title: The promises and challenges of pre-exposure prophylaxis as part of the emerging paradigm of combination HIV prevention.
abstract: BACKGROUND
  Towards the end of the twentieth century, significant success was achieved in reducing incidence in several global HIV epidemics through ongoing prevention strategies. However, further progress in risk reduction was uncertain. For one thing, it was clear that social vulnerability had to be addressed, through research on interventions addressing health systems and other structural barriers. As soon as antiretroviral treatment became available, researchers started to conceive that antiretrovirals might play a role in decreasing either susceptibility in uninfected people or infectiousness among people living with HIV. In this paper we focus on the origin, present status, and potential contribution of pre-exposure prophylaxis (PrEP) within the combination HIV prevention framework.
  
  
  CONCLUSIONS
  After a phase of controversy, PrEP efficacy trials took off. By 2015, daily oral PrEP, using tenofovir alone or in combination with emtricitabine, has been proven efficacious, though efficacy seems heavily contingent upon adherence to pill uptake. Initial demonstration projects after release of efficacy results have shown that PrEP can be implemented in real settings and adherence can be high, leading to high effectiveness. Despite its substantial potential, beliefs persist about unfeasibility in real-life settings due to stigma, cost, adherence, and potential risk compensation barriers.
  
  
  CONCLUSIONS
  The strategic synergy of behavioural change communication, biomedical strategies (including PrEP), and structural programmes is providing the basis for the combination HIV prevention framework. If PrEP is to ever become a key component of that framework, several negative beliefs must be confronted based on emerging evidence; moreover, research gaps regarding PrEP implementation must be filled, and appropriate prioritization strategies must be set up. Those challenges are significant, proportional to the impact that PrEP implementation may have in the global response to HIV.
authors.affiliation: Center for Interdisciplinary Studies in Sexuality, AIDS and Society, Universidad Peruana Cayetano Heredia, Lima, Peru.|Network for Multidisciplinary Studies in ARV-Based HIV Prevention (NEMUS), Lima, Peru; carlos.caceres@upch.pe.
authors.forename: Carlos F
authors.initials: CF
authors.lastname: Cáceres
authors.affiliation: HIV Department, World Health Organization, Geneva, Switzerland.
authors.forename: Florence
authors.initials: F
authors.lastname: Koechlin
authors.affiliation: Network for Multidisciplinary Studies in ARV-Based HIV Prevention (NEMUS), Lima, Peru.|Center for AIDS Prevention Studies, University of California - San Francisco, San Francisco, CA, USA.
authors.forename: Pedro
authors.initials: P
authors.lastname: Goicochea
authors.affiliation: The Bill and Melinda Gates Foundation, Seattle, WA, USA.
authors.forename: Papa-Salif
authors.initials: PS
authors.lastname: Sow
authors.affiliation: HIV Department, World Health Organization, Geneva, Switzerland.
authors.forename: Kevin R
authors.initials: KR
authors.lastname: O'Reilly
authors.affiliation: The Fenway Institute, Fenway Health, Boston, MA, USA.
authors.forename: Kenneth H
authors.initials: KH
authors.lastname: Mayer
authors.affiliation: Joint United Nations Programme on HIV/AIDS, Geneva, Switzerland.
authors.forename: Peter
authors.initials: P
authors.lastname: Godfrey-Faussett
mesh_terms: D019380:Anti-HIV Agents / Q000008:administration & dosage*; D004359:Drug Therapy, Combination; D000068679:Emtricitabine / Q000008:administration & dosage; D015658:HIV Infections / Q000517:prevention & control*; D006801:Humans; D065129:Pre-Exposure Prophylaxis; D000068698:Tenofovir / Q000008:administration & dosage
chemical_list: D019380:Anti-HIV Agents; D000068698:Tenofovir; D000068679:Emtricitabine
keywords: HIV prevention; antiretrovirals; health policy; pre-exposure prophylaxis; public health