Adoption of guidelines on and use of oral pre-exposure prophylaxis: a global summary and forecasting study

Abstract

Background: In 2016, the UN General Assembly set a global target of 3 million oral pre-exposure prophylaxis (PrEP) users by 2020. With this target at an end, we aimed to assess global trends in the adoption of WHO PrEP recommendations into national guidelines and numbers of PrEP users, defined as people who received oral PrEP at least once in a given year, and to estimate future trajectories of PrEP use.

Methods: In this global summary and forecasting study, data on adoption of WHO PrEP recommendations and numbers of PrEP users were obtained through the Global AIDS Monitoring system and WHO regional offices. Trends in these indicators for 2016-19 by region and for 2019 by country were described, including by gender and priority populations where data were available. PrEP user numbers were forecasted until 2023 by selecting countries with at least 3 years of PrEP user data as example countries in each region to represent possible future PrEP user trajectories. PrEP user growth rates observed in example countries were applied to countries in corresponding regions under different scenarios, including a COVID-19 disruption scenario with static global PrEP use in 2020.

Findings: By the end of 2019, 120 (67%) of 180 countries with data had adopted the WHO PrEP recommendations into national guidelines (23 in 2019 and 30 in 2018). In 2019, there were about 626 000 PrEP users across 77 countries, including 260 000 (41·6%) in the region of the Americas and 213 000 (34·0%) in the African region; this is a 69% increase from about 370 000 PrEP users across 66 countries in 2018. Without COVID-19 disruptions, 0·9-1·1 million global PrEP users were projected by the end of 2020 and 2·4-5·3 million are projected by the end of 2023. If COVID-19 disruptions resulted in no PrEP user growth in 2020, the projected number of PrEP users in 2023 is 2·1-3·0 million.

Interpretation: Widespread adoption of WHO PrEP recommendations coincided with a global increase in PrEP use. Although the 2020 global PrEP target will be missed, strong future growth in PrEP use is possible. New PrEP products could expand the PrEP user base, and, with greater expansion of oral PrEP, further adoption of WHO PrEP recommendations, and simplified delivery, PrEP could contribute to ending AIDS by 2030.

Funding: Unitaid, Bill & Melinda Gates Foundation, and WHO.

Figure 1

Adoption of the WHO recommendations on oral PrEP into national guidelines globally by 2019 Pending adoption was defined as plans to adopt the recommendation in the next 2 calendar years. Estimates were based on data from the Global AIDS Monitoring system and reporting to WHO. See the appendix (pp 1–7) for details on data. PrEP=pre-exposure prophylaxis.

Figure 2

Numbers of countries that have adopted the WHO recommendations on oral PrEP into national guidelines per year by WHO region The figure includes countries that are yet to implement these guidelines. Pending adoption was defined as plans to adopt the recommendation in the next 2 calendar years. Estimates were based on the Global AIDS Monitoring system and reporting to WHO. See the appendix (pp 1–7) for details on data. Regions refer to WHO regional offices. AFRO=African region. EMRO=Eastern Mediterranean region. EURO=European region. PAHO=region of the Americas. PrEP=pre-exposure prophylaxis. SEARO=South-East Asia region. WPRO=Western Pacific region.

Figure 3

Numbers of people who have received oral PrEP at least once (PrEP users) globally in 2019 Estimates were based on data from the Global AIDS Monitoring system and reporting to WHO. See the appendix (pp 1–7) for details on data. PrEP=pre-exposure prophylaxis.

Figure 4

Numbers of people who received oral PrEP at least once (PrEP users) per year by WHO region Data for 2012–15 were added for illustration of longer-term trends and were taken from Sullivan and colleagues, which were limited to the USA. Estimates for 2016–19 were based on the Global AIDS Monitoring system and reporting to WHO. See the appendix (pp 1–7) for details on data. Regions refer to WHO regional offices. AFRO=African region. EMRO=Eastern Mediterranean region. EURO=European region. PAHO=region of the Americas. PrEP=pre-exposure prophylaxis. SEARO=South-East Asia region. WPRO=Western Pacific region.

Figure 5

Forecasted global numbers of PrEP users per year until 2023 PrEP users were defined as people who have received oral PrEP at least once. (A) Without COVID-19 disruptions, projections based on three observed example trajectories for each region applied to all countries in the region; lower growth was based on the example trajectories with 25% lower growth at each time step; countries that had adopted the WHO PrEP recommendations or were pending the adoption were assumed to introduce PrEP services in 2020; in the linear growth scenario, the same number of PrEP users was added to each country as observed between the past 2 years of data availability and no country was assumed to introduce PrEP services. (B) Forecasted PrEP users by WHO region without assumed COVID-19 disruptions in 2023; vertical lines represent the average growth scenarios (upper limit) and 25%-reduced growth scenarios (lower limit); diamonds represent 2019 PrEP user numbers. (C) The modelled COVID-19 disruption scenario assumed no growth in 2020 and PrEP seeding in countries was postponed until 2021. After the disruption, growth in PrEP users was modelled with the same trajectories as without COVID-19 disruptions. AFRO=African region. EMRO=Eastern Mediterranean region. EURO=European region. PAHO=region of the Americas. PrEP=pre-exposure prophylaxis. SEARO=South-East Asia region. WPRO=Western Pacific region.