Editorial
Bridging accessibility gaps in HIV prevention
According to the UNAIDS global update for 2023, the
global decline in new HIV infections was modest in
2022, with an estimated 1·3 million new infections,
down just 200 000 compared with 2021, and far short
of the 2025 target of 370 000. Equitable access to a
wide array of effective prevention options is crucial to
achieving reductions in new infections. Although oral
pre-exposure prophylaxis (PrEP) has contributed to
declines in new infections, awareness and demand are
concentrated in men who have sex with men. New PrEP
products, such as long-acting injectables and dapivirine
rings, offer expanded choice, but barriers blocking
their implementation, including regulatory approvals,
affordability, accessibility, and societal acceptance, need to
be addressed to realise their potential.
Despite the approval of preventive options such as
long-acting injectable cabotegravir and dapivirine vaginal
rings in South Africa, delays in implementation pilots
due to start in early 2023 have tempered enthusiasm
within the HIV community. Roll-out of long-acting
injectable cabotegravir has been delayed because
manufacturer packaging does not meet the country’s
regulatory requirements, hindering implementation
studies aimed at offering users a choice between different
PrEP products in a real-life environment. Even when
this roadblock is passed, there is still the uncertainty
surrounding its final pricing and the limited global supply
of cabotegravir injections due to the small number of
generic manufacturers. For the dapivirine vaginal ring,
delays were caused by issues in post-importation testing,
although the pilots can now begin.
In this issue, Patel and colleagues make a compelling
case for the importance of providing a choice of HIV
prevention options and implementing effective delivery
approaches while considering individual preferences and
needs. Information and choice are particularly important
for women, who in a country such as the USA comprise
18% of new HIV diagnoses but represent only 8% of PrEP
users. UNAIDS estimates that about 210 000 adolescent
girls and young women (aged 15–24 years) acquired HIV
in 2022. Compared with oral PrEP, the dapivirine vaginal
ring and long-acting injectable cabotegravir could offer
more discreet options for women in vulnerable situ­
ations, helping to overcome regional stigmas surrounding
female-controlled prevention methods. The sustained
www.thelancet.com/hiv Vol 10 August 2023
duration of long-acting injectables can also enhance See Comment page e492
convenience and accessibility for people who inject drugs, For the latest global HIV
statistics in the UNAIDS 2023
for whom unstable living situations or substance use report see https://www.unaids.
patterns can hinder adherence to daily oral PrEP. org/en/resources/
documents/2023/global-aids-
Historically, the implementation of HIV prevention update-2023
products has posed significant challenges for health- For more on delays on new PrEP
options in South Africa see
care systems. Following WHO’s recommendation for https://www.spotlightnsp.
oral PrEP in 2015 for populations at high risk of HIV, it co.za/2023/06/28/in-depth-hiv-
prevention-shots-and-vaginal-
quickly became evident that different regions, countries, rings-this-is-why-sa-pilots-have-
and communities face a variety of challenges in adopting not-yet-started/
it, partly influenced by sociocultural norms, beliefs, and For more on PrEP use by women
in USA see https://aidsvu.org/
practices. No country is free from these roadblocks. For national-women-girls-hiv-aids-
example last month the USA, which in 2012 was the awareness-day-2023/
For more on the PrEP Access and
first country to approve oral PrEP, reintroduced the PrEP
Coverage Act see https://www.
Access and Coverage Act, which aims to bridge access smith.senate.
gov/u-s-senator-tina-smith-
gaps by providing zero-cost coverage for both public and reintroduces-legislation-to-
private insurance payers and establishing a national grant expand-access-to-lifesaving-hiv-
prevention-drugs/
programme for the uninsured. However, the act is already
For more on the Texas ruling see
undermined by the ruling of a federal judge in Texas https://www.nbcnews.com/
that funding HIV prevention for LGBTQ+ people violates think/opinion/texas-prep-hiv-
ruling-goes-against-
religious freedom of private companies. The ruling casts a commonsense-rcna47059
grave shadow over Americans’ access to HIV prevention.
Although key populations continue to bear a
disproportionately heavy burden of HIV relative to their
population size, targeted approaches for these groups
have yielded remarkable results, leading to a substantial
reduction in HIV transmission rates. An example of this
progress is the shift in the landscape of new HIV infections
in the UK, where, the number of reported new HIV
diagnoses among heterosexual individuals has surpassed
that among men who have sex with men. Health-care
systems face the impending need to scale awareness and
generate demand by showcasing the inclusive nature of
PrEP to all potential users who might benefit. Moving
away from moral judgment and creating an environment
where individuals feel comfortable expressing their needs
and are able to access easily understandable information
are key to reaching all of society.
Awareness and demand for PrEP must include all
those at risk of HIV. Through educational and access
programmes that place people’s multifaceted diversity
at their centre, health-care systems should seek to
obtain more than just functional HIV prevention
products, and strive to enable equitable delivery of the
incoming array of PrEP options. ■ The Lancet HIV
e485