By Jonna Lorenz
Global use of pre-exposure prophylaxis for HIV has increased as more countries have adopted the World Health Organization's recommendations.
Adoption of the World Health Organization (WHO) recommendations for pre-exposure prophylaxis for HIV was associated with a global increase in PrEP use, but did not meet targets, a new study found.
The global summary and forecast study, published in The Lancet HIV , analyzed data on the adoption of the WHO PrEP recommendation and the number of PrEP users from 2016 to 2019 and forecasted the number of PrEP users through 2023.
“Since 2015, when the WHO recommended offering oral PrEP to anyone at substantial risk of HIV infection as part of combination prevention, global use has increased markedly,” Robin Schaefer, PhD, a consultant for the World Health Organization’s global HIV, hepatitis, and STI programs, told Contagion . “A considerable number of PrEP users can be found around the world, and this increase in use coincided with the widespread adoption of WHO recommendations in national guidelines. Our research suggests a considerable increase in PrEP use in the coming years.”
The study found that there were 626,000 PrEP users in 77 countries in 2019, after two-thirds of the countries (120) had adopted the WHO recommendations in their national guidelines. This was a 69% increase from the 370,000 PrEP users in 66 countries in 2018, when 30 countries had adopted the recommendations but fell short of the target of 3 million oral PrEP users by 2020 set by the UN General Assembly in 2016. The study projected 900,000 to 1.1 million PrEP users worldwide by the end of 2020 and 2.4 million to 5.3 million PrEP users by the end of 2023.
“Our analysis suggests strong future growth in PrEP use, with a four- to eight-fold increase in the number of PrEP users in 2023 compared to 2019,” said Schaefer. “Preliminary data for 2020 suggest that significant growth in PrEP use continued despite disruptions caused by COVID-19 in many settings. Therefore, these future scenarios may not be unrealistic, particularly in light of the availability of new PrEP products.”
In 2019, more countries had adopted the WHO's PrEP recommendations (120) than the number of countries reporting PrEP users (77). The study authors noted that PrEP implementation is facilitated by the development of operational guidelines and protocols, provider training, supply chains, monitoring and evaluation systems, and demand creation. The cost of PrEP could be a barrier to implementation for some.
“Oral PrEP is safe and highly effective at preventing HIV when taken as prescribed,” Schaefer said. “There are now hundreds of thousands of PrEP users worldwide, and PrEP can make substantial contributions to the UN declaration to end AIDS as a public health threat by 2030. PrEP should be offered free of charge to anyone at substantial risk of HIV infection, without discrimination or stigma, and all individuals who request PrEP should be considered for initiation.”
New PrEP products and formulations could contribute to the future growth of PrEP use, along with global investments such as the U.S. Presidents' Plan for AIDS Relief, the Global Fund to Fight AIDS, Tuberculosis and Malaria, national governments, and private organizations.
“The COVID-19 pandemic has accelerated trends toward demedicalized, simplified, and differentiated PrEP services, which could further remove barriers to PrEP uptake and use,” said Schaefer. “WHO is working on revised implementation guidance for oral PrEP. Earlier this year, WHO recommended the dapivirine vaginal ring as an additional PrEP option for cisgender women, and WHO is preparing for future recommendations on other PrEP products, such as long-acting injectable cabotegravir. These PrEP products are likely to increase PrEP use by providing users with more options.”
The study was funded by Unitaid, the Bill & Melinda Gates Foundation, and the WHO.
Efforts are underway to increase PrEP uptake. Up to 1.1 million Americans could benefit from PrEP, according to the U.S. Centers for Disease Control and Prevention. Kimberly Green, PhD, director of the global program, Primary Health Care, at PATH, recently spoke with Contagion about the barriers to PrEP access and strategies for greater access covered in her presentation at the recent IAS 2021 conference.
Boosting adherence has also been a focus for healthcare providers. A recent study in Africa found that PrEP initiation among women was high, but adherence declined over time.