Pre-exposure prophylaxis (PrEP) programmes should adopt modern marketing strategies that are attractive to healthy individuals and that might promote an inclusive and holistic vision of PrEP, Dr K Rivet Amico and Professor Linda-Gail Bekker argue in an opinion piece published in The Lancet HIV.
They note that the roll-out of PrEP has lagged in many settings – including most generalised epidemic settings. However, there are successes which can be learned from and the authors call for PrEP programmes to change in three ways.
Focus on protection, not risk
Guidelines focus on identifying individuals who are at risk, but messaging about risks is essentially negative. Messaging that focuses on protection and health is more positive. People should be asked how confident they feel in maintaining their HIV-negative status, rather than how 'at risk' they feel, the authors say.
Framing PrEP in terms of protection, wellbeing and feeling safe from HIV is more empowering. The approach is especially likely to be effective with people who do not already have elevated perceptions of personal risk, such as women and young people.
Promote PrEP as available to everyone
Targeting PrEP programmes to particular risk groups has unintended consequences, Amico and Bekker believe. When PrEP is primarily offered to sex workers, the intervention is seen to only be appropriate for sex workers. When PrEP is promoted primarily to gay men, it feels less relevant to women and others who could benefit.
“We strongly recommend the adoption of universal PrEP access, meaning all people should know about PrEP and be able to access it if appropriate,” they write.
Integrate PrEP with other valued health services
Programmes which focus on PrEP and do not provide other services that people want are more likely to have large numbers of clients dropping out of care. If PrEP is the only reason people come to a clinic, it is not surprising that when people are no longer interested in PrEP they simply stop attending.
PrEP should be considered one part of a broader health package. Initial interest in PrEP might be enough to get people through the door, but comprehensive and engaged care that offers services of relevance and value to clients will help maintain long-term engagement.
The situation in England
The editors of The Lancet HIV contrast Dr K Rivet Amico and Professor Linda-Gail Bekker's recommendations with the current state of PrEP policy in England. PrEP is only available through the Impact trial, which has been oversubscribed by gay and bisexual men, with capacity reached in many clinics and potential participants turned away. A proposal to expand the number of trial participants has been delayed while cash-starved local authorities (who pay for the clinical services providing PrEP but not the medication itself) are consulted on the impact this will have. PrEP knowledge and awareness is far higher among gay and bisexual men than in other social groups.
"Why is NHS England dragging its heels on universal access (that is, providing PrEP to all who would benefit regardless of membership of certain key populations) and instead capping the numbers of those who can access the trial?" the journal asks. "High coverage, rapid roll-out, and consideration of the health and geographical inequalities faced by many at risk of HIV, will be needed to maximise the preventive effects of PrEP."
Amico KR & Bekker LG. Global PrEP roll-out: recommendations for programmatic success. Lancet HIV, online ahead of print, 2019. (Full text freely available.)
For the greatest impact, end caps on PrEP access now. Lancet HIV (editorial), online ahead of print, 2019. (Full text freely available.)