Scaling Up HIV Prevention Pills: What PEPFAR's Early PrEP Adopters Did Right

Taken daily, preexposure prophylaxis (PrEP) reduces the risk of getting HIV. By 2018, key populations — female sex workers, men who have sex with men (MSM) and transgender women — and their partners accounted for an estimated 54 percent of new HIV infections worldwide. So the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), the largest bilateral funder of HIV programs, set out to put PrEP in their hands. Two years of data from 35 PEPFAR-supported country and regional programs show where it worked, and why.

The growth

Growth among the general population was nearly three times that among key populations. Even so, key populations made up 29–56 percent of all PrEP initiations — a notable success, since they are a small share of the population, and achieved even without laws protecting them when they seek HIV services.

The early adopters

Six programs — the Asia Region, Kenya, South Africa, Uganda, Vietnam and Zimbabwe — qualified as early adopters for key populations (more than 150 new key-population clients a quarter, totaling at least 1,000). Five identified what made them succeed:

• national, regional and international stakeholder meetings;
• engaged ministries of health and community advocates;
• HIV treatment guidelines revised to include PrEP;
• training for HIV service providers;
• drug procurement policies.

What sped growth further was government ownership — writing policies and guidelines, adapting training, accrediting sites, reporting data — and taking PrEP beyond the clinic: to drop-in centers and safe spaces, social media, sex clubs and gay bars, and peer outreach in the community.

What comes next

As of October 2018, only 13 of the 35 programs offered PrEP to key populations. Advocacy could push others to write national guidelines, and PrEP programs can double as HIV testing gateways, identifying people with undiagnosed infections and starting them quickly on treatment. Because PrEP works only with consistent use, PEPFAR has required programs since 2019 to monitor adherence, retention, coverage and impact, and alternatives to daily pills, such as event-driven dosing and long-acting injectables, were being explored.

Sources

Based on "Expansion of HIV Preexposure Prophylaxis to 35 PEPFAR-Supported Early Program Adopters, October 2016–September 2018," by Gaston Djomand and colleagues, Morbidity and Mortality Weekly Report, Centers for Disease Control and Prevention; a work of the United States government in the public domain.