WHO HIV PrEP Recommendations Associated with Global Increase in Use

Global use of HIV pre-exposure prophylaxis has risen as more countries have adopted World Health Organization recommendations.

Adoption of World Health Organization (WHO) recommendations for HIV pre-exposure prophylaxis was associated with a global increase in PrEP use, but fell short of targets, a new study determined.

The global summary and forecast study, published in The Lancet HIV, analyzed data on the adoption of WHO PrEP recommendation and numbers of PrEP users from 2016-2019 and forecasted numbers of PrEP users through 2023.

“Since 2015, when WHO recommended to offer oral PrEP to anyone at substantial risk of HIV as part of combination prevention, global use has increased markedly,” Robin Schaefer, PhD, a consultant for the World Health Organization’s Global HIV, Hepatitis and STI programs told Contagion. “Sizable number of PrEP users can be found across the world, and this increase in use coincided with widespread adoption of the WHO recommendations into national guidelines. Our research suggests sizable further increase in PrEP use in the next few years.”

The study found that there were 626,000 PrEP users in 77 countries in 2019, after two-thirds of countries (120) had adopted WHO recommendations into national guidelines. This was a 69% increase from 370,000 PrEP users across 66 countries in 2018, when 30 countries had adopted the recommendations, but fell short of a goal of 3 million oral PrEP users by 2020 set by the UN General Assembly in 2016. The study projected 900,000 to 1.1 million global PrEP users by the end of 2020 and 2.4 million to 5.3 million PrEP users by the end of 2023.

“Our analysis suggests strong future growth in PrEP use, with a four- to eight-fold increase in the number of PrEP users in 2023 compared to 2019,” Schaefer said. “Preliminary data for 2020 suggests that significant growth in PrEP use continued despite disruptions by COVID-19 in many settings. Therefore, these future scenarios may not be unrealistic, particularly in light of new PrEP products becoming available.”

In 2019, more countries had adopted WHO PrEP recommendations (120) than the number of countries that reported PrEP users (77). The study authors noted that PrEP implementation is facilitated by development of operational guidelines and protocols, provider training, supply chains, monitoring and evaluation systems, and demand creation. Cost of PrEP could be a barrier to implementation for some.

“Oral PrEP is safe and highly effective at preventing HIV when taken as prescribed,” Schaefer said. “There are now hundreds of thousands of PrEP users globally, and PrEP can make substantial contributions to the UN declaration of ending AIDS as a public health threat by 2030. PrEP should be offered to anyone at substantial risk of HIV infection in discrimination- and stigma-free way, and everyone asking for PrEP should be considered for PrEP initiation.”

New PrEP products and formulations could contribute to future growth of PrEP use along with global investments such as from the US Presidents Plan for AIDS Relief, the Global Fund to Fight AIDS, Tuberculosis and Malaria, national governments and private organizations.

“The COVID-19 pandemic has accelerated trends towards de-medicalised, simplified, and differentiated PrEP service delivery, which could further remove barriers to uptake and use of PrEP,” Schaefer said. “WHO is working on revised oral PrEP implementation guidance. Earlier this year, WHO recommended the dapivirine vaginal ring as an additional PrEP option for cisgender women, and WHO is preparing for future recommendations on further PrEP products, such as long-acting injectable cabotegravir. These PrEP products are likely to increase PrEP use by providing choice to users.”

The study was funded by Unitaid, the Bill & Melinda Gates Foundation and WHO.

Efforts to increase PrEP uptake are ongoing. As many as 1.1 million Americans could benefit from PrEP, according to the U.S. Centers for Disease Control and Prevention. Kimberly Green, PhD, global program director, Primary Health Care, PATH, recently spoke with Contagionabout barriers to PrEP access and strategies for greater access covered in her presentation at the recent IAS 2021 conference.

Boosting adherence also has been a focus for health care providers. A recent study in Africa found the PrEP initiation among women was high but adherence declined over time.