Europe's PrEP Gap: Half a Million MSM Who Need It Can't Access

An estimated 500,000 men who have sex with men (MSM) in Europe and Central Asia who report they would be “very likely” to initiate pre-exposure prophylaxis (PrEP) if possible do not have access to it, a new study shows. Sex between men is the predominant mode of HIV transmission in Western and Central Europe when the transmission route is known, accounting for half of new HIV diagnoses.

The study in Eurosurveillance included data from 53 countries surveyed by the European Centre for Disease Prevention and Control (ECDC) and the Joint United Nations Programme on HIV/AIDS (UNAIDS). Using the European MSM Internet Survey (EMIS-2017), authors examined data on self-reported PrEP use and expressed need for PrEP. EMIS-2017 was conducted in 33 languages and included 127,000 MSM from 47 countries.

Investigators from the National AIDS Trust, the London School of Hygiene and Tropical Medicine, Public Health England, and ECDC analyzed the availability of PrEP in various countries before establishing the PrEP access gap. The research team found that PrEP availability has expanded since 2016, when only France reported that PrEP was nationally available and reimbursed. A total of 14 countries studied provide and reimburse PrEP within their national health systems.

This left nearly 40 countries reporting that PrEP was not nationally available and/or reimbursed. Thirty-two of those countries provided data on barriers to implementation. The most common barrier cited was the cost of the drug. Twenty-four countries reported high drug costs, with 15 of them stating that cost was a high-importance barrier and 7 citing it as a medium-importance barrier. Concerns about the impact of PrEP on sexual behaviors were raised in 18 countries surveyed.

The level of unmet need for PrEP was then estimated using EMIS-2017 data. The PrEP gap was defined by the difference between the proportion of respondents currently using PrEP and those who would be “very likely” to use PrEP if they could access it. Authors noted that willingness of MSM to use PrEP has a positive correlation with risk of acquiring HIV sexually, making respondents who answered “very likely” who did not have access likely a particularly at-risk group.

The estimated PrEP gap ranged from 4.3% in Portugal to 44.8% in Russia. The countries with PrEP gaps close to that of Russia, such as Turkey or Belarus, were concentrated in Eastern Europe or Central Asia. The overall EU PrEP gap was calculated as 17.4%. Authors used the assumption that 2.77% of the adult male population in the EU are MSM and applied an adjustment factor of 1.6 to counter for self-selection bias in order to produce the estimate of 500,000 MSM not currently using PrEP but likely to do so.

Study authors stated that they “assume that the fundamental reason for this gap is that in the majority of countries, easy access to free or subsidized PrEP is either not possible or not easy…in the countries where formal PrEP provision occurs, the gap was smaller and in countries where there is no formal access, it was larger.”

To keep pace with the United Nations (UN) Sustainable Development Goal of ending the AIDS epidemic by 2030, global access to PrEP would have to be expanded. The UN has recommended as one of its global targets that 3 million people access PrEP by 2020.