Equitable coverage for HIV-Pre-Exposure Prophylaxis and optimization of HIV Prevention programme delivery

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Background Oral HIV Pre-Exposure prophylaxis (PrEP) is a highly effective biomedical intervention for reducing HIV acquisition, and is recommended by the WHO as part of a comprehensive approach to HIV prevention1. In England, PrEP can be acquired through a number of different routes, including: 1) A private prescription from a doctor (cost to patient is £400 per month; 2) private online providers (cost to patient is £35-£45 a month); 3) an ongoing implementation trial (the PrEP Impact Trial), funded by NHS England (no cost to patient). The PrEP Impact Trial will run until October 2020 in sexual health clinics and will collect biomedical outcome data (i.e., the proportion of clinic attendees meeting PrEP eligibility criteria, proportion prescribed PrEP, duration of their eligibility; HIV/STI diagnoses; adverse events). However, only data on trial participants will be collected; questions remain regarding eligibility among people who do not attend sexual health clinics, and the attitudes of the wider community.PrEP provision programmes have been implemented in many locations worldwide, however, there have been reports of low uptake among certain populations, including young men who have sex with men (MSM) 2,3 and heterosexual men and women2. Furthermore, despite a fall in the rate of new HIV diagnoses in England, not all groups, for example heterosexual men and women, have seen sustained or equal rates of decline4. These populations may benefit from interventions to increase PrEP awareness, uptake, and adherence. In order to identify which populations are most at need of interventions, requires both an estimation of the at risk population eligible for PrEP, and the uptake within that population. The population of MSM in England who are eligible for PrEP has been estimated5, however, other risk groups, including black and minority ethnic heterosexual men and women, are less well characterised.There is currently no standardised measure to evaluate uptake, coverage and need in at-risk populations. Such a measure could be used to evaluate current and future PrEP implementation programmes, and identify groups that could benefit from additional interventions to increase uptake and support PrEP adherence. Overall AimThe aim of this work is to develop a measure of equitable PrEP coverage for populations at high risk of HIV in England, and explore the barriers and facilitators to PrEP access, uptake and adherence.