Reducing inequalities is the primary focus of the UNAIDS global HIV strategy 2021–26.11UNAIDS
End inequalities. End AIDS. Global AIDS Strategy 2021–2026. Unequal access to PrEP around the world is a major hindrance to its potential impact. By 2020, it was estimated that just less than 1 million people had initiated oral PrEP,12

Segal K. The evolution of oral PrEP access: tracking trends in global oral PrEP use over time. HIV Research For Prevention (HIV R4P; virtual); Jan 28, 2021 (abstr 1346).

far less than the 2020 UNAIDS target of 3 million.13UNAIDS
HIV prevention 2020 road map: accelerating HIV prevention to reduce new infections by 75. Access to PrEP is still highly concentrated in a fairly small number of countries (figure). By the end of 2020, fewer than 20 countries recorded more than 10 000 PrEP initiations, with the USA accounting for approximately a fifth of total PrEP initiations.12

Segal K. The evolution of oral PrEP access: tracking trends in global oral PrEP use over time. HIV Research For Prevention (HIV R4P; virtual); Jan 28, 2021 (abstr 1346).

Although some countries have incorporated PrEP into their national health systems, many low-income and middle-income countries rely on programmes funded by international donors and others provide access only to some people who are at risk through small demonstration projects. In Asia, for example, which accounted for nearly 20% of the world's HIV infections in 2019, PrEP is only meaningfully available in Thailand and Vietnam.12

Segal K. The evolution of oral PrEP access: tracking trends in global oral PrEP use over time. HIV Research For Prevention (HIV R4P; virtual); Jan 28, 2021 (abstr 1346).

This is despite increasing epidemics among key populations in several countries in the region, including Indonesia, the Philippines, and Pakistan. Similarly, despite eastern and southern Africa accounting for approximately 43% of global HIV infections in 2019, major PrEP programmes have been limited to fewer than ten countries, with only South Africa having initiated more than 100 000 PrEP users by the end of 2020.12

Segal K. The evolution of oral PrEP access: tracking trends in global oral PrEP use over time. HIV Research For Prevention (HIV R4P; virtual); Jan 28, 2021 (abstr 1346).

The pace of PrEP initiations in Africa has been increasing,12

Segal K. The evolution of oral PrEP access: tracking trends in global oral PrEP use over time. HIV Research For Prevention (HIV R4P; virtual); Jan 28, 2021 (abstr 1346).

and nine of the ten countries with the highest PrEP use per capita are now located there (table); however, the rate of uptake is still too slow to expect a substantial population impact on the HIV epidemic.

FigurePrEP initiations by country, 2020

TableEstimated population, estimated number of PrEP users, and PrEP use per 10 000 people in 2020 for countries with more than 2000 estimated PrEP users

PrEP=pre-exposure prophylaxis.

Within countries, inequalities have quickly emerged in PrEP access. There are divergent rates of PrEP uptake along racial and ethnic, socioeconomic, geographical, age, and self-identity lines. In western high-income countries, for example, uptake has typically been highest among gay men connected to urban gay communities and lower among minority ethnic groups, migrants, non-gay-identifying MSM, those with little access to health care, and those living in less urban areas.15Grulich AE Guy R Amin J et al.Population-level effectiveness of rapid, targeted, high-coverage roll-out of HIV pre-exposure prophylaxis in men who have sex with men: the EPIC-NSW prospective cohort study., 16Annequin M Villes V Delabre RM et al.Are PrEP services in France reaching all those exposed to HIV who want to take PrEP? MSM respondents who are eligible but not using PrEP (EMIS 2017). Even within groups with high levels of access, there is still a substantial gap between the estimated number suitable for or in need of PrEP and the number who have ever accessed it.17Aung E Chan C McGregor S Holt M Grulich AE Bavinton BR Identifying gaps in achieving the elimination of HIV transmission among gay, bisexual, and other men who have sex with men in Australia: the Gaps Project report.