Global PrEP roll-out: recommendations for programmatic success

Summary

Pre-exposure prophylaxis (PrEP) is being adopted and rolled out in diverse regions, communities, and groups. Although it has been shown to be effective, in some settings PrEP roll-out has lagged, in part due to flawed messaging. Lessons can be learned and principles applied from marketing to highlight the potential pitfalls of current roll-out strategies focused on selective and siloed service provision. After exploration of the way PrEP is promoted in awareness messaging (the sell), marketed to select and often stigmatised groups (the brand), and offered as a special or non-integrated service (product placement), we propose that current strategies can ultimately slow roll-out and contribute to stigma surrounding PrEP use. We propose alternatives for programmes and ministries to consider as they develop long-term plans for HIV prevention. We propose that the sell should focus on protection or wellness framing, the branding should convey PrEP as appropriate for anyone in need, and the provision of PrEP should be placed in the context of other relevant and valued health services. As has been shown in some PrEP programmes, it is possible for programmes to adopt modern marketing strategies that are attractive to healthy clients and might promote an inclusive and holistic vision of biomedical prevention.

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.