Serodiscordant partnerships and opportunities for pre-exposure prophylaxis among partners of women and men living with HIV in St. Petersburg, Russia

PrEP for women in Europe: a systematic literature review

BACKGROUND

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.

METHODS

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.

RESULTS

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%]).

CONCLUSIONS

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.

The PrEP Care Continuum Among Cisgender Women Who Sell Sex and/or Use Drugs Globally: A Systematic Review

HIV prevalence among cisgender female sex workers (FSW) and/or women who use drugs (WWUD) is substantially higher compared to similarly aged women. Consistent with PRISMA guidelines, we conducted the first systematic review on the pre-exposure prophylaxis (PrEP) continuum among FSW and/or WWUD, searching PubMed, Embase, CINAHL, PsycInfo, and Sociological Abstracts. Eligibility criteria included: reporting a PrEP related result among FSW and/or WWUD aged 18 + ; peer-reviewed; and published in English between 2012 and 2018. Our search identified 1365 studies; 26 met eligibility requirements, across the following groups: FSW (n = 14), WWUD (n = 9) and FSW-WWUD (n = 3). Studies report on at least one PrEP outcome: awareness (n = 12), acceptability (n = 16), uptake (n = 4), and adherence (n = 8). Specific barriers span individual and structural levels and include challenges to daily adherence, cost, and stigma. Combining health services and long-acting PrEP formulas may facilitate better PrEP uptake and adherence. The limited number of studies indicates a need for more research.