Abstract
IntroductionTowards the end of the twentieth century, significant success was achieved in reducing incidence in several global HIV epidemics through ongoing prevention strategies. However, further progress in risk reduction was uncertain. For one thing, it was clear that social vulnerability had to be addressed, through research on interventions addressing health systems and other structural barriers. As soon as antiretroviral treatment became available, researchers started to conceive that antiretrovirals might play a role in decreasing either susceptibility in uninfected people or infectiousness among people living with HIV. In this paper we focus on the origin, present status, and potential contribution of pre-exposure prophylaxis (PrEP) within the combination HIV prevention framework.DiscussionAfter a phase of controversy, PrEP efficacy trials took off. By 2015, daily oral PrEP, using tenofovir alone or in combination with emtricitabine, has been proven efficacious, though efficacy seems heavily contingent upon adherence to pill uptake. Initial demonstration projects after release of efficacy results have shown that PrEP can be implemented in real settings and adherence can be high, leading to high effectiveness. Despite its substantial potential, beliefs persist about unfeasibility in real-life settings due to stigma, cost, adherence, and potential risk compensation barriers.ConclusionsThe strategic synergy of behavioural change communication, biomedical strategies (including PrEP), and structural programmes is providing the basis for the combination HIV prevention framework. If PrEP is to ever become a key component of that framework, several negative beliefs must be confronted based on emerging evidence; moreover, research gaps regarding PrEP implementation must be filled, and appropriate prioritization strategies must be set up. Those challenges are significant, proportional to the impact that PrEP implementation may have in the global response to HIV.
Highlights
Towards the end of the twentieth century, significant success was achieved in reducing incidence in several global HIV epidemics through ongoing prevention strategies
The development of effective antiretrovirals (ARVs) led, from the start, to conceiving of biomedical prevention tools to decrease either susceptibility in uninfected people or infectiousness among people living with HIV (PLH)
Within the HIV field, secondary prophylaxis against Pneumocystis carinii pneumonia with cotrimoxazole was introduced among PLH [33]
Summary
By the end of the twentieth century, two decades after the HIV epidemic became visible, substantial success in slowing down HIV transmission had been achieved with ongoing prevention strategies, but it seemed far from stopping epidemic growth [1,2]. The use of combined antiretroviral treatment (ART) to prevent disease progression [3] and the development of effective regimes to prevent mother-tochild transmission (PMTCT) [4] were major steps in the HIV response. In response to those, ‘‘structural interventions’’ targeting legal, institutional, social, cultural, and economic determinants of HIV vulnerability are considered essential to the HIV response [21]. This new environment of bio-behavioural, individuallevel interventions, along with appropriate social-structural. We focus on the origin, present status, and potential contribution of PrEP within the combination HIV prevention framework
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