ViewpointGlobal PrEP roll-out: recommendations for programmatic success
Introduction
Half a decade has passed since the original discoveries that oral co-formulated tenofovir disoproxil fumarate and emtricitabine before and after exposure to HIV prevents HIV infection1, 2 and that durable viral suppression prevents onward transmission.3 Second only to a cure or vaccine, these prevention discoveries have re-energised hopes for not only control of the epidemic but also elimination of new HIV cases. Universal, immediate treatment for people living with HIV has widespread adoption, and a groundswell of community action is helping to educate all communities that U=U (undetectable=untransmittable),4 which might have a substantial effect on reducing HIV stigma and improving mental health of people living with HIV. However, modelling of long-term outcomes5 and emerging data6, 7 suggest that universal treatment alone will not eliminate new infections. Several trials still in the field will continue to provide data on the effects of universal test and treat on communities and populations.8 Pre-exposure prophylaxis (PrEP), although increasingly adopted by health ministries worldwide (figure),9 is experiencing a more restricted roll-out, but early evidence suggests that the addition of PrEP to universal test and treat might substantially enhance reduction in new infections. Where PrEP has effectively been combined with scale-up of treatment, such as among populations of men who have sex with men (MSM) in London, UK, New South Wales, Australia, and San Francisco, USA, we are seeing impressive reductions in new infections.10, 11
Although variability exists in the roll-out of PrEP in different regions, ranging from inclusive programmes with wide access to availability only through certain sites doing studies, several commonalities in the marketing of PrEP are emerging that raise concerns for the long-term success of PrEP implementation and related programmes. Here, we identify these concerns and the potential ill-effects, while calling for immediate reconsideration of each approach. Our intention is to call attention to limitations in current roll-out strategies that could have lasting negative effects on PrEP uptake in communities that could otherwise benefit from it.
Unintended consequences resulting in poor PrEP uptake and persistence might arise from PrEP implementation programmes through three mechanisms: a persistent focus on risk and risk awareness as a motivator for people to seek out and use PrEP (product value, or the sell); targeting of only certain groups for PrEP access or support programmes (branding); and availability of PrEP outside of, rather than integrated within, other services (product placement). We strongly recommend reconsideration of these approaches and present alternatives and a rationale for each.
Section snippets
The sell: focus on protection, not risk
We propose movement away from the focus on individual risk when trying to engage potential PrEP users. Guidelines abound with recommendations focused on identification of people at risk and harnessing risk perception as a method to motivate PrEP access, uptake, and adherence. This approach adopts a risk framework, where the product (PrEP) we are said to be selling centres on reducing risk from a loss-framed perspective. Loss-framing for prevention emphasises risks, whereas gain-framing
The brand: implement universal PrEP access
Although framing PrEP in terms of safety, health, and wellness certainly influences branding, product branding also encompasses other emotional connections one develops towards products based, in part, on who offers them and who is using them. Numerous PrEP programmes use targeting to identify those at-risk for HIV by their being part of a particular group or by behaviours and, to a lesser extent, location of residence. Echoed by PrEP guidelines that list criteria for who should be offered
Product placement: client-centred services
PrEP needs to be nested within health promotion more generally. Prevention-effective adherence refers to use of PrEP during times when there is at least potential for HIV exposure. Clinics and programmes that only or mainly offer PrEP and fail to provide enough service to make longer-term engagement desirable are more likely to experience high drop-off. PrEP might best be considered as part of a health package that meets the prevention and treatment needs of communities.23, 24 Our systems of
Conclusions
Global PrEP roll-out requires substantial invigoration if we are to meet the modest expectations of UNAIDS and make a dent in global new infection rates. Although the world is learning how to best apply PrEP and there are some notable best practice models and significant reduction in new infections in several settings around the world, there is still much work to be done. Of note, clinics such as the Dean Street Clinic in London, UK, Fenway Clinic in Boston, MA, USA, and the innovative
References (30)
- et al.
Universal test and treat and the HIV epidemic in rural South Africa: a phase 4, open-label, community cluster randomised trial
Lancet HIV
(2018) - et al.
Rapidly declining HIV infection in MSM in central London
Lancet HIV
(2017) - et al.
Population-level effectiveness of rapid, targeted, high-coverage roll-out of HIV pre-exposure prophylaxis in men who have sex with men: the EPIC-NSW prospective cohort study
Lancet HIV
(2018) - et al.
Antiretroviral prophylaxis for HIV prevention in heterosexual men and women
N Engl J Med
(2012) - et al.
Preexposure chemoprophylaxis for HIV prevention in men who have sex with men
N Engl J Med
(2010) - et al.
Treatment to prevent transmission of HIV-1
Clin Infect Dis
(2010) U=U taking off in 2017
Lancet HIV
(2017)- et al.
HIV treatment as prevention: systematic comparison of mathematical models of the potential impact of antiretroviral therapy on HIV incidence in South Africa
PLoS Med
(2012) - et al.
Reduced community viral load does not coincide with a reduction in the rate of new HIV diagnoses and recent infections: data from a region of southern Italy
HIV Med
(2017) - et al.
Comparative assessment of five trials of universal HIV testing and treatment in sub-Saharan Africa
J Int AIDS Soc
(2018)
PrEP initiations by country worldwide. AIDS Vaccine Advocacy Coalition
Perceived risk as a moderator of the effectiveness of framed HIV-test promotion messages among women: a randomized controlled trial
Health Psychol
The strategic use of gain- and loss-framed messages to promote healthy behavior: how theory can inform practice
J Commun
Sixty years of fear appeal research: current state of the evidence
Int J Psychol
Explaining the efficacy of pre-exposure prophylaxis (PrEP) for HIV prevention: a qualitative study of message framing and messaging preferences among US men who have sex with men
AIDS Behav
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