BACKGROUND: Pre-exposure prophylaxis (PrEP) is a highly effective intervention that can prevent HIV acquisition. Through the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), the US Centers for Disease Control and Prevention (CDC) supports PrEP programs for key populations (KP) (i.e., Female Sex workers (FSW), men who have sex with men (MSM), transgender people (TG), people who inject drugs (PWID) and people in prisons and other enclosed settings). UNAIDS’ current goal is to reach 10 million people with PrEP by 2025. We examined CDC’s scale-up of PrEP during Covid-19 among KP beneficiaries to evaluate progress towards the UNAIDS goal.
METHODS: Using programmatic data from PEPFAR’s Monitoring, Evaluation and Reporting system, we assessed the number and percentage of KP beneficiaries who initiated PrEP, by KP group and by year, from 2019 to 2022 in 30 countries. We assessed trends by year among 27 countries with complete testing and PrEP initiation data. We also consulted narrative reports of program services to understand changes made to PrEP delivery.
RESULTS: CDC supported 1,371,984 PrEP initiations during 2019–2022, of whom 520,981 identified as KP. The percentage of HIV-negative KP accepting PrEP increased by 532%, from 3.1% in 2019 to 19.6% in 2022. The largest relative increases in uptake were among PWID and prisoners, although the absolute percentages were <10%. Although FSW and MSM showed highest uptake in 2022, over 70% of these KP did not initiate PrEP.

Key Population groups	PrEP Initiation among Key Population beneficiaries supported by CDC in 27 PEPFAR-funded countries, 2019–2022. Numbers of KP enrolled in PrEP/ number of HIV-negative KP (%)				% Increase in proportion of HIV-negative KP accepting PrEP from 2019 to 2022
	2019	2020	2021	2022
Female sex workers (FSW)	13,180/245,659 (5.4%)	34,978/508,598 (6.9%)	91,521/700,578 (13.1%)	163,638/695,078 (23.5%)	335%
Men who have sex with men (MSM)	66,059/54,209 (11.2%)	118,555/238,672 (7.8%)	52,350/381,094 (13.7%)	88,084/340,985 (25.8%)	130%
People who inject drugs (PWID)	690/90,619 (0.8%)	2,573/184,876 (1.4%)	9,277/174,085 (5.3%)	16,866/178,902 (9.4%)	1075%
People in prisons	5,514/269,276 (0.2%)	589/146,251 (0.4%)	8,842/150,051 (5.9%)	7,086/195,015 (3.6%)	1700%
Transgender people	183/1,801 (10.2%)	635/2,250 (28.2%)	1,516/4,959 (30.6%)	2,341/11,406 (20.5%)	101%
Total	20,626/661,564 (3.1%)	57,330/1,080,647 (5.3%)	163,506/1,410,767 (11.6%)	278,015/1,421,386 (19.6%)	532%

CONCLUSIONS: Despite Covid-19 disruptions in service delivery, we observed substantial PrEP scale-up in CDC programs. Program modifications such as HIV self-testing, telemedicine, and community-based deliveries may have facilitated PrEP expansion during this time. To reach UNAIDS’ global goal, additional innovations, such as long-acting injectable PrEP, event-driven PrEP, and programs to increase PrEP awareness/literacy among beneficiaries and providers may increase uptake by KP. Continuous monitoring and evaluation of KP PrEP programs is critical to meet ambitious UNAIDS global targets.