title: PrEP in Europe - expectations, opportunities and barriers.
abstract: In contrast to the global trend showing a decline in new HIV infections, the number reported in the World Health Organization (WHO) region of Europe is increasing. Health systems are disparate, but even countries with free access to screening and treatment observe continuing high rates of new infections in key populations, notably men who have sex with men (MSM). Pre-exposure prophylaxis (PrEP) is only available in France. This commentary describes the European epidemics and healthcare settings where PrEP could be delivered, how need might be estimated for MSM and the residual barriers to access.
  
  
  
  Health systems and government commitment to HIV prevention and care, both financial and political, differ considerably between the countries that make up Europe. A common feature is that funds for prevention are a small fraction of funds for care. Although care is generally good, access is limited in the middle-income countries of Eastern Europe and central Asia, and only 19% of people living with HIV received antiretroviral therapy in 2014. It is challenging to motivate governments or civil society to implement PrEP in the context of this unmet treatment need, which is driven by limited national health budgets and diminishing assistance from foreign aid. The high-income countries of Western Europe have hesitated to embrace PrEP for different reasons, initially due to key gaps in the evidence. Now that PrEP has been shown to be highly effective in European MSM in two randomized controlled trials, it is clear that the major barrier is the cost of the drug which is still on patent, although inadequate health systems and diminishing investment in civil society are also key challenges to overcome.
  
  
  
  The momentum to implement PrEP in European countries is increasing and provides a welcome opportunity to expand and improve clinical services and civil society support focused on HIV and related infections including other sexually transmitted and blood-borne infections.
authors.affiliation: Medical Research Council Clinical Trials Unit, University College London, London, UK; s.mccormack@ucl.ac.uk.
authors.forename: Sheena Mary
authors.initials: SM
authors.lastname: McCormack
authors.affiliation: Mouvement Français pour le Planning Familial, Paris, France.
authors.forename: Veronica
authors.initials: V
authors.lastname: Noseda
authors.affiliation: Department of Infectious Diseases, Saint-Louis Hospital, and University of Paris Diderot, Sorbonne Paris Cité.|INSERM U941, Paris, France.
authors.forename: Jean-Michel
authors.initials: JM
authors.lastname: Molina
mesh_terms: D019380:Anti-HIV Agents / Q000627:therapeutic use*; D005060:Europe / Q000453:epidemiology; D005260:Female; D015658:HIV Infections / Q000188:drug therapy / Q000453:epidemiology / Q000517:prevention & control*; D006285:Health Planning; D018451:Homosexuality, Male; D006801:Humans; D008297:Male; D065129:Pre-Exposure Prophylaxis / Q000191:economics
chemical_list: D019380:Anti-HIV Agents
keywords: Europe; MSM; PWID; health systems; migrants