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Person-centered HIV PrEP for cisgender women
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Nature Medicine Nov 2023
Two modelling studies offer compelling evidence that less-than-perfect adherence to HIV pre-exposure prophylaxis can still provide reasonable protection for cisgender women - providing optimism for a more person-centered approach and lower discontinuation rates.
Although the studies from Moore et al.7 and Zhang et al.8 rely on simulations, they both reached similar inferences that replicate observational data from entirely different studies. Both studies are limited by the fact that the models assume a uniform level of HIV acquisition risk alongside the adherence data, while evidence is emerging that adherence may change in line with different levels of HIV risk6. Because we do not know the timing of pill taking in relation to condom-less sex, it is not possible to confidently recommend event-driven PrEP among cisgender women based on these analyses. Finally, these studies have not explored the effect of less than 100% adherence on acquiring HIV drug resistance, although this may be offset by overall reductions in HIV incidence12.
In conclusion, although we have entered an era in which we have a range of antiretroviral therapy-based prevention options for cisgender women, including long-acting injectable and vaginal rings, evidence in these studies reassures us that for those women who are able to persist in taking between 4-7 tablets per week, TDF/FTC is an effective, accessible and affordable choice of PrEP regimen.
The Achilles' heel of TDF/FTC in cisgender women has been the emphasis on 100% daily tablet-taking, which can prevent young women from initiating treatment and, importantly, drives high PrEP discontinuation rates2. A frequently cited reason for stopping is 'Why take a pill a day to stop taking a pill a day?' - a reference to the similarity between daily TDF/FTC and daily antiretroviral therapy, and the insistence in both settings on 100% adherence. The papers by Moore et al.7 and Zhang et al.8 suggest that there is scope for more person-centred advice around 'good enough' adherence for those women who can take 4-7 tablets per week. Instead of the current emphasis on only 100% daily adherence, we can encourage daily pill taking but focus counselling on drug continuation; indeed, fewer than half of all women starting PrEP in Africa currently collect their second prescription. This will enable a range of PrEP options and delivery models for women.
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