Creating Greater PrEP Access with Large Public Health Goals and Local Service Models

The advent of pre-exposure prophylaxis (PrEP) has been a much needed addition to HIV prevention measures. Although numbers show there has been greater adoption annually, it continues to be underutilized both in the United States and internationally.

According to the US Centers for Disease Control and Prevention, as many as 1.1 million Americans could benefit from PrEP, including 175,000 women and 780,000 people of color.

Yet, statistics on usage remains low compared to the prospective benefactors.

According to AIDSVu, there were only 77,120 PrEP users in the US in 2016. They also found that there was a 73 percent increase year over year in persons using PrEP across the US from 2012 to 2016.

Internationally, both the United Nations (UN) and the World Health Organization (WHO) have identified PrEP adoption as significant, but utilization rates for PrEP are also below targets and expectations.

Back in 2015, the WHO recommended offering once-daily oral PrEP to people at substantial risk of HIV acquisition, and in the following year, the United Nations General Assembly set a global target of 3 million oral pre-exposure prophylaxis (PrEP) users by 2020. ¹

Although the UN 2020 global PrEP target was going to be missed, 180 countries reportedly adopted the WHO PrEP recommendations into national guidelines. And in 2019, there were about 626,000 PrEP users across 77 countries. ¹

Although this seems to be a macro upward trend, much of what works has to do on a very local level between a provider and individuals to uncover the socioeconomic and structural issues that prevent PrEP initiation.

Kimberly Green, PhD, global program director, Primary Health Care, PATH, presented at the recent IAS 2021 conference. Her presentation, titled, Differentiated PrEP Delivery-From Pilots to Pushing Towards the Global PrEP targets, covered both barriers to PrEP access as well as service delivery models. PATH is an international nonprofit public health organization. In her outreach, she tried to understand what providers were doing in terms of delivering PrEP in a simpler way to create better access on a micro level.

As part of her presentation, Green discussed how lowering the threshold to start PrEP could make more people eligible for the therapy. For example, creatinine has been found to increase in some people who take PrEP, so this could remain a barrier to initiation. “In the WHO guidelines that were announced at the conference [IAS 2021], they have made creatinine measurement a whole lot simpler saying it is optional for individuals under the age of 30 who are otherwise healthy,” Green stated. “Steps and actions like that can really make it a lot easier to access PrEP.”

In another potential service model for PrEP, Green discussed the “de-medicalizing” of PrEP, where lay providers—who are not physicians—are able to have discussions with people and play a part in PrEP delivery. She does, however, make the point to say that PrEP utilization can help users get into the health care funnel and connect to primary care services. 

Contagion spoke to Green about her presentation and she offered some insights into strategies for greater access, the limitations COVID-19 placed on PrEP adherence, and other valuable takeaways regarding PrEP access.

References

1. Schafer et al. Adoption of guidelines on and use of oral pre-exposure prophylaxis: a global summary and forecasting study; Lancet HIV 202; Published Online; July 12, 2021 https://doi.org/10.1016/ S2352-3018(21)00127-2