PrEP is short for pre-exposure prophylaxis and refers to a drug taken regularly before a person is exposed to HIV in order to reduce the risk of catching the virus. The drug can be taken daily in the form of a pill or once every two months through injection. Meanwhile, PEP refers to post-exposure prophylaxis, a small dose of tablets which should be taken within 72 hours after exposure to HIV to reduce the risk of the virus taking hold in your body. PrEP will typically be recommended to and taken by people who are at particular risk of catching HIV; this includes MSM (men who have sex with men), gay men, those who inject drugs, sex workers, and those in serodiscordant partnerships in which one partner is HIV positive and the other HIV negative. PEP is not intended to be used regularly, and the demographic groups who use it largely overlap with those using PrEP.
Government budgets and priorities, as well as the welfare state structures, significantly impact PrEP and PEP accessibility and costs. This post examines access and affordability in the USA, Latin America, Europe and Sub-Saharan Africa. Differences in these regions will, of course, be acknowledged, but due to limitations of both data and space, some generalizations will be made.
THE USA
The USA is a liberal welfare state in which healthcare is not universally granted on the basis of citizenship but is more so tied to employment. Resultantly, those not covered face high costs. Most insurance plans and state Medicaid programs cover PrEP as part of the Affordable Care Act, and thus the drug is free under almost all health insurance plans. For those who lack prescription insurance coverage, however, a 30-day supply of the Truvada drug will cost you $1,758 (or around $21,000 a year), and the drug must be taken regularly for 7-20 days to be effective. PEP is also typically covered in full by Medicaid and private insurance providers, but for those without insurance, the drug dose can cost anywhere between $600 and $1000. The US also has a range of financial support schemes available for those not covered and will often offer the drug regardless of a patient's present potential to pay.
As in most countries, PrEP is only available in the US by prescription. Any healthcare provider can prescribe PrEP, but this may still be a barrier to some, and efforts are thereby being made to allow pharmacists to dispense PrEP too. Since 90% of Americans live within a 5-mile radius of a pharmacy, policymakers have argued that pharmacists should be able to provide PrEP in a limited quantity without a doctor's prescription. A recent California law allows PEP and 60 days of PrEP to be dispensed without a prescription.
The emergency department interestingly has an opt-out approach to screening for HIV in which anyone who meets the risk criteria and is not knowledgeably HIV positive may be tested during a visit. Although PrEP and PEP are used mainly by the risk groups mentioned, both are marketed and available to anyone without HIV. In 2020, PrEP was taken by about 25% of the 1.2 million people for whom the drug was recommended.
Sub-Saharan Africa
The welfare states of Sub-Saharan Africa are commonly unstable and lack funding, particularly due to the large informal sector in which few people will have full-time jobs that are taxed and monitored by the government. This results in a significantly lower GDP and tax base as well as little official employment data. PrEP and PEP can, therefore, not be accessed through public health programs in this region. In order to make PrEP accessible and free of charge, many governments have prioritized HIV prevention and treatment in their budget allocation. In Eswatini, for instance, where 27% of the population has HIV, PrEP is entirely free of charge. However, a large portion of this funding comes from NGOs (non-governmental organizations) and donors such as The United States President’s Emergency Plan for AIDS Relief, which will not be sustainable in the long run. Hopefully, as these countries develop more established welfare states, they will come to rely less and less on donations.
Sub-Saharan Africa makes up more than half of the world’s PrEP users, and seven of the top ten PrEP countries are in this region. The region does not have as defined risk groups as the US, and thus the goal has always been to cover both high-risk populations as well as the general population.
PrEP and PEP require a doctor’s prescription in a majority of these countries, which poses issues with accessibility, especially for those living in more rural areas. The stigma associated with HIV may also prevent many in-risk populations from seeking help. As compared to the US, PrEP and PEP are accessible through a multitude of avenues that seek to reach as many different types of people as possible. Kenya, for instance, uses mobile clinics, family planning clinics, hospitals, NGOs, general health clinics, testing centers, and research clinics.
LATIN AMERICA
As of 2021, only 11 of the 17 Latin American countries provided access to PrEP. Of these, only Brazil and Mexico provide PrEP through the public healthcare sector free of charge. In countries such as Uruguay, Chile, Costa Rica and Guatemala, people can access PrEP and PEP only under private healthcare schemes and the Internet. In the remaining countries, PrEP access is only limited to specific one-off research projects. Since most countries in the region are classed as “middle-income countries,” few have access to the international price reduction grants that low-income countries do. In order to increase access, some funding still comes from donors such as the Pan American Health Organization (PAHO) Strategic Fund.
As compared to both the US and Africa, most countries in Latin America (with the exception of Argentina, Brazil, Chile, Colombia, Mexico and Uruguay) focus only on at-risk populations due to budget limitations. As with all other regions discussed, a medical prescription is typically required, and therefore access still needs to be improved, especially in more remote areas and due to stigma.
Europe And Central Asia
Interestingly, Europe is very varied in regard to access and has only backed PrEP and PEP use positively since 2016, four years after the FDA approved the drug. This hesitation is due to a worry that mainstream use of these drugs would discourage other safe sex practices. As of 2022, 23 of 53 countries offered and reimbursed PrEP and PEP through public healthcare or private insurance. In 15 countries, the generic drug was available, although only partially reimbursed. Multiple countries such as Serbia, Romania, Bulgaria, Greece and Moldova have not formally made PrEP available. Despite Europe's robust and established welfare systems, risk groups were mainly those eligible and targeted for the drug. In 30 of 35 countries, MSM and gay men were eligible.
PrEP and PEP are available for undocumented immigrants free of charge in 19 countries, and in another 4, it is available at a cost. This is significant firstly due to immigrant sex work; according to the International Committee on the Rights of Sex Workers in Europe, sex work has become an increasingly popular income stream for asylum seekers, and it is estimated that migrant sex work makes up 65% of sex work in Western Europe. Moreover, Europe has experienced significant immigration streams (particularly from North Africa and the Middle East) in the past decade, with 626,065 asylum applicants in 2014.
In all the countries in which PrEP and PEP are officially available, doctors need to prescribe these drugs, and in four of the countries in the European and Central Asian region, the doctor must be an infectious disease specialist. Pharmacists cannot prescribe either drug in any country.
PrEP and PEP remain vital components in the battle against the spread of HIV, but their success is highly contingent on accessibility. Both drugs should be free of charge, in particular for at-risk populations. It is also important for policy to adapt to its country's context and population, such as the US providing in-pharmacy prescriptions due to the high prevalence of pharmacies or Kenya providing mobile clinics to reach more remote and rural areas. Education which seeks to alleviate the stigma and encourage other safe sex practices, is critical in sustainable PrEP and PEP outreach policies.
Written by Ellen Gisto.