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Unmet Needs
Doing Better: Unmet Needs in HIV Prevention and Treatment

Released: October 18, 2024

Expiration: October 17, 2025

Yvonne Gilleece
Yvonne Gilleece, MB, BCh, BAO, FRCP
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Key Takeaways
  • There is much that can be done within the clinic to help reduce the impact of many overarching impediments to HIV prevention access, beginning with developing a deeper understanding of how these forces affect individuals in need of HIV prevention services and seeking the insights of those individuals on how we can do better.

Keeping the Promise of PrEP
Despite more than a decade of having a daily oral pill that is highly effective at preventing HIV with strong adherence and, more recently, the emergence of a long-acting injectable option for HIV prevention, we still face more than 1 million new HIV acquisitions worldwide each year and relatively limited uptake of these powerful prophylactic strategies among people at elevated risk of exposure to HIV.

According to the AIDS Vaccine Advocacy Coalition’s global pre-exposure prophylaxis (PrEP) tracker, approximately 7.5 million people had started PrEP by the third quarter of 2024, which is well below the 2025 UNAIDS target of 21.2 million people. In Europe, access to PrEP varies substantially, depending on whether there is a national reimbursement scheme or whether individuals have to buy PrEP agents via national or overseas pharmacies.

Common challenges across most countries include limited access to PrEP services, few community-based PrEP services, lack of national awareness campaigns, and inequitable access across different subgroups, which can have a substantial impact on racial/ethnic minority populations and transgender individuals.

As healthcare professionals (HCPs), we cannot fully ameliorate the barriers resulting from systemic societal and governmental influences. However, there is much that can be done within the clinic to help reduce the impact of many overarching impediments to HIV prevention access, beginning with developing a deeper understanding of how these forces affect individuals in need of HIV prevention services and seeking the insights of those individuals on how we can do better.

More Options, More Choice
Increasing PrEP availability and use includes expanding the number and types of options available to fit a broader range of lifestyle needs and to overcome adherence challenges that differ for different people. The first PrEP option to become available was a daily oral pill, which has demonstrated high efficacy among men who have sex with men. As a result, that is the group for which daily oral PrEP has gained the most traction.

A considerable shortcoming with daily oral PrEP options has been the finding that, although FTC/TDF is highly effective at preventing HIV in cisgender women when used with high adherence (which demonstrates that it is pharmacokinetically effective), the actual prevention effect in this group has been lower across multiple studies owing to generally poor adherence for multiple reasons including risk of discovery and domestic violence.

Thankfully, clinical trials with new and emerging as well as investigational long-acting injectable options, such as every-2-months cabotegravir and every-6-months lenacapavir, have shown remarkably high efficacy across populations, including men who have sex with men, transgender women, and cisgender heterosexual women. These options hold the promise of overcoming the adherence challenges of daily oral PrEP for anyone who can better incorporate a long-acting option into their lives.

Treating People With HIV, Not Just HIV
For individuals already living with HIV, there are many effective, well tolerated therapies allowing a highly individualized treatment approach that fully suppresses the virus while also giving high quality of life This means identifying the regimen that fits best with an individual’s overall lifestyle and holistic care needs.

Even when a person initiates an HIV regimen that works extremely well for them, it is important to recognize that their needs can change over time. The regimen that was a perfect fit when they started treatment may no longer be the best option as their lives evolve, particularly over the decades of lifelong HIV therapy. The plethora of available safe and effective options allows for modification of treatment when needed, through the same carefully considered, shared decision-making approach that should be used for initial antiretroviral therapy (ART) selection. Yet only 77% of all people living with HIV in 2023 were accessing treatment, highlighting the need for the healthcare field to improve on meeting individualized HIV treatment needs, both with the arsenal of medications we already have and through the appropriate use of continuously emerging options to fit critical gaps.

The success of ART in achieving the ultimate goal of the HIV care continuum, namely sustained viral suppression, is dependent upon many factors that influence whether each person living with HIV is able to continue taking the medication consistently and attending regular clinic follow-up visits—factors that certainly include characteristics of the regimen itself but also go beyond the medication and include structural barriers such as socioeconomic challenges; psychosocial issues, HIV-related stigma and fear of disclosure; and the success of the relationship between each person living with HIV and their HCP.

As noted for PrEP, there are many strategies that HCPs can implement in their clinical practice to learn which of these barriers may be affecting their people’s abilities to engage with HIV care and to then reduce the impact of those challenges. This is how we can ensure that each person living with HIV receives a regimen that is as effective and easy to take as possible, for the long term.

Keeping Up, Learning More
Both HIV prevention and treatment strategies continue to introduce a wider array of options, and newer data on current options continue to provide further insights on long-term safety, efficacy, and patient preferences. HCPs can best serve those in their care by staying informed of these new developments and by engaging with experts for perspectives on how these data may improve overall care.

To learn more about best practices for achieving these goals, please join me and my colleagues, Dinah Bons; Justyna Kowalska, MD, PhD; Angelina Namiba; Jürgen Rockstroh, MD; and Sophie Strachan, for a live EBAC/AMA-certified symposium on November 11 at the 2024 HIV Glasgow meeting. With perspectives from advocates and experts, we will discuss how to overcome obstacles to PrEP uptake in key populations, how emerging options may help more people benefit from an individualized PrEP option that works in their lives, and how to optimize the use of antiretroviral agents at multiple stages of the care continuum. Click here to register to join us in person or online.