The global HIV response stands at a crossroads. Pre-exposure prophylaxis (PrEP)—one of the most effective tools in HIV prevention—has achieved remarkable scientific progress, yet access remains deeply inequitable and is now at a heightened threat to further be underfunded or not funded at all. By the end of 2024, approximately 8 million people had initiated PrEP. While this is a significant milestone, it still falls short of the UNAIDS target of 10 million person-years of PrEP use. Modeling suggests that 40 million more initiations are needed to reach epidemic control in sub-Saharan Africa.
PrEP refers to the use of antiretroviral medication by HIV-negative individuals to prevent HIV infection. When taken consistently, PrEP reduces the risk of sexual transmission by about 99 percent. PrEP is the result of decades of progress in HIV prevention science and is a cornerstone of modern HIV prevention because it fills gaps where other methods fall short, empowers individuals at substantial risk, and reduces stigma associated with HIV prevention by offering a discreet, proactive method. In high-prevalence settings, PrEP also relieves pressure on overburdened health systems by preventing new infections, thus reducing long-term treatment costs.
Oral PrEP has saved countless lives, but real-world impact has been constrained by implementation challenges including poor adherence, limited access, and complex delivery models resulting in low coverage. Studies show that 30–50% of oral PrEP users discontinue within six months. Meanwhile, unused medication expires on pharmacy shelves and in households—a costly inefficiency in an era of shrinking public health budgets.
Long-acting injectable PrEP (LA-PrEP) has the potential to transform this landscape. With better adherence, greater convenience, and prospects for long-term cost-effectiveness, LA-PrEP represents a major advancement. Yet its rollout in low- and middle-income countries has been slow. Recent shifts in U.S. global health funding—particularly the decision by PEPFAR to review PrEP programs—further complicate access. But the reality is clear: we cannot afford to wait.
Today, the question is no longer whether we have the tools to end HIV—it’s whether we will deploy them quickly and equitably in a world of constrained resources. The most effective prevention tools mean little if people cannot access them.
Traditional clinic-based PrEP delivery continues to exclude many: individuals who face stigma, those unable to take time off work, and people living far from health facilities. It is time to embrace and rapidly scale alternative models that meet people where they are.
Pharmacy-based PrEP delivery is an underutilized opportunity. In many low- and middle-income countries, up to 60% of people first seek care at pharmacies. Pharmacies offer discreet, convenient, no-appointment-needed services and extended hours. A pilot program delivering PrEP through pharmacies in Kenya reached more individuals with behaviors associated with HIV risk who rarely visit public health facilities. Peer-led and community-based PrEP delivery has also proven feasible, and acceptable. These approaches bring services directly into communities, especially reaching populations at risk and underserved groups. Telehealth is another promising avenue. Both PrEP users and providers report high satisfaction with virtual consultations, highlighting its potential for expanding access, particularly in rural or hard-to-reach areas.
Our guiding principle should be that PrEP delivery fits into people’s lives—not the other way around.
At the same time, the financing landscape is shifting. Every country must urgently rethink HIV prevention financing. Increased domestic investment, engagement of the private sector, and integration of HIV services into broader health systems are all strategies that must be pursued. The era of vertical, siloed HIV funding may be ending—and with it comes an opportunity to improve efficiency and sustainability.
PrEP represents one of the most powerful tools we have to end HIV as a public health threat. But for it to realize its full potential, we have triple task ahead of us: accelerate the rollout of long-acting PrEP, decentralize PrEP delivery through pharmacies, community platforms, and telehealth, and mobilize sustainable financing for cost-effective, high-impact strategies.
The HIV epidemic will not end with yesterday’s tools and today’s budgets. Innovation is no longer optional—it is imperative.