Expanding PrEP treatments

Too many people continue to become infected with HIV globally and in sub-Saharan Africa particularly, so I appreciate your leader highlighting the need to improve prevention efforts (“How to beat HIV” September 23rd). Pre-exposure prophylaxis (PrEP), using drugs to reduce the risk of HIV infection, is a critical tool in efforts to end the epidemic. Oral PrEP works for everyone, men and women, regardless of sexual orientation.

True, the impact of PrEP among women in sub-Saharan Africa has been suboptimal because of challenges with adhering to daily pill-taking, limited access and stigmatisation. However, making oral PrEP easily and widely accessible in communities has been shown to facilitate its uptake. Indeed, research such as the SEARCH study in Kenya and Uganda has found this approach to be associated with lower HIV infection risks among men and women.

New PrEP options, including a long-lasting injection and the vaginal ring, are exciting and needed. People should have choices that suit their needs. Cabotegravir, an injectable PrEP, has been found highly effective at preventing HIV. However, manufacturing injectable PrEP is complicated and generic cabotegravir is years away. Access remains very limited. Moreover, most projects planning to offer injectable PrEP do not focus on so-called key populations who are at particularly high risk of HIV, such as sex workers, transgender people and men who have sex with men. Even in sub-Saharan Africa, where girls and young women face substantial HIV risk, about half of new infections are among key populations and their sexual partners. Punitive laws like those criminalising samesex relations undermine HIV-prevention efforts. Removing these barriers is critical to ensuring health-care access for those who need it most, something no new pharmaceutical product will do.

DR ROBIN SCHAEFER

Forum for Collaborative Research University of California, Berkeley