Rapid scale-up of oral pre-exposure prophylaxis (PrEP) for key populations: experience from the PEPFAR/USAID-funded EpiC project

BACKGROUND: Improved access to oral pre-exposure prophylaxis (PrEP) as part of a comprehensive prevention strategy is urgently needed to respond to the unmet prevention needs of high-risk key populations (KPs), including sex workers, men who have sex with men (MSM), transgender (trans) people, and people who inject drugs (PWID), and to interrupt HIV transmission among them. The PEPFAR/USAID-funded Meeting Targets and Maintaining Epidemic Control (EpiC) project expanded differentiated service delivery (DSD) models to support PrEP scale-up in 16 countries.
DESCRIPTION: From October 2018 to September 2020, EpiC implemented PrEP programs tailored to high-risk KP individuals in 16 countries across Africa, Asia, and the Caribbean. The program trained providers to offer PrEP services through DSD models, including at KP-run community sites such as drop-in centers, mobile units, and facilities. Routine program data were collected, aggregated, and analyzed to understand trends in PrEP uptake and the major factors relevant to scale-up.
LESSONS LEARNED: Over the two-year period, EpiC expanded PrEP services from nine to 16 countries. In FY19, we initiated 4.5% of the 252,671 KP individuals who tested HIV negative onto PrEP. In FY20, we identified an additional 25,727 HIV-negative KP individuals and initiated 8.0% of those who tested negative onto PrEP. The relative increase in PrEP initiation was greatest among trans people (3.6 times in FY20 as in FY19). While no countries were offering PrEP to PWID in FY19, 1,322 (17.2%) were initiated on PrEP in FY20 (Table 1). The scale-up of DSD models, including the introduction of community-based initiation in FY20, contributed to the rapid expansion of PrEP to KPs, although overall PrEP uptake remains low.

Table 1. PrEP uptake among HIV-negative KP individuals in FY19 and FY20

	KP Type	FY19			FY20
		Tested HIV Negative	Started PrEP	% Who Started PrEP	Tested HIV Negative	Started PrEP	% Who Started PrEP
	FSWs	132,062	3,400	2.6	150,797	6,330	4.2
	MSM	112,454	7,759	6.8	108,855	12,988	12.0
	Trans	7,659	296	3.9	11,052	1,514	14.0
	PWID	496	0	0.0	7,694	1,322	17.2
	Total	252,671	11,455	4.5	278,398	22,154	8.0

CONCLUSIONS: As we strive toward achieving epidemic control, sustained collaboration with the KP community, governments, donors, and other stakeholders is essential for addressing barriers to PrEP uptake among KPs. Furthermore, expansion of DSD models for PrEP services is needed for PrEP scale-up.