Global implementation of PrEP for HIV prevention: setting expectations for impact

Abstract

Introduction Questions remain whether HIV pre‐exposure prophylaxis (PrEP) can be translated into a successful public health intervention, leading to a decrease in population‐level HIV incidence. We use examples from HIV treatment and contraceptives to discuss expectations for PrEP uptake, adherence, and persistence and their combined impact on the epidemic. Discussion Targets for PrEP uptake must be based on the local HIV epidemic and will depend on appropriate estimates of the key populations at risk for HIV. However, there is evidence that targets, once established, can successfully be met and that uptake may increase with awareness. Messaging around adherence should include that daily adherence is the goal (except for those MSM for whom event‐driven dosing is a good fit), but perfect adherence should not be a barrier. Ideally, clients persist on PrEP for as long as they are at risk for HIV. While PrEP will be most effective when coverage is focused on high‐risk populations, normalizing rather than stigmatizing PrEP will be highly beneficial. Conclusions While many challenges to PrEP implementation exist, we focused on the three key steps of uptake, adherence and persistence as measurable processes that can lead to improved coverage and decreased HIV incidence.

Youth‐friendly services and a mobile phone application to promote adherence to pre‐exposure prophylaxis among adolescent men who have sex with men and transgender women at‐risk for HIV in Thailand: a randomized control trial

“…TFV‐DP DBS concentrations ≥700 fmol/punch, deemed to be protective from HIV for the preceding 30 days [42] in this study was found in 46% to 52% of participants at both three and six months, similar figures to those seen in US adolescent studies conducted between 2013 and 2014 (30% to 50%) at the same time points [21,35]. An earlier adolescent study in 2010 that saw protective levels of only 20% by six months [43], a trend of improved adherence in newer studies also observed in adult studies, presumed to be due to higher general knowledge in PrEP efficacy and better informed and more motivated study participants in PrEP studies [44,45]. The fact that all aforementioned studies including this study did not see any HIV seroconversions despite imperfect PrEP adherence may have been due to PrEP use being effectively used in an event‐driven fashion during risky events.…”

“…This may be a more appropriate goal to aim for in adolescents where the expectation of perfect adherence may become a barrier for those who would otherwise benefit from PrEP [44,46]. We believe that in this study, a mix of few sex acts, use of alternate HIV protection methods such as condoms and reduced perceived risk of situations driven by incomplete neurocognitive development typical of the adolescence phase of growth contributed to the inconsistent PrEP use seen [44‐45,47]. This emphasises the need to combine PrEP with condoms and other HIV prevention modalities as a package to protect adolescents against HIV.…”

Exploring the Use of Oral Pre-exposure Prophylaxis (PrEP) Among Women from Durban, South Africa as Part of the HIV Prevention Package in a Clinical Trial

“…Several women reported missing doses of PrEP with more than 50% of participants reporting missing ≥ 2 doses over the prior 30 days, implying protection might have been inadequate as at least 6 doses a week are required for adequate protection in non-rectal HIV exposure [ 24 ]. Reasons for missing doses because participants forgot, were busy, and feared or experienced side effects have been documented in other studies [ 25 ].…”

Eliciting Preferences for HIV Prevention Technologies: A Systematic Review

“…Pre-exposure prophylaxis is the newest of the technologies, and the first biomedical intervention for sexual prevention of HIV since condoms. Despite being approved for use in the USA since 2012, uptake has been low, and persistence lower still [ 111 ]. Alternative formulations and modalities of PrEP hold promise for overcoming some of the challenges with PrEP as a daily pill, such as adherence and persistence [ 112 , 113 ].…”