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PrEP Promise

CE / CME

PrEP: Fulfilling the Promise of Current and Future Regimens

Nurses: 0.75 Nursing contact hour

Physicians: maximum of 0.75 AMA PRA Category 1 Credit™

Pharmacists: 0.75 contact hour (0.075 CEUs)

Released: November 20, 2023

Expiration: November 19, 2024

Linda-Gail Bekker
Linda-Gail Bekker, MBChB, DTMH, DCH, FCP(SA), PhD
CME/CE Information

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The Full Potential of PrEP Is Not Being Realized

Despite the major advances in treatment and prevention and the global public health investment, the HIV pandemic continues to pose a major global health challenge. Approximately one third of people living with HIV are undiagnosed, not in care, or not receiving effective therapy.18 PrEP is one of the major strategies that we have to improve this continuum of care and prevention.

More than a decade ago, the WHO first recommended the use of oral PrEP as a prevention option for people who are at high risk of HIV infection. By the second quarter of 2023, 4.9 million people had initiated oral PrEP worldwide.19 Despite evidence of impact on incidence in large cities, widespread PrEP uptake continues to lag. Access to PrEP currently remains too low for it to affect the course of the global epidemic.

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PrEP Inequities

Until recently, PrEP use was concentrated in high-income countries. In these settings, socioeconomic and racial and ethnic disparities skew awareness and use of PrEP. Even in countries with widespread PrEP availability, such as the United States, inequalities are apparent in the divergent rates of PrEP uptake along socioeconomic, racial and ethnic, geographic, age, and self-identity lines.20 There was pronounced uptake in some countries in Eastern and Southern Africa, but other regions of low- and middle-income countries have seen insufficient progress in expanding the access and use of PrEP, including Western and Central Africa, Asia, the Pacific, Eastern Europe, and Latin America.19

The most recent CDC data show that, in 2022, 36% of people who could benefit from PrEP in the United States were receiving it, but there are large disparities in uptake by race and ethnicity.21 In 2022, 94% of White people who could benefit from PrEP received it, but only 13% of Black people and 24% of Hispanic or Latino/Latina people who could benefit received it. This is despite the fact that most new infections are now occurring in these populations.

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Barriers to PrEP in the Community

One of the initial causes of the PrEP disparities in the United States was the way in which PrEP was rolled out. Given the high cost of the medication, the quickest access was among people who had insurance, who could afford copays, and who had a physician who was highly motivated to talk about PrEP.  

There are higher proportions of people who are uninsured in the places where HIV prevalence is highest, and these are often people without access to primary care.22,23 For example, in the United States, for people who are either underinsured or who cannot afford copays for medications or doctor visits, it has taken more effort to create other kinds of systems, such as PrEP access programs. Setting up these programs and educating on their availability has slowed widespread PrEP availability over the past 10 years. These inequities are once again in sharp focus, with LA injectable PrEP being of high cost and inaccessible in many settings.

Early marketing—which focused on risk—was ineffective for many communities who either had low perceived risk for HIV or already felt that they were stigmatized based on risk.24 Improved outreach to these communities is needed.

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Approaches to Removing PrEP Barriers

Another barrier is having to show up at a health facility, which is more suited to caring for sick people and providing therapy.25 How we provide PrEP has been a barrier, because some of our service delivery models have been therapeutic and curative in their paradigm and not really suited to healthy individuals who have busy lives to lead.

Other barriers have been awareness about availability. Hence, demand has not been as high as it should be. Healthcare professionals have not always bought fully into the concept of a pre-exposure prophylactic, so we also have to overcome that prejudice.

The goal is to reduce those barriers as much as possible, with simplification, demedicalization, and making sure there are options around service delivery (differentiated services).

It is important that healthcare professionals move out of a therapeutic way of thinking. These are antiretrovirals, but they are being used for prevention. We must shift from the therapeutic paradigm into a preventive paradigm.

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Targeting Key Populations Disproportionately Affected by HIV

The WHO has identified 5 key populations disproportionately affected by HIV—populations for whom they have provided guidance on targeted HIV prevention and treatment implementation strategies.26 These key populations are men who have sex with men, people who use and inject drugs, people in prisons, sex workers, and transgender people. Young people in each group are particularly at risk of HIV acquisition, and in Africa, young women and girls carry the burden of acquisition risk.

Although PrEP is not meant to be a lifelong prevention strategy, high adherence (daily use or adherence to the 2-1-1 strategy) is needed during periods of potential HIV exposure when an individual is at risk of HIV. This can be challenging to achieve, especially among the young and most vulnerable. To fully realize its benefits, individuals need to not only initiate PrEP, but also continue to take PrEP during periods they are at risk.

For instance, a study conducted in Latin America, ImPrEP, enrolled more than 9000 individuals who initiated PrEP. An important clinical outcome evaluated in this study was persistence: 8% of people who received the first dispensation never came back.27

Adherence was evaluated based on the medication possession rate. Individuals who were younger, who were transgender, and who had a lower education level had a lower medication possession rate, implying lower effective use. Longer-term engagement in care also was reported at 70%, but the younger, less-educated, poor, transgender women had the least long-course engagement in care.27 Targeted support is needed for these populations to facilitate PrEP persistence.

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Barriers to PrEP Persistence

In multiple studies, reasons for stopping or never initiating PrEP include low self-perceived risk, concerns about medication adverse events, a desire not to take a daily pill, stigma, violence, mental health, or competing life events.23,28-36 Many of the same barriers to uptake are also important to consider for effective use and persistence on PrEP.

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Interventions to Support PrEP Persistence

To overcome barriers to both uptake and persistence on PrEP, interventions should consider PrEP regimen options, modalities, and delivery methods and provide targeted support of the individual receiving PrEP.37-40

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