HIV PrEP uptake increases sixfold in 4 years, still falls short of global goals
HIV PrEP uptake has increased sixfold globally in the last 4 years but remains short of the UNAIDS target of 3 million users, according to data reported during the HIV Research for Prevention virtual conference.
Kate Segal, MA, who manages product introduction and access at the nonprofit HIV prevention advocacy group AVAC, and colleagues used data from the AVAC Global PrEP Tracker to assess trends in global and regional PrEP initiation.
Segal said AVAC has maintained the tracker — an open-access database of PrEP programs — since 2014. The tracker “is a tool that can be used to inform ongoing implementation and advocacy efforts,” Segal told Healio.
“AVAC collects and aggregates data into global and country-level snapshots, and for each country, we provide details about the types of ongoing programs, target populations, project geographies, number of initiations, approval status of Truvada and generic PrEP for prevention, and more,” she said. “By tracking these metrics, we have been able to see which countries are scaling PrEP and glean lessons from implementation that can be applied more broadly.”
For their study, Segal and colleagues examined data from the third quarter of 2016 through the fourth quarter of 2020. What they found was that overall, global PrEP uptake increased from 102,446 initiations in 2016 to 928,750 in 2020. However, annual growth slowed over time, from 97% from 2017-2018, to 58% from 2018-2019, to 55% from 2019-2020.
At the regional level, Oceania had a high rate of change, with total PrEP initiations increasing from 318 to 40,280 — an increase largely driven by uptake in Australia, Segal and colleagues said. Sub-Saharan Africa also substantially expanded PrEP access, from 4,154 initiations in 2016 to 517,727 in 2020, comprising 56% of the global total, according to the researchers. That growth was fueled by South Africa and Kenya, with 101,007and 82,886 cumulative initiations, respectively, according to the data.
Segal and colleagues reported that Brazil is leading PrEP uptake in Latin America and the Caribbean, accounting for the vast majority of initiations, while Thailand comprises 43% of initiations in Asia.
Segal said the single biggest action that could increase PrEP uptake globally is to make it widely available and let people know it exists.
“PrEP was introduced to populations deemed high risk, which consequently stigmatized the product ⎼⎼ a stigma programs are now working to mitigate,” she said. “Making it available to the general population ⎼⎼ while simultaneously tailoring outreach to settings and populations with a high HIV burden ⎼⎼ can help to normalize it.”
She said making PrEP available in a variety of service delivery channels would also help to increase access.
“In many places, PrEP is primarily available in health facilities providing HIV services. Expanding delivery models that bring PrEP closer to the user, including via mobile clinics, community-based services, integrated HIV and sexual reproductive health services, youth-friendly services, multi-month dispensing, and mobile health, makes it easier for PrEP users to incorporate it into their lives,” she said. “We have seen a shift toward these models in response to COVID-19. Sustaining them will be important for upholding access.”
The United States had the most cumulative initiations at 203,837 — about one-fifth of the global total, although the country has experienced “comparatively modest growth rates,” Segal and colleagues noted.
Segal said there is a disconnect in the U.S. between the epidemiology of new HIV infections and PrEP access, which she says is underpinned by geographic and racial inequities. Within this context, she said the cost of PrEP services and the complexities of navigating the U.S. health care system are major barriers to access, particularly for communities in which the HIV epidemic is concentrated, including among Black and Latino men who have sex with men and in the South, where more than half of all new HIV diagnoses in the U.S. occur.
Globally, Segal said access and cost are just big pieces of the puzzle ⎼⎼ not the only ones. The reasons why individuals stop using PrEP also need to be addressed. According to Segal, there are many reasons for this, including a change in HIV risk levels, a preference for another prevention method, and stigma. Programs and interventions to support PrEP users who want to continue use are “critical” to addressing these barriers, especially stigma, she said.
“While it’s hard to quantify the impact that stigma has had on PrEP uptake globally, it is undeniable that prevention programs generally — and PrEP programs specifically — struggle with the stigma of taking a pill for HIV prevention every day,” Segal said. “There tends to be a fear of any association with HIV ⎼⎼ whether it’s the rattle of a pill bottle, the color of PrEP pills, or being seen by neighbors in the HIV unit of a clinic ⎼⎼ so users may prefer services and products that are discrete and disguisable. Stigma from providers has also been an issue. For instance, adolescent girls and young women may feel judged by providers, discouraging them from seeking HIV prevention services.”