National Institute for Health Research Applied Research Collaboration North West London, Chelsea and Westminster Hospital, London, UK
Patient Experience Research Centre, School of Public Health, Imperial College London, London, UK.
Sex Transm Infect. 2024 Apr 18;100(3):166-172. doi: 10.1136/sextrans-2023-055989.
HIV pre-exposure prophylaxis (PrEP) is highly effective in preventing HIV acquisition. In England, NHS availability was limited to participants of the PrEP Impact Trial until late 2020. Some key populations at greater risk of HIV were under-represented in the trial suggesting inequities in trial PrEP access. We used the PrEP-to-need ratio (PnR; number of PrEP users divided by new HIV diagnoses) to investigate whether PrEP access improved following routine commissioning in October 2020 and identify populations most underserved by PrEP.
Aggregated numbers of people receiving ≥1 PrEP prescription and non-late new HIV diagnoses (epidemiological proxy for PrEP need) were taken from national surveillance data sets. We calculated the PnR across socio-demographics during Impact (October 2017 to February 2020; pre-COVID-19 pandemic) and post-commissioning PrEP era (2021) in England.
PnR increased >11 fold, from 4.2 precommissioning to 48.9 in 2021, due to a fourfold reduction in non-late new HIV diagnoses and near threefold increase in PrEP users. PnR increased across genders, however, the men's PnR increased 12-fold (from 5.4 precommissioning to 63.9 postcommissioning) while the women's increased sevenfold (0.5 to 3.5). This increasing gender-based inequity was observed across age, ethnicity and region of residence: white men had the highest PnR, increasing >13 fold (7.1 to 96.0), while Black African women consistently had the lowest PnR, only increasing slightly (0.1 to 0.3) postcommissioning, suggesting they were the most underserved group. Precommissioning, the PnR was 78-fold higher among white men than Black women, increasing to 278-fold postcommissioning.
Despite the overall increase in PrEP use, substantial PrEP Impact trial inequities widened postcommissioning in England, particularly across gender, ethnicity and region of residence. This study emphasises the need to guide HIV combination prevention based on equity metrics relative to the HIV epidemic. The PnR could support the optimisation of combination prevention to achieve zero new HIV infections in England by 2030.
艾滋病毒暴露前预防（PrEP）在预防艾滋病毒感染方面非常有效。在英国，NHS 的供应仅限于 PrEP 影响试验的参与者，直到 2020 年底。一些感染艾滋病毒风险较高的关键人群在试验中代表性不足，这表明试验 PrEP 准入存在不平等。我们使用 PrEP 需求比（PnR；接受 PrEP 的人数除以新诊断的艾滋病毒病例数）来调查 2020 年 10 月常规委托后 PrEP 准入是否有所改善，并确定 PrEP 服务不足的人群。
从国家监测数据集中获取至少接受 1 次 PrEP 处方和非新诊断的新艾滋病毒病例（PrEP 需求的流行病学替代指标）的人数。我们在英格兰的 Impact 期间（2017 年 10 月至 2020 年 2 月；新冠疫情前）和委托后 PrEP 时代（2021 年）计算了社会人口统计学方面的 PnR。
由于非新诊断的新艾滋病毒病例减少了四倍，PrEP 使用者增加了近三倍，PnR 增加了 11 倍以上，从委托前的 4.2 增加到 2021 年的 48.9。PnR 在性别上有所增加，但男性的 PnR 增加了 12 倍（从委托前的 5.4 增加到委托后的 63.9），而女性的 PnR 增加了 7 倍（从 0.5 增加到 3.5）。这种基于性别的不平等现象在年龄、种族和居住地地区都有所观察到：白人男性的 PnR 最高，增加了 13 倍以上（从 7.1 增加到 96.0），而黑人女性的 PnR 一直较低，仅略有增加（从 0.1 增加到 0.3），表明她们是最服务不足的群体。委托前，白人男性的 PnR 是黑人女性的 78 倍，委托后增加到 278 倍。
尽管 PrEP 的使用总体上有所增加，但英格兰在委托后扩大了 PrEP 影响试验的不平等，特别是在性别、种族和居住地地区。这项研究强调需要根据艾滋病毒流行情况，以公平指标为指导，制定艾滋病毒综合预防措施。PnR 可以支持优化组合预防，以实现到 2030 年在英格兰实现零新艾滋病毒感染的目标。
