PrEP Implementation in Africa and Around the World

Pre-exposure prophylaxis (PrEP) for HIV prevention has contributed to reductions in HIV infections among men who have sex with men in North America, Europe, and Australia. However, PrEP is underutilized in other geographic areas, including Africa. Worldwide, PrEP Watch estimates that approximately 1.3 million people have used PrEP between 2016 and 2019—far below the 2020 UNAIDS target of 3 million people receiving PrEP. At IDWeek 2021, data assessing gaps in delivery and evaluation of strategies to improve uptake of HIV PrEP were presented. I believe these data and strategies can be easily replicated across Africa and the rest of the globe to help us improve on PrEP delivery and uptake.

Diversity
The community engagement process for recruitment of participants to the phase III lenacapavir PURPOSE 2 trial, which assessed biannual SC injections for HIV PrEP, had goals to achieve inclusivity and diversity in the participant population. Prespecified distribution of participants included populations historically underrepresented in HIV prevention research, such as Black and Hispanic/Latinx gay, bisexual, and other men who have sex with men; transgender women and men; and gender nonbinary individuals. This was achieved through a weekly metrics review during enrollment and representation of diverse populations in study teams. This study is a good reminder that equity in health can be achieved only if it is purposefully planned and implemented.

Gaps in PrEP Delivery and Uptake
Data from studies evaluating gaps in PrEP delivery and uptake across diverse populations in the United States also were presented during IDWeek 2021.

• Tao and colleagues used pharmacy record data and deidentified prescription claims to compare emtricitabine (FTC)/tenofovir alafenamide (TAF) and FTC/tenofovir disoproxil fumarate (TDF) persistence in PrEP users. Analyses of prescription refills served as markers of persistence and showed that FTC/TAF users were twice as likely to have persistent use and reinitiation after stopping. This product is still under evaluation for use as HIV PrEP for cisgender women.
• Use of order sets as clinical support tools has been shown to improve adherence to standard practice guidelines in medicine. Dao and colleagues demonstrated that use of order sets that included HIV testing every 3 months, hepatitis serology, renal function, and sexually transmitted infection testing for PrEP prescriptions markedly increased prescription accuracy and laboratory monitoring. Order sets use could resolve previously identified issues related to low PrEP knowledge among healthcare professionals (HCPs).
• In a survey of HCPs caring for adolescents, Allen and colleagues found that only 25% of HCPs screened patients for HIV, only 32% could correctly name PrEP medication, and only 15% correctly identified laboratory monitoring for PrEP.
• Use of order sets as clinical support tools has been shown to improve adherence to standard practice guidelines in medicine. Dao and colleagues demonstrated that use of order sets that included HIV testing every 3 months, hepatitis serology, renal function, and sexually transmitted infection testing for PrEP prescriptions markedly increased prescription accuracy and laboratory monitoring. Order sets use could resolve previously identified issues related to low PrEP knowledge among healthcare professionals (HCPs).
• In a survey of HCPs caring for adolescents, Allen and colleagues found that only 25% of HCPs screened patients for HIV, only 32% could correctly name PrEP medication, and only 15% correctly identified laboratory monitoring for PrEP.
• Using a survey assessing family planning providers in 224 family planning clinics that were assessed for PrEP efficacy (individual belief in their capacity to perform task), Ramakrishnan and colleagues found that family planning providers were most comfortable with screening for PrEP eligibility and least comfortable with initiation and follow-up.
• Musoke and colleagues reported doubling of PrEP initiations after an intense PrEP education campaign among providers in a veterans’ clinic. At the same clinic, efforts to increase PrEP prescriptions by identifying individuals diagnosed with a sexually transmitted infection using electronic medical records and placing a “PrEP candidacy” note in patient charts had no effect on PrEP uptake.

Each of these studies highlights potential opportunities and strategies for increasing PrEP delivery and uptake, and these learnings could be used by HCPs in Africa to implement in their practices.

My Key Takeaways
Consistently across populations, provider knowledge on PrEP administration was demonstrated to be low. One study that used an education campaign demonstrated doubling in PrEP initiation. We have safe and effective medications for PrEP, and we need to implement strategies like those examined here to improve provider knowledge so that more patients who qualify for PrEP are offered and prescribed it. This is of particular importance on the African continent to improve the frequency of PrEP prescribing.

Your Thoughts?
What do you think is the biggest barrier that prevents providers from prescribing PrEP? Join the discussion by posting a comment. For more details on this and other key HIV issues from IDWeek 2021, review more CCO Conference Coverage, including Capsule summary slidesets, video recaps with expert faculty, and other ClinicalThought commentaries highlighting US and global perspectives.