Background:
In 2022, World Health Organization recommended the expansion of event-driven pre-exposure prophylaxis (ED-PrEP) to prevent HIV not only among men who have sex with men (MSM) but also all people assigned male at birth (AMAB) who are not using estradiol-based exogenous hormones. The USAID- and PEPFAR-funded Meeting Targets and Maintaining Epidemic Control (EpiC) project offered ED-PrEP as another option to oral daily PrEP to people AMAB not using estradiol-based exogenous hormones across three sub-Saharan African countries.
Methods:
Using various differentiated service delivery (DSD) models, EpiC offered HIV-negative people AMAB who are MSM, who purchase sex, who are transgender, and other people AMAB options for daily PrEP and ED-PrEP in Ghana, Liberia, and Eswatini. ED-PrEP was recommended for people who had infrequent and predictable sexual encounters or anyone who wanted to enroll. Routinely collected programmatic data was analyzed to understand preference and uptake by population and age groups across the three countries.
Results:
Between October 2021 and May 2023, EpiC newly initiated 8,495 individuals AMAB on oral PrEP in the three countries, among whom 7,101 (84.40%) initiated on ED-PrEP. A larger proportion of people AMAB who were not MSM chose ED-PrEP over traditional daily PrEP (95.36%) compared to MSM (76.85% chose ED-PrEP). The proportion of those who initiated ED-PrEP over daily PrEP was highest among individuals 40–44 years of age (95.20%; 536/569) and lowest among those 50 and over (49.72%; 90/195) (Figure 1) Oral PrEP uptake among people AMAB who were not MSM (84.58%) was higher than among MSM (75.92%). PrEP uptake among those to whom it was offered increased from 39.99% (October 2020–September 2021) to 72.57% (October 2021–May 2023) after ED-PrEP was offered in Ghana and Eswatini. The increase was most pronounced among those aged 50 year and older, from 18.95% to 75.58%.
Conclusions:
The results demonstrate the feasibility of offering ED-PrEP to all people AMAB and the preference of some of these individuals for ED-PrEP compared to daily oral PrEP. Scale-up of ED-PrEP may improve oral PrEP uptake among all people AMAB warranting ED-PrEP expansion efforts beyond MSM. More efforts are needed to improve access to ED-PrEP through various DSD models as we scale oral PrEP provision. More research is needed to understand preferences for all individuals AMAB-not just MSM-and to improve uptake strategies.
