Expansion of HIV Preexposure Prophylaxis to 35 PEPFAR-Supported …

Summary

What is already known about this topic?

Preexposure prophylaxis (PrEP) reduces human immunodeficiency virus (HIV) infection incidence.

What is added by this report?

During October 2016–September 2018, in 15 of 35 country or regional programs supported by the U.S. President’s Emergency Plan for AIDS Relief, the increase in PrEP coverage among the general population was approximately triple that among female sex workers, men who have sex with men, and transgender women. Critical factors associated with successful PrEP implementation in these populations include stakeholder engagement, existing PrEP delivery guidelines, HIV service provider training, and a drug procurement system.

What are the implications for public health practice?

Sharing best practices could facilitate adoption of PrEP in other country or regional programs and contribute to epidemic control.

The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), the largest bilateral funder of human immunodeficiency virus (HIV) prevention and control programs worldwide, currently supports implementation of preexposure prophylaxis (PrEP) to reduce HIV incidence among persons at substantial risk for infection, including female sex workers, men who have sex with men (MSM), and transgender women (hereafter referred to as key populations). Recent estimates suggest that 54% of all global new HIV infections in 2018 occurred among key populations and their sexual partners (1). In 2016, PEPFAR began tracking initiation of PrEP by key populations and other groups at high risk (2). The implementation and scale-up of PrEP programs across 35 PEPFAR-supported country or regional programs* was assessed by determining the number of programs reporting any new PrEP clients during each quarter from October 2016 to September 2018. As of September 2018, only 15 (43%) PEPFAR-supported country or regional programs had implemented PrEP programs; however, client volume increased by 3,351% over the assessment period in 15 country or regional programs. Scale-up of PrEP among general population clients (5,255%) was nearly three times that of key population clients (1,880%). Among key populations, the largest increase (3,518%) occurred among MSM. Factors that helped drive the success of these PrEP early adopter programs included initiation of national, regional, and multilateral stakeholder meetings; engagement of ministries of health and community advocates; revision of HIV treatment guidelines to include PrEP; training for HIV service providers; and establishment of drug procurement policies. These best practices can help facilitate PrEP implementation, particularly among key populations, in other country or regional programs to reduce global incidence of HIV infection.

International, national, subnational, nongovernmental, and academic PEPFAR implementing partners reported PrEP data from country or regional programs for eight quarters (i.e., October–December 2016 through July–September 2018). The primary outcome measured was the number of persons (including new enrollees) who received PrEP during the reporting period, disaggregated by key population group (i.e., female sex workers, MSM, and transgender women). To assess implementation and scale-up of PrEP, the number and percentage of the 35 PEPFAR-funded country or regional programs that reported PrEP initiation among key populations or the general population and the number of new PrEP clients in each program were determined. The relative percentage change in PrEP initiation for the general population and that in the key populations over time were also compared.

Country or regional programs with >150 new key population clients across multiple quarters totaling ≥1,000 clients were classified as early adopters of PrEP among key populations. The threshold of 150 clients per quarter was determined by a minimum enrollment rate of 50 key population clients per month during a quarter. Using previous analyses of PrEP implementation (3,4), critical factors and scale-up accelerators that facilitate early coverage and rapid growth among PrEP programs were identified. This list of factors was provided to implementing partners in the early adopter programs, who were asked to determine whether these factors were relevant to the growth of their respective programs.

During the analysis period, 35 PEPFAR-supported country or regional programs were assessed. Substantial scale-up of PrEP initiation among 15 of these programs took place, commencing with 888 new clients during October–December 2016 and ending with 30,644 during July–September 2018 (Figure), representing a 3,351% overall increase among general population and key population clients over the assessment period. Scale-up of PrEP initiation among the general population (5,255% increase) was nearly three times that among the key populations (1,880%), and the increases in PrEP initiation within the key populations substantially varied among key population groups (Table 1). For example, the largest increase in enrollment of new clients within the key populations occurred among MSM (3,518%), whereas the increase among transgender women was substantially lower (573%). The percentage of new key population clients among all new PrEP clients varied over the analysis period (range = 29%–56%) and was 32% in the most recent quarter (July–September 2018). Overall, among 35 PEPFAR-supported country or regional programs, 15^† (34%) have reported providing PrEP services to general population clients, and 13^§ have reported providing PrEP services to key population clients.

Among all PEPFAR-supported programs, six (Asia Region, Kenya, South Africa, Uganda, Vietnam, and Zimbabwe) were classified as early adopters of PrEP for key populations. Implementing partners in five of these programs (all except Vietnam) identified critical factors for early adoption of PrEP (Table 2), including national and regional stakeholder meetings with strong ongoing engagement and advocacy from ministries of health, community advocates, and multilateral partners such as the World Health Organization and the Joint United Nations Programme on HIV/AIDS (UNAIDS). Five early adopter programs included PrEP services in national treatment and prevention guidelines despite the lack of favorable legal environments to safeguard key populations from violence and discrimination. Early programs also reported standardized, routine HIV service provider training and the ability of their governments to procure PrEP.

Factors that accelerated PrEP scale-up included active government ownership of the national PrEP program and innovations in PrEP service delivery. Most governments supported PrEP programs by drafting policies and guidelines, developing or adapting PrEP training curricula, accrediting sites, and collecting and reporting data. PrEP marketing innovations, including promoting PrEP outside the typical clinical platform through drop-in centers or key population safe spaces; on social media; at meeting places such as sex clubs and gay bars; and in the community through peer outreach also were critical accelerators (5).