At the upcoming BHIVA Spring Conference 2024 in Birmingham the plenary talk will be given by Dr John Saunders on ‘Pathways to prevention: Rethinking PrEP delivery’. Even with PrEP freely available on the NHS, PrEP delivery continues to be a major challenge and making progress is vital in the quest to eradicate HIV. Here our Research Lead, Ant, looks at some of the key issues and what he expects to see in this engaging plenary session.

PrEP Provision Now

The provision of PrEP through the NHS has led to a dramatic decline in the number of HIV cases throughout the UK (Murchu et al., 2022; Nutland, 2018) but this has been an uphill struggle and, despite its success, PrEP continues to face challenges. While there are issues ahead that require our attention, (e.g. reducing PrEP uptake inequalities, the so-called ‘PrEP gap’; O’Halloran et al., 2019), there’s also still scope to build on and learn from PrEP provision now and our experiences with PrEP to date with the aim of improving equitable access and reduced stigma around PrEP (Khan et al., 2023).

Improving PrEP awareness

Rollout across parts of the UK was slowed by judicial reviews, limited or controlled access, and ongoing underfunding (specifically through NHS England; Nagington & Sandset, 2020) and this has resulted in a lack of education and awareness about PrEP, its use and who can benefit from it. PrEP has been available on the NHS since 2020, yet lack of awareness continues to be a major barrier to access (e.g., Edeza et al., 2021). While sexual health campaigns have been designed to target groups with increased likelihood of HIV, cultural and social implications prevent open discussion, which is reinforced by ongoing HIV stigma in many communities. One key result of this is low peer-to-peer knowledge exchange, reducing opportunity to increase PrEP awareness and acceptability through word of mouth (Patel et al., 2018). Notably, social discussion of PrEP through online platforms (e.g., Reddit) has become more commonplace (Loosier et al., 2022), which exemplifies the potential of other forms of social interaction in improving PrEP update.

Understanding HIV incidence

Even for people who are aware of PrEP and amongst sexual health professionals, it’s not always well understood who may need access to HIV prevention. This acts as a barrier to PrEP access for those who would be considered a high priority for PrEP as part of a harm reduction model (Sewell et al., 2020). One example of this is cisgender women who, according to the latest UKHSA statistics, are least likely to be offered a HIV test but are showing increases in HIV infection across England (UKHSA, 2023). Opt-out HIV tests serve as a useful tool to address underdiagnosis in these groups (Montoy et al., 2016), and pilot trials on opt-out testing are being expanded throughout the UK (Kirby, 2024), but improved HIV detection doesn’t address the need for more widespread HIV prevention. PrEP counselling and in-clinic discussions need to be adequately improved to ensure PrEP needs are being highlighted and addressed (Whelan et al, 2023).

Read our earlier blog for more about the UKHSA stats»

Structural challenges

Finally, we continue to face structural barriers to PrEP from UK health systems drastically impacting uptake (MacDonald et al., 2023). With limited and oversubscribed services, absence of streamlined user interfaces (e.g., online booking systems) and a disjointed NHS, even if the above matters are addressed, PrEP uptake will still be limited by access to services. One solution that is often presented is moving away from PrEP provision exclusively through secondary care services thereby providing more direct connection to numerous target communities while enhancing patient choice (Scott et al., 2024).

Rethinking PrEP Delivery

In my view there are a number of avenues to be explored to ameliorate PrEP access and reduce HIV infections, and there is a lot we can learn not just from past experiences but also from other global health systems.

Changing how PrEP is accessed

Looking at pharmacy distribution to reduce sexual health clinic burden, as well as partnerships in less ‘clinical’ venues will make strides in reaching underserved populations. It’s easy to see how the exclusive association of PrEP with sexual health care could be a deterrent to many people with ‘PrEP need’. However, this potential to significantly increase demand will need to be met by a corresponding increase in supply chain capability to avoid PrEP shortages such as those already being faced in Germany. As a demonstration of the desirability of ready access to PrEP, the US makes PrEP available through many insurance providers, yet despite this there is still demand for premium ‘telemedicine’ services providing PrEP access, pre- and post-testing, aftercare and prescriptions. This demand is also somewhat reminiscent of what was seen in the UK before NHS availability where those that were aware of PrEP and had the means to do so were paying for access (Delpech, V., 2017).

Providing quality ongoing care

While improved access to care offers many benefits, it’s vital that this does not compromise the quality of care and that PrEP users continue to be appropriately tested, counselled on the risks of PrEP use and have access to ongoing care. It is also noted how specialist care is needed with virologic failure and resistance to antiretroviral regimens amongst people living with HIV (Sharma et al., 2024). While ‘breakthrough’ infections of HIV among PrEP-users with high adherence is extremely rare, likelihood is increased during undiagnosed acute HIV infection (Gibas et al., 2019). The relative security of PrEP use is, obviously. good news but this possibility demonstrates the need for PrEP care needs to remain regimed, regulated and consistent to ensure rapid detection of these rare incidents. Maintaining this while providing reliable, accessible PrEP supply requires active development of healthcare practitioner knowledge and confidence to communicate about PrEP (e.g., Desai et al., 2016). It would be imperative to closely monitor and continually develop best practice as PrEP is rolled out through different ways.

New forms of PrEP

It seems likely that current PrEP approaches will remain dominant for some time to come. Yet, clinical trials are ongoing for long-acting injectable PrEP, and showing promising results (Liegeon & Ghosn, 2023). This would dramatically alter the experience of PrEP use by shifting from a daily pill to an injection every 8 weeks or so. This diversifies how PrEP can be delivered and can make it more accessible. As, for example, it may address ‘pill fatigue’ and reduce mishaps in adherence (i.e. missed pills). Conversely, new approach present their own issues around cost-effectiveness, logistics, and ensuring the service to provide timely injections for all who need them. While we still have much work to do with current PrEP uptake, hopefully, lessons can be learnt that can be applied to ensure rapid success and efficacy of alternative approaches as they become available.

Similarly, the APPROACH study (Barouch et al., 2018) is evaluating the efficacy of a HIV vaccine. While there is a lot of excitement around this, with human trials only just starting, there is a long way to go before this could become a reality, and still faces many of the same challenges as long-acting PrEP. As such, in my view, our focus for now should be on maximising our efforts with existing tools and interventions to ensure we continue making progress towards eradicating HIV.

What I hope to hear at BHIVA

I will be watching Dr. Saunders BHIVA plenary with keen interest. The aforementioned issues with the current provision of PrEP are but a few considerations of what could be discussed. I expect targeting demographics with greatest need for PrEP and exploring alternative routes to access medication will likely be a top priority. Contemplation on reducing structural barriers like appointment management systems would also be interesting.

I’ll be there with the Preptrack team and look forward to updating on interesting discussions around PrEP provision. If you are also attending the conference, come and say hello and learn how Preptrack is supporting access to PrEP information and helping PrEP users stay on top of their PrEP regime.

References

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• Barouch, D. H., Tomaka, F. L., Wegmann, F., Stieh, D. J., Alter, G., Robb, M. L., … & Schuitemaker, H. (2018). Evaluation of a mosaic HIV-1 vaccine in a multicentre, randomised, double-blind, placebo-controlled, phase 1/2a clinical trial (APPROACH) and in rhesus monkeys (NHP 13-19). The Lancet, 392(10143), 232-243.
• Delpech, V. (2017). Highlights from the BHIVA Satellite Symposium, IAS Conference, Paris, France, July 2017:‘Tougher times: adapting to increasing demand with declining resources’. Prevalence, 1, 1-99.
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• Patel, V. V., Ginsburg, Z., Golub, S. A., Horvath, K. J., Rios, N., Mayer, K. H., … & Arnsten, J. H. (2018). Empowering with PrEP (E-PrEP), a peer-led social media–based intervention to facilitate HIV preexposure prophylaxis adoption among young Black and Latinx gay and bisexual men: protocol for a cluster randomized controlled trial. JMIR research protocols, 7(8), e11375.
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