IN 2016, the UN issued its ““, aiming to rid the world of the HIV epidemic by 2030. One target for 2020 was to reduce new HIV infections to fewer than 500,000 by, among other things, reaching 3 million at-risk people with pre-exposure prophylaxis (PrEP) by this year. But this target is set to be missed by a country mile, hindering the global fight.
PrEP is a pill containing two chemicals, tenofovir and emtricitabine, that kills HIV before it can infect a person. It can be taken either daily, or at specific times prior to sex, and has been shown to help protect many groups particularly at risk of transmission, including sex workers, intravenous drug users and men who have sex with men.
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PrEP is both highly effective and works where the use of condoms and other prevention methods may not, for example in cases of sexual assault or needle sharing. It also empowers women, particularly important in sub-Saharan Africa where , rising to two-thirds of new infections in young people.
Yet PrEP uptake remains underwhelming. In 2018, only 380,000 people were on the medication worldwide. Half of them were in the US, and very few in areas with high HIV prevalence, for example in eastern and southern Africa. “It’s very patchy,” says Rosalind Coleman, a PrEP consultant with the Joint UN Programme on HIV/AIDS (UNAIDS). Although every person who regularly takes PrEP helps stem the spread of the virus, “it’s nowhere near enough if we want PrEP to have an impact on the HIV epidemic”, she says.
Last month, UNAIDS published a global survey of barriers to PrEP access. Of 69 countries reporting PrEP availability, . For the rest, high cost and limited accessibility of treatment were the most frequently cited problems.
Stigmatisation of at-risk groups plays its part too. The survey revealed that in some countries possession of PrEP can even be used as evidence of sex work or other criminalised sexual activity. “The systems often actually screen out or exclude exactly the people who need PrEP,” says Mitchell Warren of AVAC, an HIV prevention charity based in New York.
Combating prejudice against PrEP users will take time, as will overcoming the disinclination of some at-risk people to take it – because taking a daily pill doesn’t fit with their lifestyle, for example, or they don’t want a constant reminder that they are at risk.
Meanwhile, there is a more mundane barrier. There have been decades of campaigns about condom use and other safe sex practices to lower HIV rates, but PrEP is a newcomer struggling to catch up. Awareness of how it works, and who should take it, remains low. “PrEP got developed,” says Warren. “Science showed that it worked, but most people in the world don’t know it exists.”
Where that barrier can be broken down, change can happen fast. In South Africa, a concerted education effort has seen the country recently , with an estimated 35,000 people using it. Young people at higher risk of HIV infection were particularly eager, says Linda-Gail Bekker of the Desmond Tutu HIV Centre at the University of Cape Town, who helped run clinical trials on PrEp in South Africa. “Once people wrap their heads around it and they recognise that they are going to be able to be in charge of their own destiny, as it were – this is what we’re really hearing from young women – they do get very excited,” she says.
Easier, more convenient methods of using PrEP are also being developed, including a version that needs to be taken only monthly. But with just a decade left to meet the UN’s goals, there is one thing above all that must be spread: awareness that PrEP exists, and that it works.
