or monthly ring. The development of a vaginal ring that lasts 3 months should help with adherence. It also creates less pollution than the monthly DVR.

At HIVR4P, this study showed that the 3-month DVR was pharmacokinetically superior to the 1-month DVR, which is very reassuring. I believe this new method is very important, particularly in Europe, because it is challenging to get women to enroll in PrEP. Women do not perceive themselves to be at risk for HIV. In my practice in Italy, I find that most women who initiate PrEP do so because they have partners with HIV. These women see PrEP as needed only if they are engaging in certain risk behaviors, rather than seeing it as preventative healthcare that should be considered for everyone. I believe that implementing a 3-month form of PrEP that targets women could be very important for increasing PrEP uptake, especially as the messaging on PrEP in Europe is generally very male-biased.

PrEP Barriers and Facilitators
It can be challenging to motivate people to use long-acting PrEP in the clinical setting. In the PILLAR study, investigators found that having peer support and enthusiastic staff made a difference. The same is true in my clinic. Having someone who can be an enthusiastic supporter of the injection—whether it be a doctor, pharmacist, or nurse—can greatly help with adherence.

In this study, the current standard of care approach to PrEP was compared with an approach using motivational tools, and the results were much improved with motivational tools. It is very common for such organizations to be understaffed, and many patients have a fear of pain from the injection. Therefore, having someone present who could motivate these patients is really important. This study could have important ramifications on how PrEP is administered in Europe, because it identifies actionable barriers to PrEP and provides clear ways in which clinics can help support patients and facilitate PrEP implementation.  

Factors Affecting PrEP
Another study in an Italian cohort of more than 1700 PrEP users assessed PrEP efficacy, adherence, and discontinuation. In this observational study, the objective was to understand the rate of seroconversion, which was actually low. Only 6 seroconversions were observed, much lower than that noted in randomized clinical trial control arms in high-risk populations.

The factors found to influence adherence or discontinuation were mostly related to the use of chemsex, which was used by 19% of participants. This suggests that if chemsex is used, PrEP is not adhered to, individuals engage in risky behaviors, and the risk of HIV acquisition increases.

By contrast, a high education level and age older than 40 years seemed to protect from discontinuation and poor adherence. This study also suggests that cost is a barrier to PrEP persistence, as access to free drug supplies was associated with a lower risk of discontinuation. I think what is useful here is that the factors that can lead to poor adherence need to be understood. 

Involving Our Stakeholders
The last study I want to discuss, HPTN 091 (the I Am study), took place in Brazil and in the United States, but I think it has important implications in Europe and across the world.

It examined the implementation of immediate vs deferred colocation of gender-affirming hormone therapy with peer health navigation for PrEP in transgender women. This study showed that, regardless of immediate or deferred colocation of GAHT services, all participants were highly engaged in PrEP.

To me, the important message from the study was how it was redesigned thanks to the involvement of the target group it was meant to help. It was originally designed as a comparison of the intervention (combining PrEP with peer health navigation and gender-affirming hormone therapy) vs standard of care (PrEP alone). But with meaningful community involvement, it was redesigned to include access to peer health navigation and gender-affirming hormone therapy for all participants. The investigators believe that, by involving the community in the study design, enrollment and retention in the study was increased. 

Your Thoughts?
What do you find to be the greatest barrier to PrEP implementation and adherence? Get involved in the discussion by posting a comment below.