Disparities in PrEP use and unmet need across PEPFAR-supported programs: doubling down on prevention to put people first and end AIDS as a public health threat by 2030

Abstract

Background: In 2023, an estimated 1.3 million people newly acquired HIV. In the same year, 3.5 million individuals received pre-exposure prophylaxis (PrEP), falling short of the UNAIDS target of 21.2 million by 2025. With over 90% of global PrEP programming supported by PEPFAR, a better understanding of disparities in PrEP provision is needed to inform PEPFAR's approach to reach and deliver prevention services and achieve UNAIDS 95-95-95 goals in all populations by 2025. The objective of this paper is to assess unmet PrEP need in PEPFAR-supported countries.

Methods: We analyzed FY2023 Monitoring, Evaluation, and Reporting (MER) results from 48 PEPFAR-supported countries to calculate PrEP-to-need ratios (PnR) by geography and population. PnR offers an ecological measure to identify disparities and missed opportunities for PrEP programming. PnR was calculated as the ratio of PrEP users to the number of positive HIV tests. PrEP users are defined through new initiations (PrEP_NEW) and re-initiations or continuation (PrEP_CT). HTS_TST_POS measures the number of positive HIV tests and was used as a proxy for new diagnoses. PnR was also calculated using Naomi-estimated 2023 HIV incidence, where available. A higher PnR indicates more PrEP users relative to PrEP need in a population.

Results: In FY23, 1,760,888 people initiated PrEP, and 1,736,144 people tested positive for HIV. PnR ranged from 0.12 (India) to 6.46 (Brazil), and 19 (40%) countries had fewer PrEP users than positive HIV tests (PnR <1.0). By population, people 15-24 years old, people who inject drugs, and transgender populations had the highest median PnR. When examining estimated HIV incidence, Mozambique and South Africa reported lower than average PnR and higher than average HIV incidence.

Conclusion: PrEP use relative to population need varied greatly by country and subpopulation across PEPFAR programs, suggesting a need for greater advocacy, inclusivity, accessibility, and integrated prevention programming. PnR may be a useful indicator of population PrEP coverage and unmet need, and can inform effective, data-driven, and person-centered PEPFAR prevention programming and policies. Tailoring PrEP scale-up strategies by age, sex, key population, and geography is crucial to achieving UNAIDS targets and ending the AIDS epidemic as a public health threat for all by 2030.

Keywords: AGYW; HIV; HIV prevention; PEPFAR; PrEP; PrEP-to-need ratio; key populations.

Figure 1

PrEP-to-need ratio (PnR) in PEPFAR-supported countries in FY23. *PnR not calculated due to incomplete PrEP and/or HTS data. Refer to Supplemental Table S1 for all PnR estimates and details on data availability.

Figure 2

Distribution of MER PrEP-to-need ratio (PnR) in PEPFAR-supported countries by sex and age in FY23.

Figure 3

Distribution of MER PrEP-to-need ratio (PnR) by key population in FY23. Outliers beyond the upper and lower limit were removed from this visualization for ease of interpretation across key populations, through the data is included in the box plots. Refer to Supplemental Table S1 for all PnR estimates, including outliers. FSW, female sex workers; MSM, men who have sex with men; PWID, people who inject drugs; TG, transgender.

Figure 4

Relationship between HIV incidence and MER PrEP-to-need ratio (PnR) in select PEPFAR-supported countries in FY23. Data is limited to countries with available HIV incidence from the Naomi model. BEN, Benin; BWA, Botswana; BFA, Burkina Faso; BDI, Burundi; CMR, Cameroon; CIV, Cote d'Ivoire; COD, Democratic Republic of Congo; SWZ, Eswatini; ETH, Ethiopia; GHA, Ghana; HTI, Haiti; KEN, Kenya; LSO, Lesotho; LBR, Liberia; MWI, Malawi; MLI, Mali; MOZ, Mozambique; NAM, Namibia; RWA, Rwanda; SEN, Senegal; SLE, Sierra Leone; ZAF, South Africa; TGO, Togo; TZA, United Republic of Tanzania; UGA, Uganda; ZMB, Zambia; ZWE, Zimbabwe.