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Sexual Health Sexual Health Society
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REVIEW

Getting pre-exposure prophylaxis (PrEP) to the people: opportunities, challenges and emerging models of PrEP implementation

Patrick S. Sullivan A C and Aaron J. Siegler B
+ Author Affiliations
- Author Affiliations

A Department of Epidemiology, Rollins School of Public Health, Emory University, 1518 Clifton Road NE, Atlanta, GA 30322, USA.

B Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, 1518 Clifton Road NE, Atlanta, GA 30322, USA.

C Corresponding author. Email: pssulli@emory.edu

Sexual Health 15(6) 522-527 https://doi.org/10.1071/SH18103
Submitted: 29 May 2018  Accepted: 1 October 2018   Published: 27 November 2018

Abstract

Pre-exposure prophylaxis (PrEP) with tenofovir disoproxil fumarate and emtricitabine (TDF/FTC) is now accepted as an efficacious approach to preventing HIV acquisition among people at high risk of HIV infection but, in most places, PrEP uptake to date has not been sufficient to have a large effect on HIV incidence. In this paper we consider several key elements of the effort to expand PrEP uptake for at-risk populations who would benefit most, such as increasing access to PrEP, integrating PrEP programs with other services, promoting PrEP persistence and developing systems for monitoring PrEP use. We used a PrEP Continuum framework to describe barriers to equitable uptake of PrEP, and to illustrate possible solutions to barriers. Access to PrEP includes regulatory issues and geographic proximity to PrEP providers. Integrating PrEP programs with other comprehensive sexual health services, through clinic-based programs or technology-based approaches, offers opportunities to identify PrEP candidates and improve linkages to PrEP care. Once at-risk people are prescribed PrEP, lowering barriers to persistence on PrEP is critical to realising the most population benefits. To understand progress and identify underserved groups and communities, systems to monitor the uptake of PrEP are needed. Making the most of a new biomedical intervention tool requires ongoing research about implementation, scale-up through multiple channels, including community-based organisations, and high-quality monitoring of uptake. We must turn to questions of PrEP implementation and continue to seek innovative approaches to reduce barriers to PrEP uptake and persistence on PrEP.

Additional keywords: health equity, HIV prevention, men who have sex with men, people who inject drugs.


References

[1]  Sullivan PS, Carballo-Diéguez A, Coates T, Goodreau SM, McGowan I, Sanders EJ, Smith A, Goswani P, Sanchez J. Successes and challenges of HIV prevention in men who have sex with men. Lancet 2012; 380 388–99.
Successes and challenges of HIV prevention in men who have sex with men.Crossref | GoogleScholarGoogle Scholar |

[2]  Brookmeyer R, Boren D, Baral SD, Bekker LG, Phaswana-Mafuya N, Beyrer C, Sullivan PS. Combination HIV prevention among MSM in South Africa: results from agent-based modeling. PLoS One 2014; 9 e112668
Combination HIV prevention among MSM in South Africa: results from agent-based modeling.Crossref | GoogleScholarGoogle Scholar |

[3]  Jenness SM, Goodreau SM, Rosenberg E, Beylerian EN, Hoover KW, Smith DK, Sullivan P. Impact of the Centers for Disease Control’s HIV preexposure prophylaxis guidelines for men who have sex with men in the United States. J Infect Dis 2016; 214 1800–7.
Impact of the Centers for Disease Control’s HIV preexposure prophylaxis guidelines for men who have sex with men in the United States.Crossref | GoogleScholarGoogle Scholar |

[4]  Sullivan PS, Sineath C, Kahle E, Sanchez T. Awareness, willingness and use of oral pre-exposure prophylaxis (PrEP) among a national sample of US men who have sex with men. In: Davidovich U, editor. Proceedings of the 12th AIDSImpact Conference; 28–31 July 2015; Amsterdam, Netherlands. Amsterdam: AIDSImpact; 2015. Abstract 52.4.

[5]  Hood JE, Buskin SE, Dombrowski JC, Kern DA, Barash EA, Katzi DA, Golden MR. Dramatic increase in preexposure prophylaxis use among MSM in Washington state. AIDS 2016; 30 515–9.

[6]  Shacklett BL, Derdeyn CA, Folayan MO, Landovitz RJ, Anthony C, Behrens AJ, Hope TJ, Landais E, Leal L, Marrazzo JM, Morris L, Mugo N, Ngure K, Noseda V, Ranasinghe S, Tully DC, Voronin Y, Warren M, Wibmer CK, Xie IY, Scarlatti G, Thyagarajan B. HIVR4P 2016, partnering for prevention: conference summary and highlights. AIDS Res Hum Retroviruses 2017; 33 749–59.

[7]  Holt M, Lea T, Mao L, Kolstee J, Zablotska I, Duck T, Allan B, West M, Lee E, Hull P, Grulich A, De Wit J, Prestage G. Community-level changes in condom use and uptake of HIV pre-exposure prophylaxis by gay and bisexual men in Melbourne and Sydney, Australia: results of repeated behavioural surveillance in 2013–17. Lancet HIV 2018; 5 e448–56.
Community-level changes in condom use and uptake of HIV pre-exposure prophylaxis by gay and bisexual men in Melbourne and Sydney, Australia: results of repeated behavioural surveillance in 2013–17.Crossref | GoogleScholarGoogle Scholar |

[8]  Morgan E, Moran K, Ryan DT, Mustanski B, Newcomb ME. Threefold increase in PrEP uptake over time with high adherence among young men who have sex with men in Chicago. AIDS Behav 2018; 22 3637–44.

[9]  Serota DP, Rosenberg ES, Lockard AM, Rolle C-PM, Luisi N, Cutro S, del Rio C, Siegler AJ, Sanchez TH, Sullivan PS, Kelley CF. Beyond the biomedical: preexposure prophylaxis failures in a cohort of young black men who have sex with men in Atlanta, Georgia. Clin Infect Dis 2018; 67 965–70.
Beyond the biomedical: preexposure prophylaxis failures in a cohort of young black men who have sex with men in Atlanta, Georgia.Crossref | GoogleScholarGoogle Scholar |

[10]  Sullivan PS, Rosenberg ES, Sanchez TH, Kelley CF, Luisi N, Cooper HL, Diclemente RJ, Wingwood GM, Frew PM, Salazar LF, del Rio C, Mulligan MJ, Peterson JL. Explaining racial disparities in HIV incidence in black and white men who have sex with men in Atlanta, GA: a prospective observational cohort study. Ann Epidemiol 2015; 25 445–54.
Explaining racial disparities in HIV incidence in black and white men who have sex with men in Atlanta, GA: a prospective observational cohort study.Crossref | GoogleScholarGoogle Scholar |

[11]  Goparaju L, Praschan NC, Warren-Jeanpiere L, Experton LS, Young MA, Kassaye S. Stigma, partners, providers and costs: potential barriers to PrEP uptake among US women. J AIDS Clin Res 2017; 8 730
Stigma, partners, providers and costs: potential barriers to PrEP uptake among US women.Crossref | GoogleScholarGoogle Scholar |

[12]  Kelley CF, Kahle E, Siegler A, Sanchez T, del Rio C, Sullivan PS, Rosenberg ES. Applying a PrEP continuum of care for men who have sex with men in Atlanta, Georgia. Clin Infect Dis 2015; 61 1590–7.
Applying a PrEP continuum of care for men who have sex with men in Atlanta, Georgia.Crossref | GoogleScholarGoogle Scholar |

[13]  Nunn AS, Brinkley-Rubinstein L, Oldenburg CE, Mayer KH, Mimiaga M, Patel R, Chan PA. Defining the HIV pre-exposure prophylaxis care continuum. AIDS 2017; 31 731–4.
Defining the HIV pre-exposure prophylaxis care continuum.Crossref | GoogleScholarGoogle Scholar |

[14]  World Health Organization (WHO). Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection: recommendations for a public health approach, 2nd ed. Geneva, Switzerland: WHO; 2016. Available online at: http://www.who.int/iris/handle/10665/208825 [verified 28 October 2018].

[15]  AVAC. Regulatory Status of TDF/FTC for PrEP. New York, NY, USA: AVAC; 2018. Available online at: https://www.avac.org/infographic/regulatory-status-tdfftc-prep [verified 28 October 2018].

[16]  World Health Organization (WHO). Number of people (all ages) living with HIV. Geneva, Switzerland: WHO; 2018. Available online at: http://www.who.int/gho/hiv/epidemic_status/cases_all/en/ [verified 28 October 2018].

[17]  World Health Organization (WHO). WHO implementation tool for pre-exposure prophylaxis of HIV infection. Geneva, Switzerland: WHO; 2017. Available online at: http://www.who.int/hiv/pub/prep/prep-implementation-tool/en/ [verified 28 October 2018].

[18]  Centers for Disease Control and Prevention (CDC). US Public Health Service preexposure prophylaxis for the prevention of HIV infection in the United States – 2014 clinical practice guideline. Atlanta, GA, USA: CDC; 2014. Available online at: http://wwwcdcgov/hiv/pdf/prepguidelines2014pdf [verified 28 October 2018].

[19]  Coleman R, Prins M. Options for affordable pre-exposure prophylaxis (PrEP) in national HIV prevention programmes in Europe. Euro Surveill 2017; 22 17–00698
Options for affordable pre-exposure prophylaxis (PrEP) in national HIV prevention programmes in Europe.Crossref | GoogleScholarGoogle Scholar |

[20]  Baeten JM. Amplifying the population health benefits of PrEP for HIV prevention. J Infect Dis 2018; 217 1509–11.
Amplifying the population health benefits of PrEP for HIV prevention.Crossref | GoogleScholarGoogle Scholar |

[21]  Bien CH, Patel VV, Blackstock OJ, Felsen UR. Reaching key populations: PrEP uptake in an urban health care system in the Bronx, New York. AIDS Behav 2017; 21 1309–14.
Reaching key populations: PrEP uptake in an urban health care system in the Bronx, New York.Crossref | GoogleScholarGoogle Scholar |

[22]  Liu A, Cohen S, Follansbee S, Cohan D, Weber S, Sachdev D, Buchbinder S. Early experiences implementing pre-exposure prophylaxis (PrEP) for HIV prevention in San Francisco. PLoS Med 2014; 11 e1001613
Early experiences implementing pre-exposure prophylaxis (PrEP) for HIV prevention in San Francisco.Crossref | GoogleScholarGoogle Scholar |

[23]  Florida Department of Health. Pre-exposure prophylaxis/post-exposure prophylaxis. Tallahassee, FL, USA: Florida Department of Health; 2018. Available online at: http://orange.floridahealth.gov/programs-and-services/infectious-disease-services/prep/index.html; permanent archive available at:http://www.webcitation.org/73YQhKvQs [verified 30 October 2018].

[24]  Hoffman S, Guidry JA, Collier KL, Mantell JE, Boccher-Lattimore D, Kaighobadi F, Sandfort TGM. A clinical home for preexposure prophylaxis: diverse health care providers’ perspectives on the ‘purview paradox’. J Int Assoc Provid AIDS Care 2016; 15 59–65.
A clinical home for preexposure prophylaxis: diverse health care providers’ perspectives on the ‘purview paradox’.Crossref | GoogleScholarGoogle Scholar |

[25]  Siegler AJ, Wirtz S, Weber S, Sullivan PS. Developing a web-based geolocated directory of HIV pre-exposure prophylaxis-providing clinics: the PrEP locator protocol and operating procedures. JMIR Public Health Surveill 2017; 3 e58
Developing a web-based geolocated directory of HIV pre-exposure prophylaxis-providing clinics: the PrEP locator protocol and operating procedures.Crossref | GoogleScholarGoogle Scholar |

[26]  Centers for Disease Control and Prevention (CDC). Dear Colleague: April 25, 2018. Atlanta, GA, USA: CDC; 2018. Available online at: https://www.cdc.gov/hiv/library/dcl/dcl/042518.html [verified 28 October 2018].

[27]  Bratcher A, Wirtz SS, Siegler AJ. Users of a national directory of PrEP service providers: beliefs, self-efficacy, and progress toward prescription. J Acquir Immune Defic Syndr 2018; 78 e28–30.
Users of a national directory of PrEP service providers: beliefs, self-efficacy, and progress toward prescription.Crossref | GoogleScholarGoogle Scholar |

[28]  Siegler AJ, Bratcher A, Weiss KM, Mouhanna F, Ahlschlager L. Location location location: an exploration of disparities in access to publicly listed HIV preexposure prophylaxis clinics in the United States. Ann Epidemiol 2018;
Location location location: an exploration of disparities in access to publicly listed HIV preexposure prophylaxis clinics in the United States.Crossref | GoogleScholarGoogle Scholar |

[29]  Weiss KM, Bratcher A, Sullivan PS, Siegler AJ. Geographic access to PrEP clinics among men who have sex with men in the United States: documenting PrEP deserts. In: Richman DD, editor. Proceedings of the Conference on Retroviruses and Opportunistic Infections; 4–7 March 2018; Boston, MA, USA. San Francisco: IAS-USA; 2018.

[30]  Krakower D, Ware N, Mitty JA, Maloney K, Mayer KH. HIV providers’ perceived barriers and facilitators to implementing pre-exposure prophylaxis in care settings: a qualitative study. AIDS Behav 2014; 18 1712–21.
HIV providers’ perceived barriers and facilitators to implementing pre-exposure prophylaxis in care settings: a qualitative study.Crossref | GoogleScholarGoogle Scholar |

[31]  Mayer KH, Chan PA, Patel RR, Flash CA, Krakower DS. Evolving models and ongoing challenges for HIV preexposure prophylaxis implementation in the United States. J Acquir Immune Defic Syndr 2018; 77 119–27.

[32]  Calabrese SK, Krakower DS, Mayer KH. Integrating HIV preexposure prophylaxis (PrEP) into routine preventive health care to avoid exacerbating disparities. Am J Public Health 2017; 107 1883–9.

[33]  Jenness SM, Maloney KM, Smith DK, Hoover KW, Goodreau SM, Rosenberg ES, Weiss KM, Liu AY, Rao DW, Sullivan PS. Addressing gaps in HIV preexposure prophylaxis care to reduce racial disparities in HIV incidence in the United States. Am J Epidemiol 2018;
Addressing gaps in HIV preexposure prophylaxis care to reduce racial disparities in HIV incidence in the United States.Crossref | GoogleScholarGoogle Scholar |

[34]  Chan PA, Mena L, Patel R, Oldenburg CE, Beauchamps L, Perez-Brumer AG, Parker S, Mayer KH, Mimiaga MJ, Nunn A. Retention in care outcomes for HIV pre-exposure prophylaxis implementation programmes among men who have sex with men in three US cities. J Int AIDS Soc 2016; 19 20903
Retention in care outcomes for HIV pre-exposure prophylaxis implementation programmes among men who have sex with men in three US cities.Crossref | GoogleScholarGoogle Scholar |

[35]  Hojilla JC, Vlahov D, Crouch PC, Dawson-Rose C, Freeborn K, Carrico A. HIV pre-exposure prophylaxis (PrEP) uptake and retention among men who have sex with men in a community-based sexual health clinic. AIDS Behav 2018; 22 1096–9.
HIV pre-exposure prophylaxis (PrEP) uptake and retention among men who have sex with men in a community-based sexual health clinic.Crossref | GoogleScholarGoogle Scholar |

[36]  Doblecki-Lewis S, Liu A, Feaster D, Cohen SE, Cardenas G, Bacon O, Andrew E, Kobler MA. Healthcare access and PrEP continuation in San Francisco and Miami following the U.S. PrEP Demo Project. J Acquir Immune Defic Syndr 2017; 74 531–8.
Healthcare access and PrEP continuation in San Francisco and Miami following the U.S. PrEP Demo Project.Crossref | GoogleScholarGoogle Scholar |

[37]  Liu AY, Cohen SE, Vittinghoff E, Anderson PL, Doblecki-Lewis S, Bacon O, Chege WS, Postel BS, Matheson T, Amico KA, Liegler T, Rawlings KM, Trainor N, Blue RW, Estrada V, Coleman ME, Cardenas G, Feaster DJ, Grant R, Philip SS, Elion R, Buchbinder S, Kolber MA. Preexposure prophylaxis for HIV infection integrated with municipal- and community-based sexual health services. JAMA Intern Med 2016; 176 75–84.

[38]  Siegler A, Liu A, Mayer KH, Thure K, Fish R, Andrew E, Gelman M, Sullivan PS. An exploratory assessment of the feasibility and acceptability of home-based support to streamline HIV pre-exposure prophylaxis (PrEP) delivery. J Int AIDS Soc 2016; 19 110

[39]  Siegler A. Making it last: a randomized, controlled trial of a home care system to promote persistence in PrEP care. Washington, DC, USA: Department of Health and Human Services; 2018. Available online at: https://projectreporter.nih.gov/project_info_details.cfm?aid=9410856&icde=39587307 [verified 28 October 2018].

[40]  Siegler A. ATN 159: ePrEP, a randomized, controlled trial of an electronic HIV pre-exposure prophylaxis care system among rural MSM. Raleigh, NC, USA: University of North Carolina; 2018. Available online at: https://itechnetwork.org/protocols/atn-159-eprep/ [verified 28 October 2018].

[41]  Patel RR, Chan PA, Mena L, Crowley JS, McCoy K, Nunn A. Time to make the jump: translating HIV pre-exposure prophylaxis research into real-world public health impact. J Acquir Immune Defic Syndr 2017; 75 e144–6.
Time to make the jump: translating HIV pre-exposure prophylaxis research into real-world public health impact.Crossref | GoogleScholarGoogle Scholar |

[42]  Parisi D, Warren B, Leung SJ, Akkaya-Hocagil T, Qin Q, Hahn I, Stevens L. A multicomponent approach to evaluating a pre-exposure prophylaxis (PrEP) implementation program in five agencies in New York. J Assoc Nurses AIDS Care 2018; 29 10–19.
A multicomponent approach to evaluating a pre-exposure prophylaxis (PrEP) implementation program in five agencies in New York.Crossref | GoogleScholarGoogle Scholar |

[43]  Boren D, Sullivan PS, Beyrer C, Baral SD, Bekker LG, Brookmeyer R. Stochastic variation in network epidemic models: implications for the design of community level HIV prevention trials. Stat Med 2014; 33 3894–904.
Stochastic variation in network epidemic models: implications for the design of community level HIV prevention trials.Crossref | GoogleScholarGoogle Scholar |

[44]  Sullivan PS, Jones J, Kishore N, Stephenson R. The roles of technology in primary HIV prevention for men who have sex with men. Curr HIV/AIDS Rep 2015; 12 481–8.
The roles of technology in primary HIV prevention for men who have sex with men.Crossref | GoogleScholarGoogle Scholar |

[45]  Office of National AIDS Policy. National HIV/AIDS strategy for the United States: updated to 2020. Indicator supplement. Washington, DC, USA: The White House; 2016. Available online at: https://www.hiv.gov/sites/default/files/nhas-indicators-supplement-dec-2016.pdf [verified 1 November 2017].

[46]  Mera R, McCallister S, Palmer B, Mayer G, Magnuson D, Rawlings K. Truvada (TVD) for HIV pre-exposure prophylaxis (PrEP) utilization in the United States (2013–2015). In: Mayer K, editor. Proceedings of the 21st International AIDS Conference; 8–22 July 2016; Durban, South Africa. Geneva: International AIDS Society; 2016. Abstract TUAX0105LB.

[47]  Sullivan PS, Mera Giler R, Mouhanna F, Pembleton ES, Guest JL, Jones J, Castel AD, Yeung H, Kramer M, McCallister S, Siegler AJ. Trends in use of emtricitabine/tenofovir disoproxil fumarate for pre-exposure prophylaxis (PrEP) against HIV infections, United States, 2012–2017. Ann Epidemiol 2018;
Trends in use of emtricitabine/tenofovir disoproxil fumarate for pre-exposure prophylaxis (PrEP) against HIV infections, United States, 2012–2017.Crossref | GoogleScholarGoogle Scholar |

[48]  Siegler A, Mouhanna F, Mera Giler R, Weiss K, Pembleton E, Guest J, Jones J, Castel A, Yeung H, Kramer M, McCallister S, Sullivan PS. The prevalence of PrEP use and the PrEP-to-need ratio in the fourth quarter of 2017, United States. Ann Epidemiol 2018;
The prevalence of PrEP use and the PrEP-to-need ratio in the fourth quarter of 2017, United States.Crossref | GoogleScholarGoogle Scholar |

[49]  Gallagher KM, Sullivan PS, Lansky A. Behavioral surveillance among persons at risk for HIV infection in the US: the National HIV Behavioral Surveillance System. Public Health Rep 2007; 122 32–8.
Behavioral surveillance among persons at risk for HIV infection in the US: the National HIV Behavioral Surveillance System.Crossref | GoogleScholarGoogle Scholar |

[50]  Centers for Disease Control and Prevention (CDC). HIV infection risk, prevention, and testing behaviors among men who have sex with men – National HIV Behavioral Surveillance, 20 U.S. Cities, 2014. HIV Surveillance Special Report 15. Atlanta, GA, USA: CDC; 2018. Available online at: https://www.cdc.gov/hiv/pdf/library/reports/surveillance/cdc-hiv-hssr-nhbs-msm-2014.pdf [verified 28 October 2018].

[51]  Centers for Disease Control and Prevention (CDC). HIV infection, risk, prevention, and testing behaviors among persons who inject drugs – National HIV Behavioral Surveillance: injection drug use, 20 U.S. Cities, 2015. HIV Surveillance Special Report 18. Revised edition. Atlanta, GA, USA: CDC; 2018. Available online at: https://www.cdc.gov/hiv/pdf/library/reports/surveillance/cdc-hiv-hssr-nhbs- pwid-2015.pdf [verified 28 October 2018].

[52]  Centers for Disease Control and Prevention (CDC). HIV infection, risk, prevention, and testing behaviors among heterosexuals at increased risk of HIV infection – National HIV Behavioral Surveillance, 17 U.S. Cities, 2016. HIV Surveillance Special Report 19. Atlanta, GA, USA: CDC; 2018. Available online at: https://www.cdc.gov/hiv/pdf/library/reports/surveillance/cdc-hiv-surveillance-report-number-19.pdf [verified 28 October 2018].

[53]  Sanchez TH, Sineath RC, Kahle EM, Tregear SJ, Sullivan PS. The annual American Men’s Internet Survey of behaviors of men who have sex with men in the United States: protocol and key indicators report 2013. JMIR Public Health Surveill 2015; 1 e3
The annual American Men’s Internet Survey of behaviors of men who have sex with men in the United States: protocol and key indicators report 2013.Crossref | GoogleScholarGoogle Scholar |

[54]  Parsons JT, Rendina HJ, Lassiter JM, Whitfield TH, Starks TJ, Grov C. Uptake of HIV pre-exposure prophylaxis (PrEP) in a national cohort of gay and bisexual men in the United States. J Acquir Immune Defic Syndr 2017; 74 285–92.
Uptake of HIV pre-exposure prophylaxis (PrEP) in a national cohort of gay and bisexual men in the United States.Crossref | GoogleScholarGoogle Scholar |