Fitzgerald Naomi, Coltart Holly, Dominguez Lourdes, Flanagan Kate, Gilleece Yvonne
King's College Hospital, London, UK.
Brighton & Sussex Medical School, Brighton, UK.
HIV Med. 2023 Jul;24(7):765-776. doi: 10.1111/hiv.13458. Epub 2023 Apr 23.
Prevention of HIV transmission is fundamental to ending the HIV epidemic. Pre-exposure prophylaxis (PrEP) with oral tenofovir-emtricitabine (TDF-FTC) is an established HIV-prevention method; however, most PrEP services in Europe have been targeted at men who have sex with men (MSM). A survey in 2021 by Women Against Viruses in Europe (WAVE) showed considerable variation in PrEP access and guidance for women throughout Europe. WAVE therefore commissioned this systematic review to provide insight into PrEP provision and barriers to uptake for women in Europe.
PubMed, Embase, and Scopus were searched for studies (January 2013-May 2021) that reported on actual (e.g., efficacy and safety) or hypothetical (e.g., awareness, barriers, PrEP impact models) use of oral PrEP involving women (including cis, transgender, pregnant, migrant, and breastfeeding women). Search terms included HIV, pre-exposure prophylaxis (specifically TDF-FTC), and women. Studies performed outside of the World Health Organization European region were excluded.
The search identified 4716 unique citations, and 45 peer-reviewed articles (44 studies) were included. The majority of these studies (34/44 [77%]) included recipients or potential recipients of PrEP, representing 4699 women (243 transgender women). However, few studies were women focused (4/34 [12%]) or took place outside of Western Europe (3/34 [9%]). Across the three clinical studies that reported women-specific outcomes (60 transgender women, 13 pregnant, and 19 cis women), no breakthrough infections were recorded during the use of PrEP. Lack of awareness of PrEP, low self-estimation of HIV acquisition risk, concerns about stigma, lack of protection against other sexually transmitted infections, and PrEP interaction with hormones (for transgender women) were identified as barriers to use. The remaining studies examined healthcare professionals' perceptions of PrEP (9/44 [20%]), asked for public opinion (2/44 [5%]), or modelled the potential of PrEP for HIV prevention (1/44 [2%]).
This review revealed a notable lack of literature on PrEP for cis and transgender women in Europe. This is synonymous with a lack of PrEP provision for women in this region. Barriers to PrEP uptake are complex and rooted in institutional and societal stigma, which must be addressed at policy level. HIV prevention with PrEP is not 'one size fits all' and requires a nuanced gender-responsive approach. Further research into the use of PrEP in cis, pregnant, breastfeeding, and transgender women is essential if we are to stop HIV transmission by 2030.
预防艾滋病毒传播是终结艾滋病毒流行的根本。口服替诺福韦-恩曲他滨（TDF-FTC）进行暴露前预防（PrEP）是一种既定的艾滋病毒预防方法；然而，欧洲的大多数PrEP服务都针对男男性行为者（MSM）。欧洲女性抗击病毒组织（WAVE）在2021年进行的一项调查显示，欧洲各地女性在PrEP获取和指导方面存在很大差异。因此，WAVE委托进行了这项系统评价，以深入了解欧洲女性的PrEP提供情况和使用障碍。
在PubMed、Embase和Scopus数据库中检索2013年1月至2021年5月期间报告口服PrEP实际使用情况（如疗效和安全性）或假设使用情况（如知晓度、障碍、PrEP影响模型）的研究，研究对象包括女性（包括顺性别、跨性别、孕妇、移民和哺乳期妇女）。检索词包括艾滋病毒、暴露前预防（特别是TDF-FTC）和女性。排除在世界卫生组织欧洲区域以外进行的研究。
检索共识别出4716条独特引文，纳入45篇经同行评审的文章（44项研究）。这些研究中的大多数（34/44 [77%]）纳入了PrEP接受者或潜在接受者，涉及4699名女性（243名跨性别女性）。然而，很少有研究以女性为重点（4/34 [12%]）或在西欧以外地区开展（3/34 [9%]）。在三项报告了女性特定结果的临床研究中（60名跨性别女性、13名孕妇和19名顺性别女性），使用PrEP期间未记录到突破性感染。对PrEP缺乏知晓、对感染艾滋病毒风险的自我评估较低、对耻辱感的担忧、缺乏对其他性传播感染的防护以及PrEP与激素的相互作用（针对跨性别女性）被确定为使用障碍。其余研究考察了医疗保健专业人员对PrEP的看法（9/44 [20%]）、征求了公众意见（2/44 [5%]）或模拟了PrEP预防艾滋病毒的潜力（1/44 [2%]）。
本评价显示，欧洲关于顺性别和跨性别女性PrEP的文献显著缺乏。这与该地区女性PrEP服务的缺乏是同义词。PrEP使用障碍复杂，根源在于机构和社会的耻辱感，必须在政策层面加以解决。PrEP预防艾滋病毒并非“一刀切”，需要一种细致入微的性别敏感方法。如果我们要在2030年前停止艾滋病毒传播，对顺性别、孕妇、哺乳期和跨性别女性使用PrEP进行进一步研究至关重要。
