Expert Q&A

Improved Access to PrEP

According to the CDC, pre-exposure prophylaxis (PrEP) reduces the risk of getting HIV from sex by about 99% and reduces the risk of getting HIV from injection drug use by at least 74%. Jessica Rodrigues, MS, answered questions about her presentation at the International AIDS Conference 2022 during a session titled “Scaling PrEP: What’s the Secret Sauce?” At the time when she answered these questions, Jessica was the Director of Product Introduction and Access at AVAC.


Consultant360: To start, can you please provide an overview of your presentation titled "Scaling PrEP: What's the Secret Sauce?"

Jessica Rodrigues: The presentation on PrEP consisted of an analysis of the drivers behind the recent dramatic surge in PrEP uptake and what factors seem to contribute to PrEP scale-up, as well as a deeper dive into a few country examples. By the end of June 2022, global uptake of oral PrEP had reached nearly 3 million people. This is an exciting milestone, yet it took 10 years after US FDA approval to see this growth and eight years after the WHO recommended it as a prevention option. It still is far from the UNA's target of reaching 10 million people on PrEP by 2025.

What is interesting is that most of this growth occurred in the last two years alone. There were 1 million initiations in 2021 and another 800,000 initiations in 2022, counting for about half of all initiations in the past five years. Of these initiations, 80% were in Sub-Saharan Africa. About three-quarters of these initiations were in six countries and three of these countries, Zambia, Nigeria, and Uganda, benefited largely from PEPFAR support for oral PrEP.

Jessica Bard: What would you say are some of the barriers to access of PrEP?

Jessica Rodrigues: Barriers to access of PrEP surely vary by context, but generally what we see is that there are still really unacceptable low levels of awareness and knowledge about HIV prevention in general, and about PrEP specifically. Engaging and educating communities is critical. When we look at contraception as a parallel, we see that word of mouth really helps people to understand services and even maybe arrive at a choice before arriving at a health facility, because they have received information through community health workers, through community leaders, through peers, through family members. This lower level of awareness can lead to stigma, which is another barrier so investing in asset framing and empowering messages that focus on pleasure and providing more peace of mind is really key. So, not emphasizing avoiding risk, but emphasizing empowerment and how HIV prevention and how these different methods might fit into someone's lifestyle.

Third: up until recently, PrEP was predominantly available in HIV or STI clinics, though this is changing, which is quite encouraging. PrEP now is more widely available in women's clinics in the United States, in family planning settings, in other countries, and in primary health care. That offers an opportunity to train more providers in PrEP and encourage providers to begin with discussing relationships and sexual health with clients, and not starting with risk assessments or overstressing risk.

Lastly, I would say structural barriers, employment and housing insecurity, and transportation costs also continue to impede access.

Jessica Bard: One of your presentations in this session was titled “Scaling PrEP: What's the Secret Sauce.” What would you say is the “secret sauce” to scaling PrEP?

Jessica Rodrigues: It is always hard to say what are the specific or exact ingredients, and everyone might have a different recipe. Of course, it is context specific. But what we have seen, looking across many different countries, is that the combination of ambitious targets with earmarked funding really mirrored significant increases in PrEP uptake. For example, in countries that receive PEPFAR support, about 21 countries, there was an analysis that showed that in the year that PEPFAR earmarked and had a dedicated budget code for PrEP, there was the highest increase in the number of PrEP initiations. There certainly is a relationship between funding and, of course, reaching more people. There is a sense that there is untapped demand for PrEP, and that it is really about supporting programs and health systems to deliver PrEP more effectively.

I would say the second is early adoption. Countries that adopted PrEP soon after the WHO guidelines were released remain ahead of the curve­– early adoption as soon as regulatory approvals are available and guidelines are updated.

Lastly, simplified, demedicalized delivery that goes beyond the health facility, so telehealth multi-month dispensing of PrEP prescriptions and peer-led services in countries like Vietnam, Thailand, and Kenya really have shown to go hand-in-hand with increases in PrEP access.

Jessica Bard: We talked about the barriers, and we talked about the “secret sauce.” Can we put it all together? How do communities really overcome these barriers to be able to execute these necessary action items?

Jessica Rodrigues: I think there are multiple ways to overcome these barriers. The first is advocating for generic access so that new PrEP products are affordable. To advocate for funding for PrEP, regardless of who the payer is, whether they are governments or insurance companies or donors like PEPFAR and the Global Fund, to make significant investments in new products like cabotegravir for PrEP and the dapivirine ring.

Particularly in the United States, I would say we're hearing that some PrEP users are reporting that insurance companies are requiring a person to fail on oral PrEP before they can start CAB for PrEP. I think it's about advocating for choice and demanding that an array of options are offered instead of using a hierarchical approach because people might switch depending on their needs and depending on their circumstances.

I think now is the time to demand a seat at the table to influence national guideline adoption, particularly for low-and middle-income countries. The WHO guidelines were released at AIDS 2022, and now is the time to translate that into national guidelines.

Lastly, providing direct funding and resources to community-based organizations that are really at the front lines of providing HIV prevention access and accelerating access to create awareness, to design implementation studies, and to deliver services.

Jessica Bard: What would you say are the overall take-home messages from our conversation today?

Jessica Rodrigues: It is an exciting time for HIV prevention with more options becoming available shortly. We need to be able to convert those options into real choices for people. Providers have an instrumental role to play to engage in shared decision-making, to explore what methods work for their clients. These decisions might change over time and being cognizant of that and really respecting clients' choices and preferences.

Second, significant investment in community mobilization and demand creation for HIV prevention in general, not necessarily specific products, but really just creating more awareness and acceptance. It's not a nice to have, but it is foundational to PrEP scale up. I would say moving towards choice, not only among the products that are available, but also where you can access new prevention options, so not only choice in products, but also in delivery models.

Lastly, I'd conclude with saying now is the time to build on the gains and PrEP uptake and access and learn from the lessons, the successes, the mistakes of oral PrEP rollout to deliver new, exciting products, like cab, and the dapivirine ring.