Challenges in optimizing preexposure prophylaxis development, engagement, and access for HIV prevention

Abstract

One of the greatest successes of modern science is the development of effective antiretroviral therapy (ART) for control of HIV-1 infection. Arguably one of the more innovative responses the ongoing HIV epidemic is the repurposing of ART for preventive efforts as preexposure prophylaxis (PrEP). This strategy has been critical in the face ofto approximately 1.7 million new infections in 2018 and in the absence of an effective HIV vaccine. Notwithstanding this advance, significant scientific challenges remain for the optimal implementation of PrEP, and novel approaches are still needed (1). In the United States, currently approved PrEP consists of a single pill containing two antiretroviral drugs taken daily. While this regimen substantially reduces the risk of HIV-1 acquisition, PrEP has still not reached the majority of at-risk individuals, even in resource-rich settings (2). Comprehensive preventive services are a cornerstone of the Department of Health and Human Services strategic plan to end the HIV epidemic (3), and PrEP is the biomedical intervention currently available. Preventive interventions are at the intersection of medical and behavioral science, and their rollout can highlight disparities in health care access. PrEP is no different, requiring rigorous efforts to achieve its potential equitably across diverse groups. We propose that PrEP offers a window into the efforts to end the HIV epidemic while also illuminating the tension between [...].