Foundations for progress: insights from the PrEP Impact Trial supporting change to PrEP delivery and implementation in England.

OBJECTIVES

The HIV pre-exposure prophylaxis (PrEP) Impact Trial demonstrated the feasibility and effectiveness of PrEP in England, providing critical evidence to inform national commissioning. Using trial data, we assess regional variation in delivery and examine how service provision differences impacted outcomes across the PrEP Prevention Care Continuum (PPCC) (ie, those at risk of HIV acquisition, those eligible for PrEP, PrEP uptake and coverage).

METHODS

We assessed PPCC outcomes among HIV-negative men who have sex with men (MSM) attending trial sexual health services (SHS) from October 2017 to February 2020. Outcomes were stratified by SHS region (London, Outside London) and MSM throughput, defined as the mean annual number of MSM attendees, to approximate differences in service structure and provision based on attendee composition. HIV incidence per 100 person-years was calculated for SHS in and outside of London, restricted to those with ≥2 visits during the study period.

RESULTS

Across 157 trial SHS, 165 270 MSM attended during the study period, of whom 20 349 were enrolled in the trial. HIV incidence was calculated among 102 842 MSM, including 17 770 trial participants. PrEP uptake ranged from 42% to 92%, and coverage from 16% to 31%, varying by MSM throughput strata and consistently higher among London SHS. HIV incidence was significantly lower in trial participants (London: 0.07 (95% CI 0.04 to 0.14); Outside London: 0.22 (0.13 to 0.36)) versus non-trial attendees (London: 0.98 (0.88 to 1.10); Outside London: 0.93 (0.82 to 1.04)).

CONCLUSIONS

This analysis supports ongoing enhancements to PrEP delivery across England. Findings highlight the success of varied service models, including those not traditionally focused on MSM populations. High HIV seroconversions among individuals without clear markers of risk for HIV acquisition support the need for broader, less restrictive PrEP access, aligned with recent updates to national guidance. To evaluate the long-term impact of PrEP on HIV and sexually transmitted infection (STI) incidence, consistent, high-quality data reporting to national surveillance remains essential.