By Ethan Covey
A survey of countries included in the U.S. president’s Emergency Plan for AIDS Relief (PEPFAR) has found far higher rates of preexposure prophylaxis (PrEP) coverage among the general population than in key high-risk groups, such as female sex workers, men who have sex with men (MSM) and transgender women.
A scale-up of PrEP in all population groups at substantial risk, as well as sharing best practices, could contribute to faster HIV epidemic control (MMWR Morb Mortal Wkly Rep 2020;69:212–215).
“After the World Health Organization (WHO) released the guidelines for PrEP scale-up in 2016, CDC wanted to track the progress of PrEP implementation in PEPFAR countries, especially in a subset of early adopter countries,” said Gaston Djomand, MD, a medical epidemiologist with the HIV Prevention Branch, Division of Global HIV/AIDS and TB, CDC’s Center for Global Health. “We wanted to assess how rapidly PrEP could be implemented across the different population groups at risk of HIV infection.”
Among the CDC’s goals were identifying critical factors and actions that could facilitate the scale-up of PrEP implementation, and to share them with PEPFAR countries as best practices for reaching at-risk population groups and preventing infections. As an example, Dr. Djomand said: “Key factors for early scale-up in PEPFAR countries included active engagement by community advocates, governments and other partners; the inclusion of PrEP services in national treatment and prevention guidelines; standardized, routine provider training; and the ability of governments to procure PrEP.”
Epidemiologists analyzed data from 35 PEPFAR-supported country or regional programs over eight quarters: October–December 2016 through July–September 2018. The primary outcome was the number of people, including new enrollees, who received PrEP, disaggregated by key population group.
As of September 2018, PrEP programs had been implemented in only 15 of the PEPFAR-supported countries and regions. In those areas, client volume for PrEP increased by 3,351%. However, the rise in PrEP usage was significantly lower for individuals identified as being in key population groups. Scale-up of PrEP among general-population clients was nearly three times that of key-population clients (5,255% vs. 1,880%). Among key population groups, MSM had the largest increase in PrEP services (3,518%).
Many of the increases were substantial, but the epidemiologists noted that efforts to fill in the existing coverage gaps are needed. “PrEP programs represent a key strategy to prevent HIV acquisition in uninfected populations at continuing risk of HIV,” Dr. Djomand said. “Preventing and treating HIV infections can synergistically achieve global HIV epidemic control.”
Additionally, the report called attention to areas that could benefit from further study.
“The analysis explored the expansion of preexposure prophylaxis in PEPFAR countries, but did not longitudinally assess how long clients were staying on PrEP,” Dr. Djomand noted. “For PrEP to be effective, adherence to medication is crucial as long as individuals are at substantial risk of HIV infection. Furthermore, it is important to see how PrEP is most efficiently delivered in community settings and other settings outside of the clinical platform, and to explore whether barriers to obtaining PrEP medications exist in PEPFAR countries. Lastly, it is important to assess if differentiated service delivery models used for antiretroviral therapy among HIV-positive clients, such as community medication refills, can be applied effectively to PrEP service delivery in PEPFAR countries.”
