Towards a fair consideration of PrEP as part of combination HIV prevention in Latin America

Abstract

IntroductionDespite progress in scaling up antiretroviral treatment, HIV prevention strategies have not been successful in significantly curbing HIV incidence in Latin America. HIV prevention interventions need to be expanded to target the most affected key populations with a combination approach, including new high impact technologies. Oral pre-exposure prophylaxis (PrEP) is recommended as additional prevention choice for individuals at higher risk of infection and could become a cost-effective prevention tool. We discuss the barriers and solutions for a fair consideration of PrEP as part of combination HIV prevention strategies in Latin America.DiscussionAlthough demonstration projects are ongoing or being planned in a number of countries, to date no Latin American country has implemented a public PrEP programme. The knowledge of policymakers about PrEP implementation needs to be strengthened, and programmatic guidance and cost estimate tools need to be developed to support adequate planning. Despite high levels of awareness among health providers, especially if engaged in HIV or key population care, willingness to prescribe PrEP is still low due to the lack of national policies and guidelines. Key populations, especially men who have sex with men, transgender women and sex workers, have been engaged in demonstration projects, and qualitative research shows high awareness and willingness to use PrEP, especially if accessible in the public sector for free or at affordable price. Concerns of safety, adherence, effectiveness and risk compensation need to be addressed through targeted social communication strategies to improve PrEP knowledge and stimulate demand. Alliance among policymakers, civil society and representatives from key populations, healthcare providers and researchers will be critical for the design and successful implementation of PrEP demonstration projects of locally adapted delivery models. The use of mechanisms of joint negotiation and procurement of antiretrovirals could reduce costs and significantly increase the cost-effectiveness of PrEP.ConclusionsPrEP is an additional prevention tool and should be implemented in combination and synergy with other prevention interventions. PrEP programmes should target high-risk individuals from key populations for higher cost-effectiveness. Demonstration projects may generate strategic information for and lead to the implementation of full-scale PrEP programmes.

Next-Wave HIV Pre-Exposure Prophylaxis Implementation for Gay and Bisexual Men

“…74 Analyses of barriers to PrEP implementation at the systems level note that reducing financial burden related to medication is paramount for the feasibility and sustainability of PrEP programs. 75,76 In modeling studies, cost of PrEP medication is a critical factor in shortening the time horizon for the cost effectiveness of PrEP as an intervention. 24,77 And reviews of implementation efforts demonstrate that PrEP rollout is successful when government provides financial support and is impeded when such support is lacking.…”

Incidence and Time-Varying Predictors of HIV and Sexually Transmitted Infections Among Male Sex Workers in Mexico City

“…Yet PrEP is currently only available in three cities in Mexico and offered to only a limited number of male sex workers and other MSM in Mexico City. Furthermore, procurement prices continue to be higher in Mexico than other Latin American countries, which can be a deterrent to larger scale PrEP implementation (Ravasi et al, 2016;Pan American Health Organization & World Health Organization, 2013). Given the limited availability of PrEP for key populations in Mexico and the high rate of HIV observed in our sample, it is likely that Since only a small number of MSWs reported consistently using condoms during anal and vaginal sex (28.63%),…”

PrEP awareness among men who have sex with men at higher risk for HIV in Brazil, Mexico, and Peru, 2018

“…However, gay, bisexual and other men who have sex with men (MSM) are disproportionally impacted with HIV in Latin America (1, 6-13) and are 33.3 times more likely to be infected with HIV compared to the general population (14). This risk for HIV may be an underestimate as MSM in Latin America continually face social stigmatization and may not seek HIV testing or treatment (14,15).…”

“…When taken four to seven days a week, PrEP has been indicated to provide protection against HIV by more than 90% (22). PrEP use has been recommended by the World Health Organization (WHO) in 2014 as an additional tool to prevent HIV among MSM and was revised in 2015 to include any high-risk population (15,23,24).…”