Silver bullets and structural impediments to HIV prevention

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For HIV prevention, the past decade has been the best of times and the worst of times. Modern antiretroviral treatment effectively prevents HIV transmission,1,2 and tenofovir-based pre-exposure prophylaxis (PrEP) works extremely well when used consistently.3–5 Moreover, where population levels of virological suppression are high (eg, New South Wales, Australia, San Francisco, USA, and London, UK), addition of PrEP has been associated with decreasing HIV incidence.6–8 However, challenges to optimal deployment exist because those at greatest risk of HIV often have concomitant issues that impede adherence (eg, substance use, depression, poverty, unsupportive governments, and inadequate health-care systems).