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O20 The increasing equity gaps of pre-exposure prophylaxis (PrEP) access following its commissioning in England – a PrEP-to-need ratio investigation
  1. Flavien Coukan1,2,
  2. Ann Sullivan3,4,
  3. Holly Mitchell5,
  4. Sajjida Jaffer6,
  5. Andy Williams7,
  6. John Saunders5,8,
  7. Christina Atchison2,9,
  8. Helen Ward1,2,9
  1. 1National Institute for Health Research Applied Research Collaboration North West London, Chelsea and Westminster Hospital, London, UK
  2. 2Patient Experience Research Centre, School of Public Health, Imperial College London, London, UK
  3. 3Chelsea and Westminster NHS Foundation Trust, London, UK
  4. 4Imperial College London, London, UK
  5. 5Blood Safety, Hepatitis, Sexually Transmitted Infections (STI) and HIV Division, UK Health Security Agency, London, UK
  6. 6The Royal Marsden Hospital, London, UK
  7. 7The Royal London Hospital, London, UK
  8. 8UCL Centre for Clinical Research in Infection and Sexual Health, Institute for Global Health, University College London, London, UK
  9. 9National Institute for Health Research Imperial Biomedical Research Centre, London, UK


Introduction In England, 96% of PrEP Impact Trial (2017–2020) participants were men who have sex with men, despite accounting for <50% of new HIV diagnoses. The PrEP-to-need ratio (PnR; no. PrEP users divided by new HIV diagnoses) has been used elsewhere to explore PrEP use inequity. We used this ecological metric to investigate whether PrEP access equity improved following expanded commissioning in 2020.

Method We requested the number of people receiving ≥1 NHS PrEP prescription from GUMCAD (combined with Impact database pre-commissioning), and non-late new HIV diagnoses (epidemiological proxy for PrEP need) from HARS. We calculated the PnR across socio-demographic factors during Impact (Oct-2017 to Feb-2020) and post-commissioning PrEP era (2021) in England.

Results The overall PnR increased >11-fold pre-commissioning (PnR=3.0) to 2021 (PnR=34.2) as new HIV diagnoses dropped 4-fold while PrEP users increased 3-fold. However, while the PnR increased 12-fold (from 3.9 to 46.1) amongst all men, it increased <6-fold (0.4 to 2.3) in women (Table 1). This increasing gender equity gap was observed across age, ethnicity, and region of residence: White men had the highest PnR across periods and increased 14-fold (5.3 to 75.0) as 2.7 times as many used PrEP in 2021; meanwhile, Black African women consistently had the lowest PnR across time; doubling (0.1 to 0.2) as 1.1 times as many used PrEP in 2021 i.e. White men’s PnR was 53-fold higher than Black women’s pre-commissioning, increasing to 375-fold post-commissioning.

Abstract O20 Table 1

Distribution of the number of PrEP users, new HIV diagnosis and PnR in England during the pre- (PrEP Impact Trial – October 2017 to February 2020) and post-commissioning (2021) period of PrEP by ethnicity and gender. *LatinX flag was derived from the country of birth of the patients to investigate equity issues in that population, as this ethnic category is not available in the UK

Discussion HIV combination prevention should be guided by equity metrics relative to the HIV epidemic. While there is no set PrEP use threshold required to achieve targets of HIV incidence reduction, we demonstrated large PrEP equity gaps across gender and ethnicity pre- to post-commissioning, similarly to other HIV prevention and treatment outcomes. The PnR can support the optimisation of combination prevention to reach the Government’s aim to stop HIV transmissions by 2030.

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