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Preexposure prophylaxis (PrEP) for HIV is a highly effective tool for preventing HIV transmission in all populations and countries. However, despite being approved and available by prescription, the “PrEP gaps” (individuals meeting clinical eligibility criteria but not initiated on PrEP) are a major obstacle to eliminating HIV in Europe.

At the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) 2025, held in Vienna, Austria, from April 11 to 15, a session organized by the European AIDS Clinical Society highlighted the current status of PrEP and standards of care in Europe. 

The discussion also addressed missed opportunities and barriers to broader use, such as resource constraints, costs, war, and migration, as well as potential solutions for improving the situation.

The session was led by Teymur Noori, MSc, an expert in HIV and migrant health at the European Centre for Disease Prevention and Control, and Milosz Parczewski, MD, PhD, vice president of the Governing Board of the European AIDS Clinical Society and president of the Polish Scientific AIDS Society.

As of 2023, approximately 830,000 people are living with HIV in Europe, with approximately 110,000 new cases diagnosed annually. Epidemiologic data and transmission routes vary significantly across Europe.

• Western Europe accounts for 36% of diagnosed individuals and 24% of new diagnoses. Among them, 43% were men who had sex with men, 31% were heterosexual women, and 22% were heterosexual men. Intravenous drug users (IDUs) comprised 4% of the total participants. Notably, 59% of diagnosed individuals were born in other countries.
• Central Europe accounts for 7% of diagnosed individuals and the same percentage of new diagnoses. Among them, 40% were men who had sex with men, 19% were heterosexual women, and 36% were heterosexual men. IDUs accounted for 5%, and 59% of diagnosed individuals were born in other countries.
• Eastern Europe presents a starkly different picture, with 62% of diagnosed individuals and 69% of new cases. Only 4% of diagnoses were among men who had sex with men, whereas 36% were among heterosexual women, and 41% were among heterosexual men. IDUs accounted for 19%, and only 2% of diagnosed individuals were born in other countries. In this region, the stigma surrounding homosexuality is believed to contribute to the reporting bias.

The goal of PrEP is to reduce the incidence of HIV, which remains a significant public health challenge. The World Health Organization (WHO) has set ambitious targets to reduce new infections in Europe by 75% by 2025 and 90% by 2030, compared with 2010. However, progress is lagging in 2023, with diagnoses increasing by 9% across Europe and only a 34% reduction in EU member states. Similarly, PrEP uptake remains far below targets, with 285,000 individuals on PrEP across Europe by the end of 2023 (against a target of 500,000) and 130,000 in EU countries (against a target of 300,000).

Barriers to PrEP Implementation

What can be done to address this issue? Expanding PrEP implementation is critical; however, there is significant variability between countries in applying international guidelines and the level of public funding for this medication. The key barriers identified include, in order of importance, difficulty in accessing certain population groups, lack of PrEP availability in all regions or parts of a country, stigma associated with PrEP use, long waiting lists in countries with national programs, service costs, drug costs, and limited technical capacity among healthcare providers to prescribe PrEP.

The countries with the best PrEP implementation data are, in order, the United Kingdom, France, Germany, and Spain. However, disaggregated data reveal that men who have sex with men are the primary population reached in all of these countries, with significant gaps among women and migrants. This highlights a major equity issue in PrEP access, particularly for women, migrants, transgender individuals, sex workers, and IDUs.

PrEP remains underutilized as a prevention tool across Europe, and scaling up its use is essential to reduce transmission rates. Combining PrEP implementation with HIV screening and rapid initiation of antiretroviral therapy is necessary to achieve the Sustainable Development Goals by 2030.

Clinical Considerations

One of the most debated clinical topics is the mode of PrEP administration (continuous or event-driven) and its applicability to cisgender women, for whom the clinical effectiveness of event-driven PrEP has not been demonstrated.

In populations where efficacy has been established, both event-driven and continuous regimens have shown similar effectiveness. However, major gaps persist, mainly due to the low perceived risk for HIV among at-risk individuals and fear of stigma and discrimination. Many also lack knowledge about PrEP among those who need it, and there is a lack of awareness among healthcare providers. Additionally, the high cost of drugs for informal (nonregular) prophylaxis is another significant barrier to accessing PrEP.

Costs are particularly limited for long-acting antiretroviral agents, such as cabotegravir and lenacapavir, which could help overcome barriers to adherence. France, Italy, and the United Kingdom are considering reimbursements.

Individual online purchases are possible, but the cost of 30 tablets is around €50-€70 (approximately $54-$75) for traditional PrEP. For long-acting drugs, only the US market price for cabotegravir is available (up to $24,000), whereas lenacapavir pricing remains unknown.

Safety and Adherence

Concerns regarding safety and adherence persist. The PARTNER study concluded that the combination of tenofovir alafenamide and emtricitabine causes fewer adverse effects on bone and kidney function. However, the efficacy of this combination is highly dependent on patient adherence.

The best opportunity to achieve the WHO goals is by increasing equity in access through various management options, including primary care, with the possibility of remote visits. This should include integrated management with screening and treatment for other sexually transmitted infections, as well as immunizations for hepatitis A and B, human papillomavirus, and mpox.

This story was translated from Univadis Spain using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.