A study shows a significant progress in PrEP policies in Latin America and the Caribbean, where an increasing number of countries have begun to provide PrEP to communities at heightened risk of acquiring HIV. The study also highlights the gaps that remain in the process and provides recommendations to improve PrEP policies and access in the region.
In Latin America and the Caribbean, the incidence of new HIV cases has only declined by 1% since 2010. Furthermore, the HIV epidemic is concentrated among men who have sex with men and transgender women, which have an HIV prevalence of over 10% and 20%, respectively. PrEP is therefore urgently needed for these populations.
Luke Murphy from the University of California Los Angeles and colleagues from Peru and Canada reviewed the PrEP policy landscape throughout Latin America and the Caribbean. Their objective was to better identify implementation gaps and opportunities to improve access to PrEP in the region. They reviewed and collected information on the state of approval by national regulators of PrEP – a key step to further increasing access to it – and also compared PrEP prescribing guidelines and delivery methods in the region, up to July 2022.
The team examined many sources, including national guidelines, media stories, press releases, non-governmental organisational reports, and peer-reviewed scientific articles. To be eligible for the study, these sources had to address the approval of or access to PrEP, its availability methods, clinical guidelines or cost for Latin America and Caribbean countries. The research did not involve contacting experts in each country, such as government officials, doctors and activists.
The study reveals a very diverse PrEP policy and access landscape across Latin America and the Caribbean.
Of the thirty-three countries in the region, twenty-two (67%) have policies approving daily oral PrEP for HIV prevention with branded Truvada, fifteen having also registered the use of generic tenofovir/emtricitabine. Truvada is approved in 11 of 12 countries in South America, five of eight countries in Central America and Mexico, and six of 13 countries in the Caribbean. Of note, these figures are based on countries about which information was available. For most other countries, no information was found, rather than it being confirmed that PrEP had not been approved.
The legal environment in the Caribbean appears to be an impediment to PrEP programmes. Of five countries which criminalise homosexuality, all but one have not approved PrEP. Of four countries that ended criminalisation in the last five years, all but one have no PrEP. Finally, all four countries with no recent history of criminalisation of homosexuality have PrEP available.
No countries have approved cabotegravir-based injectable PrEP. However, Brazil had submitted an application at the time of the review, and since then Peru has done the same.
Modes of access to PrEP are quite variable. Thirteen of the countries approving PrEP provide it through their public health systems. In the other ones, PrEP can be obtained for free (although sometimes individuals must pay for follow-up tests) through non-governmental organisations, government-led implementation programmes or clinical trials. Sadly, in certain countries such as Costa Rica and Suriname, PrEP can only be purchased at pharmacies or private clinics.
The investigators also found that it is often difficult to differentiate between approvals for branded or for generic oral PrEP. This is important because generics lower the cost of PrEP, therefore facilitate its scale-up. It was also noted that in some countries not having formally approved PrEP, it may be that the medication, authorised as HIV treatment, is also used off-label for PrEP.
Fourteen countries have clinical guidelines for PrEP. Importantly, these clearly outline specific target populations, including men who have sex with men, transgender women, sex workers and serodiscordant couples.
Other significant findings were highlighted:
- From one country with guidelines to another, there can be differences in populations considered as key for PrEP programmes. For example, some countries refer to “transgender individuals” or “transgender persons” instead of trans women. Also, eight countries (Argentina, Colombia, the Dominican Republic, El Salvador, Ecuador, Guatemala, Haiti and Mexico) have included people who inject drugs in their guidelines.
- Similarly, the landscape of “risk behaviours” as inclusion criteria is heterogeneous. Risk behaviours are generally comprehensively defined in the guidelines. However, different phrasings are found, which can be so specifically described that they may end up being too rigid (such as in Ecuador) or, on the contrary, flexible enough to allow for discussion between the individual at perceived risk for HIV – be they or not outside of a key population – and the PrEP prescriber (Barbados, Chile, Colombia, Costa-Rica, El Salvador and Guatemala).
- Variations are also found in recommended PrEP modalities. Only seven country-level guidelines recommend event-driven PrEP, which has been proven to be as effective as daily PrEP. It should be noted, however, that most of the country guidelines not mentioning event-driven PrEP were published before the World Health Organisation recommended it in 2019.
- In certain countries, there can be a time lag between media announcements of PrEP availability and the reality. The authors quote a Guyanese newspaper referring to a “comprehensive plan for PrEP in Guyana” about which no official policy documents could be found, perhaps indicating delays in the writing and publications of policies and guidelines following the approval of PrEP, as well as in its actual implementation in clinics which is likely to happen even later.
- In the twenty-two countries where PrEP is approved, its cost is often unclear, with only Ecuador reporting the cost in their guidelines. Although thirty-one governments have signed on to the Pan American Health Organization’s Strategic Fund – which lowers the cost of PrEP to $4.50 a month – very little information is available publicly on medications purchased through this agreement.
Nevertheless, Murphy and colleagues acknowledge the significant advances in PrEP policies in Latin America and the Caribbean. They say there are opportunities for greater PrEP implementation in the region and recommend increased transparency about medication approvals, cost and public health policies; approval of generic and injectable PrEP; integration of PrEP in public health systems; and strengthening regional alliances to support access to PrEP.
Murphy L et al. PrEP policy implementation gaps and opportunities in Latin America and the Caribbean: a scoping review. Therapeutic Advances in Infectious Disease, 17 April 2023 (open access).
Full image credit: CDC Central America Regional Office Supporting Partner Organizations in Guatemala. Staff members of Colectivo Amigos Contra el SIDA (CAS), a free HIV and sexually transmitted disease prevention clinic for men-who-have-sex-with-men, support HIV prevention programming in Guatemala City. Image by CDC Global. Image is for illustrative purposes only. Available at www.flickr.com/photos/cdcglobal/49991680106 under a Creative Commons licence CC BY 2.0.