Abstract
BackgroundPre-exposure prophylaxis (PrEP) is a promising new HIV prevention method, especially for women. An urgent demand for implementation of PrEP is expected at the moment efficacy has been demonstrated in clinical trials. We explored the long-term impact of PrEP on HIV transmission in different HIV epidemics.Methodology/Principal FindingsWe used a mathematical model that distinguishes the general population, sex workers and their clients. PrEP scenarios varying in effectiveness, coverage and target group were modeled in the epidemiological settings of Botswana, Nyanza Province in Kenya, and Southern India. We also studied the effect of condom addition or condom substitution during PrEP use. Main outcome was number of HIV infections averted over ten years of PrEP use. PrEP strategies with high effectiveness and high coverage can have a substantial impact in African settings. In Southern India, by contrast, the number of averted HIV infections in different PrEP scenarios would be much lower. The impact of PrEP may be strongly diminished or even reversed by behavioral disinhibition, especially in scenarios with low coverage and low effectiveness. However, additional condom use during low coverage and low effective PrEP doubled the amount of averted HIV infections.Conclusions/SignificanceThe public health impact of PrEP can be substantial. However, this impact may be diminished, or even reversed, by changes in risk behavior. Implementation of PrEP strategies should therefore come on top of current condom campaigns, not as a substitution.
Highlights
Behavioral changes, such as reduction in the number of sex partners and the use of barrier methods in high-risk contacts, have slowed down the HIV epidemic in many places in the world [1,2] and will be of importance as long as no vaccine is available
In Pre-exposure prophylaxis (PrEP) scenarios with both low coverage and low effectiveness, condom substitution even led to an increase in the number of HIV infections in all three settings
Additional condom use during low coverage and low effective PrEP doubled the amount of averted HIV infections
Summary
Behavioral changes, such as reduction in the number of sex partners and the use of barrier methods in high-risk contacts, have slowed down the HIV epidemic in many places in the world [1,2] and will be of importance as long as no vaccine is available. Stop sexual HIV transmission almost completely, new intervention strategies are still urgently needed, especially those that can help women protect themselves. Pre-exposure prophylaxis (PrEP) seems a promising new intervention [7,8,9] to fill the gap in female-controlled prevention, but the method may be effective for males. Pre-exposure prophylaxis (PrEP) is a promising new HIV prevention method, especially for women. We explored the long-term impact of PrEP on HIV transmission in different HIV epidemics
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