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. 2019 Aug;22(8):e25370.
doi: 10.1002/jia2.25370.

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

Maria N Pyra  1   2 , Jessica E Haberer  3   4 , Nina Hasen  5 , Jason Reed  6 , Nelly R Mugo  1   7 , Jared M Baeten  1   2   8
Affiliations

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

Maria N Pyra et al. J Int AIDS Soc. 2019 Aug.

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.

Keywords: Adherence; HIV prophylaxis; Implementation; Prevention; Retention; Uptake.

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Figures

Figure 1
Figure 1
Conceptual framework for PrEP impact.
Figure 2
Figure 2
Rapid increase in PrEP persistence among U.S. users, by pharmacy refill Data from 2012 to 2017, a greater proportion of PrEP users were refilling their prescriptions at six months (dotted line). Data courtesy of Gilead Science Inc.
Figure 3
Figure 3
PrEP effectiveness, by study type and population. Compared to placebo populations, HIV incidence (y‐axis) decreases among those taking PrEP whether in clinical studies or open‐label settings, across various at‐risk groups: MSM, PWID, sero‐discordant couples, and women. HIV incidence is lowest when PrEP adherence is high. HR =high risk sero‐discordant couples 71; Demo, demonstration project; OLE, open‐label extension; Practice, Real‐world clinical practice; RCT, randomized controlled trial. Data sources: MSM 4, 19, 72, 73, PWID 23, 74, Serodiscordant Couples 3, 30, Vaginal Rings 1, 21, 75.
See this image and copyright information in PMC

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