Global implementation of pre-exposure prophylaxis (PrEP), a pill taken to prevent HIV infection, has made major strides in the last year. The U.S. Food and Drug Administration first approved Truvada for daily oral PrEP in July 2012, but no other country approved PrEP in the subsequent three years. In November 2015, France became the second country and the first with a centrally organized, national health system to approve PrEP. The French National Agency for Medicines and Health Products Safety authorized both a daily regimen for all people at risk for HIV infection and an intermittent or “on demand” regimen, as used in the IPERGAY study, for men who have sex with men. This authorization was made possible under a Recommendation for Temporary Use, but recent approval by the European Medicines Agency in July 2016 means that France can now apply PrEP as a permanent part of its health system.
Shortly after France’s approval of PrEP, PrEP was approved in South Africa and Kenya in December 2015. Canada, Israel, Peru, and Australia took the same step in 2016. Just last week, the High Court of Justice ruled that the National Health Service (NHS) in England can legally fund PrEP. Although the High Court ruling does not make funding PrEP automatic and the NHS is set to appeal, the decision further underscores that PrEP is a core component of HIV prevention.
Even as global implementation of PrEP gains momentum, it is not happening quickly enough for millions of men and women at risk for HIV. More countries must approve PrEP and develop effective ways to delivery PrEP to those in need. This includes mobilizing funding, raising medical provider and community awareness, and establishing policies and systems.
To ensure on-the-ground access and impact, it is also critical that all countries remove social and structural barriers to PrEP. Such barriers contribute to HIV disparities among racial, gender, and sexual minorities and could keep these and other vulnerable populations from benefiting from PrEP.
France, for instance, has made a significant investment in PrEP rollout. Up to July 2016, 1077 people, 96.4% of whom identify as gay men, started PrEP through the public health system in France; 90 clinics offer PrEP assessment and prescription and 273 doctors have been accredited as PrEP physicians. But like the United States, France must do a better job ensuring that people of African descent have access to PrEP. Data presented at the 21st International AIDS Conference (AIDS 2016) showed that 87% of PrEP users in France are French, i.e. non-migrants. This suggests a serious need to support greater PrEP uptake among migrants, especially sub-Saharan migrants, who account for nearly one-third of new diagnoses in France. Migrants in France face frequent hardship that increases HIV risk, with one study finding that more than 40% have lived a year or more without a residence permit and more than 20% lack stable housing. PrEP rollout in France will have limited effectiveness if these social problems are not addressed.
Beyond the issue of migration, France faces challenges in thinking of itself as a color-blind society and refusing to measure race in its census and health system. Despite its significant problems of racial segmentation and discrimination, France has limited tools to measure or correct them. As a result, it is difficult to assess the HIV prevention needs of French Blacks and promote PrEP through targeted policy and programmatic activity.
Social and structural barriers need to be addressed for PrEP to have large-scale impact in France and other countries. It is important that we do not ignore or reinforce racial, gender, and sexual inequalities in global HIV prevention.