Improving access to HIV prevention is critical if we want to see meaningful reductions in new infections. Although the adoption and use of oral pre-exposure prophylaxis (PrEP) has gradually increased, with an estimated half a million people initiating PrEP worldwide, we are far from achieving the global target of three million users by the end of 2020.
Eight years after oral PrEP was approved and five years after the World Health Organization recommended oral PrEP for people at substantial risk of HIV infection, now is the time to reimagine how PrEP can be delivered more effectively and to those who need it. Those who need it most may not want or be able to go to a health facility where they may face stigma, stock-outs and long waiting times.
To date, the delivery of oral PrEP – the first antiretroviral-based prevention product – has largely been facility-based, which requires multiple visits to a clinic. Some of the reasons people discontinue PrEP can be attributed to the way it is delivered. It is time for PrEP programmes to be infused with the same ingenuity that has improved access to antiretroviral therapy.
Differentiated service delivery (DSD) grew from the principle that HIV services must be adapted to the evolving and specific needs of people living with HIV. This applies equally, if not more, to prevention because it is particularly challenging to engage individuals in more formal care when they are healthy and the perceived risk of infection is low. By removing common barriers to access, reaching individuals through influential peer networks and promoting self-directed care, DSD has the potential to improve PrEP uptake and longer-term use.
Many implementers have modified the ways they deliver oral PrEP across diverse settings and populations. Programmes have pivoted and become more flexible, responding to people’s lived realities and unprecedented circumstances, including the COVID-19 pandemic. Task shifting to peers for outreach and/or medication drop off, online delivery and consultations, drop-in centres, multi-month dispensing of refills and, in some cases, HIV self-testing have all been tried to support people to start and stay on PrEP.
In Namibia, The Society for Family Health relies on trained peer navigators who meet with female sex workers at a convenient location with refills and testing kits. Through the Jilinde project in Kenya, adolescent girls and young women receive HIV prevention, integrating PrEP and sexual and reproductive health services. Peer educators mobilize peers to access safe spaces, health facilities or drop-in centres providing PrEP and SRH services on a scheduled date. Once Jilinde diversified PrEP delivery from primarily comprehensive care centres to DICE’s specific to adolescent girls and young women, youth-friendly centres and community safe spaces, the uptake increased exponentially.
Programmes have also customized PrEP delivery in response to COVID-19. The USAID/PATH Healthy Markets Project in Vietnam provides clients with a blood-based HIV self-test kit via mail, courier, peer drop off or in-person pickup. A physically distanced peer leads the client through the test or it is done online. Similarly, the Project PrEP Initiative in South Africa moved to providing a two-month supply of PrEP and contacting young people via phone and/or WhatsApp to assess continuation and support needs.
Although the shift toward differentiated PrEP delivery preceded the pandemic, COVID-19 has highlighted the urgency for DSD. As access to clinics may be impeded and heighten the risk of exposure to COVID-19, several countries, from the United States to Zimbabwe, have authorized multi-month dispensing, and some provide the option of HIV self-testing (where lab-based testing is not feasible) in revised national PrEP guidelines during the pandemic. There may be constraints in translating these policies into practice, especially during a global health emergency, but we must harness the growing commitment and creativity to reinvent PrEP delivery and ensure that this momentum endures.
More research is needed to compare the cost effectiveness, programmatic outcomes and longer-term impact of DSD models for PrEP. However, early programmatic lessons that point to improved access and, in some cases, continuation and client satisfaction are encouraging. COVID-19 may have ushered in a new era of innovation, but it is up to us to ensure that HIV prevention is transformed for good.