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The State of PrEP in 2017: Recent Data and Current Challenges

Since it was approved by the US Food and Drug Administration (FDA) in 2012, preexposure prophylaxis (PrEP) has changed the HIV prevention landscape in the United States. At the end of the first quarter of 2017, an estimated 120,000 Americans were taking emtricitabine/ tenofovir disoproxil fumarate (FTC/TDF) for PrEP. The number of new prescriptions remained stable at around 11,000 per quarter in 2016. This is good news for domestic prevention efforts, but data presented at the 2017 International AIDS Conference in Paris, France,1 highlight some of the continued challenges faced in our expansion of PrEP.

Investigators from Gilead Sciences, the manufacturer of FTC/TDF, examined pharmacy fulfillment data from January 2012 through September 20162 to describe trends and patterns in prescribing. In the first 2 years following FTC/TDF’s approval, women made up almost half (42%) of all individuals prescribed FTC/TDF for HIV prevention. Since 2014, the proportion of women has decreased dramatically, currently accounting for only 15% of all recipients. In addition, young adults represent a disproportionately small number of PrEP users relative to their importance as a key risk group3; just 11% of men and 24% of women prescribed PrEP were under age 25. Although only 40% of prescriptions had associated race and ethnicity information, the trends seem likely to reflect fundamental inequities in health care access across the United States. In 2015, blacks and Hispanics/Latinos accounted for 45% and 24% of all new HIV diagnoses4 in the United States, respectively, yet they comprised less than a quarter of all PrEP recipients (13% Hispanic/Latino, 10% black) across the 4 years of available data. (Figure).

Figure: US Population, PrEP Utilization, and HIV Incidence

Taken together, the unevenness of PrEP’s uptake across at-risk groups highlights the work that remains to be done in implementation and scale-up; bringing attention to these disparities is a necessary first step in bringing about change. However, it is important to keep in mind that although PrEP can have a meaningful impact on HIV incidence, it is by no means a magic bullet.

In fact, modeling data from the Centers for Disease Control and Prevention (CDC)5 estimate that PrEP implementation can be expected to avert approximately 17,000 new infections over a 5-year period, assuming all the goals of the National HIV/AIDS Strategy6 are reached. In contrast, 168,000 infections could be prevented if 85% of individuals diagnosed with HIV were linked with care, and 80% of those linked with care are virologically suppressed. Clearly, antiretrovirals used as PrEP and treatment as prevention have an important role to play in controlling the domestic epidemic, but their potential has not yet been fully realized.

Big advances in treatment can't make up for an inability to stop new infections, which number 5,000 per day worldwide.