Independent report

Roadmap for meeting the PrEP needs of those at significant risk of HIV

Updated 21 February 2024

Applies to England

Introduction

The government is committed to ending new HIV transmissions, AIDS and HIV-related deaths in England by 2030, and our HIV Action Plan from 2021 sets out how we will achieve our interim ambitions of an 80% reduction in diagnoses by 2025.

This includes a commitment to support the system to continue to improve access, uptake and use of HIV pre-exposure prophylaxis (PrEP) for key population groups, including in settings outside specialist sexual health services (SHSs).

PrEP is for people who do not have HIV but who are at risk of acquiring the virus. Biomedical approaches to HIV prevention such as the provision of HIV PrEP are important tools as part of a combination approach to help achieve our ambitions.

Oral antiretroviral PrEP can be prescribed daily or be taken before and after sex and significantly reduces the risk of HIV if taken as recommended. Long-acting, injectable PrEP is yet to be approved for use in the UK, but the National Institute for Health and Care Excellence (NICE) is currently looking at the cost and clinical effectiveness of cabotegravir injections for HIV prevention.

There are significant differences in PrEP need and uptake by population group - for example, heterosexual women are much less likely to have their need identified at a clinical consultation at a specialist SHS and to start and continue using HIV PrEP than gay, bisexual and other men who have sex with men (GBMSM).

This roadmap has been developed and agreed by the HIV Action Plan Implementation Steering Group (ISG) and forms part of the group’s work to monitor and drive forward the implementation of the HIV Action Plan to ensure we achieve the government’s ambitions.

Our vision

This roadmap takes into consideration access, uptake and use of PrEP as there are significant variations among key groups with a significant risk of HIV. For the purpose of this roadmap, PrEP access refers to being able to access settings where HIV PrEP is provided and, as part of ensuring equitable access, it is key to take into account which groups access those services. Access also means enabling access to PrEP services through actions such as upskilling our workforce, improving pathways in settings that prescribe PrEP, and raising awareness of PrEP among key populations. Uptake refers to HIV negative individuals with a significant risk of HIV accepting the offer of PrEP after having had their need identified. Use refers to ongoing use of PrEP as long as the individual would benefit from doing so.

Our vision of equitable access, uptake and use of HIV PrEP means ensuring that PrEP provision meets the needs of all at-risk groups, hence reducing their individual risk of acquiring HIV and contributing to our ambitions to end new HIV transmissions in England by 2030.

We are committed to achieving equitable access, uptake and use of HIV PrEP for those who could benefit irrespective of their gender, age, ethnicity, sexual orientation, disability, geographic area of residence or socio-economic background.

Our work has been informed by the findings and recommendations of research commissioned by the English HIV and Sexual Health Commissioners Group on the use of HIV PrEP, specifically to understand the barriers and facilitators for black African women, trans and non-binary people, and sex workers (women, trans or non-binary) to access PrEP and improve uptake and use of PrEP among these groups.

The report includes recommendations to improve equitable access to PrEP by addressing barriers at system (for example, training for health professionals), provider (for example, outreach activities), and personal (for example, increase awareness and knowledge of PrEP) levels, of which some are reflected below. The fulfilment of other recommendations may require specific actions for these under-served groups.

Where we are now

We know that PrEP is extremely effective at preventing HIV, and equitable access, uptake and use of PrEP among those who could benefit is part of the government’s combination approach to HIV prevention, including condom use, expanded HIV testing, timely access to antiretroviral drugs and treatment as prevention.

Our commitment to PrEP is emphasised by our investment in the successful rollout of PrEP across England, where oral PrEP is routinely available in specialist (level 3) SHSs since 2020. The delivery of HIV PrEP in specialist SHSs is commissioned by local authorities and funded through the public health grant (PHG), while PrEP medicines are funded by NHS England specialised commissioning.

The offer of HIV PrEP is based on prescribing criteria in the NHS England (NHSE) clinical commissioning policy, and clinical guidelines (in the process of being updated) on the use of PrEP, published by the British HIV Association and the British Association for Sexual Health and HIV and accredited by NICE, which allows clinicians to prescribe following a consideration of the patient’s risks and assessing the benefits and potential harms of provision.

HIV PrEP is currently provided in specialist SHSs and, among those accessing these services, heterosexual women and heterosexual men and women in black African communities are, for example, less likely to be prescribed PrEP than GBMSM. However, there is potential to improve access, uptake and use of HIV PrEP for all population groups at high risk of HIV, including GBMSM, women, trans and non-binary people, black African communities and sex workers.

How to realise our vision

We know that more work needs to be done to ensure HIV PrEP is available for all groups, including concerted action from across the health system and civil society organisations representing key groups, such as trans and non-binary people, and black African communities.

This roadmap has been informed by recommendations of the PrEP Access and Equity Task and Finish Group (annexes A and B), a sub-group of the HIV Action Plan ISG, co-chaired by the Association of Directors of Public Health and the Terrence Higgins Trust.

The PrEP roadmap focuses on the following action areas and main facilitators of equitable access, uptake and use of PrEP:

1. Funding of SHSs, including PrEP services, and HIV PrEP medicines.
2. Improving knowledge, implementation and evaluation of interventions aimed at tackling inequalities in HIV PrEP access, uptake and use.
3. Promoting awareness of PrEP among key groups at significant risk of HIV.
4. Improving HIV PrEP access pathways in specialist SHSs supporting uptake and continued use of PrEP.
5. Improving HIV PrEP access pathways in settings other than specialist SHSs.

These action areas will be implemented in collaboration with key delivery partners across the public health system, to be reviewed in 2025, and continue to be taken forward as appropriate beyond this time frame. However, throughout the implementation of the roadmap, we will work closely with stakeholders to amend key priority areas and adjust key actions as our knowledge, resources and opportunities to take effective action evolve. Hence, this roadmap will help guide our efforts to improve equitable access, uptake and use of PrEP, reflecting evolving priorities, funding availability and policy changes to ensure we achieve our ambitions in the most efficient way possible.

Key implementing and delivery partners of this roadmap have responsibilities for contributing to the delivery of HIV PrEP in the wider system, as follows.

Association of Directors of Public Health (ADPH)

ADPH represents views of Directors of Public Health, including on provision of HIV PrEP in local government-commissioned, specialist SHSs in England.

British Association for Sexual Health and HIV (BASHH)

BASHH is a professional organisation that deals with all aspects of sexual healthcare, including providing evidence-based clinical guidance on HIV PrEP.

British HIV Association (BHIVA)

BHIVA is a professional organisation and advisory body on all aspects of HIV care, including providing evidence-based clinical guidance on PrEP and representing professionals in HIV care.

Department of Health and Social Care (DHSC)

DHSC is responsible for national HIV policy in England, including commitment in the HIV Action Plan to improve equitable access, uptake and use of PrEP, and providing funding for local authority-commissioned public health services and overall NHS funding.

English HIV and Sexual Health Commissioners Group (EHSHCG)

EHSHCG is a forum for those with commissioning responsibility for sexual health and HIV to help improve population and patient-level outcomes in sexual health and HIV in England. This includes local authority commissioners who are responsible for commissioning sexual health services, including PrEP.

National AIDS Trust (NAT)

NAT is the UK’s HIV rights charity working to end new HIV transmissions and stopping HIV from standing in the way of health, dignity and equality.

NHS England (NHSE)

NHSE specialised commissioning is responsible for commissioning specialised HIV services, including funding of HIV PrEP medicines. NHSE Health and Justice is responsible for a range of healthcare services that support children and adults throughout the youth justice and criminal justice systems, including PrEP in prisons.

Terrence Higgins Trust (THT)

THT is the UK’s leading HIV and sexual health charity supporting and amplifying the voices of people living with HIV and providing services to help people achieve good sexual health.

UK Health Security Agency (UKHSA)

UKHSA collects data on HIV PrEP access and delivery for surveillance purposes, and supports efforts to inform service improvement in PrEP commissioning and delivery in England. UKHSA also undertakes research on sexually transmitted infections (STIs) and HIV, including on HIV PrEP, through the Health Protection Research Unit and other partnerships.

We recognise the vital role that the broader HIV voluntary and community sector plays in ensuring that access, uptake and use of PrEP is effective and equitable. Their insight and experience will be sought and included in the implementation of this roadmap, including through the HIV Action Plan Community Advisory Group.

Co-production and co-design with populations who use or could benefit from using HIV PrEP was central to the PrEP Access and Equity Task and Finish Group’s recommendations. This will be crucial in our work to improve equitable PrEP access, uptake and use, and should underpin all actions and inform a continuous improvement approach. A continuous improvement approach will also permit further consideration of various methods of delivering PrEP as more evidence becomes available in the future.

NHSE is responsible for commissioning healthcare for people in prisons, including STI and HIV services. HIV PrEP services in prisons are commissioned by NHSE Health and Justice and provided by specialist SHSs in line with the integrated sexual health service specification. Specialist SHS providers are responsible (where they are commissioned) for enabling access to HIV PrEP to eligible prisoners in the same way as they would for people in the community and uptake should be recorded in the national STI surveillance data sets.

HIV PrEP is made accessible through established sexual healthcare pathways in prisons and should be fully integrated in local pathways and networks. The forthcoming BASHH prison standards for sexual health, including HIV PrEP, will provide further information on this. Because of the integration of prison and local pathways, HIV PrEP provision for detained people is considered as part of several actions in this roadmap.

Action area 1: funding of SHSs and HIV PrEP

Routine HIV PrEP services are commissioned by local authorities, through the PHG. HIV PrEP medication is provided by NHSE.

Additional funding for the implementation of the actions in this roadmap of the HIV Action Plan ISG is not currently planned or available, though this does not prevent system partners from considering opportunities to:

• improve PrEP access and uptake
• learn and share best and promising practices
• tackle missed opportunities to improve PrEP access through quality improvement activities in existing resources

DHSC will monitor the funding situation (including future spending reviews) as circumstances change and we gain further knowledge of the most effective ways to deliver equitable access, uptake and use of HIV PrEP for those that could benefit. 

In summary, no additional funding is provided for local government to fund additional PrEP services through this roadmap. The roadmap does not place additional demands on local authorities in relation to HIV PrEP other than their existing responsibilities to commission SHSs, including PrEP services, that meet the needs of their local populations. However, ADPH and EHSHCG are key deliver partners in progressing the government’s work on PrEP, including efforts to improve the delivery and impact of currently commissioned services. They also have a key role in representing local government in the HIV Action Plan ISG.

Action 1.1

Existing PHG funding allocation for local government-commissioned public health services: a total of £3.6 billion will be allocated to local government in 2024 to 2025 to cover a wide range of public health services, including SHSs.

Action 1.2

National NHSE commissioning and funding of HIV PrEP medicines: NHSE to continue funding PrEP medicines through its specialist commissioning team.

Action area 2: tackling inequalities in PrEP access, uptake and use

We aim to further improve our knowledge of tackling inequalities in PrEP access, uptake and use, and how potential barriers could be overcome. PrEP use refers to both initiation and continuation of HIV PrEP.

More evidence is needed on the effectiveness of providing PrEP outside SHSs and NICE has recommended further research on PrEP provision in other settings, including if this will reach populations who could benefit from but are not currently accessing HIV PrEP.

Provision of a wider choice of PrEP methods, including injectable medicines, may improve uptake, acceptability and adherence. DHSC and its various agencies and partner organisations, including NICE and NHSE, are monitoring the potential use of new methods as evidence to support their effectiveness becomes available. This includes looking at models of care to deliver new PrEP methods along the PrEP care continuum.

Action 2.1

Roundtable to discuss NICE recommendations for further PrEP research.

DHSC to convene roundtable in 2024 to 2025 to look at evidence to date and explore opportunities for further research in line with NICE’s recommendations for PrEP research on:

• availability of PrEP outside SHSs
• different modes of PrEP delivery, particularly long-acting PrEP (such as injections) and including in women
• eligibility for PrEP (cost-effectiveness of providing PrEP to people who do not report recent condom-less sex)

Action 2.2

ISG PrEP working group to explore potential research proposal to improve our understanding of barriers and opportunities to optimise equitable PrEP access, uptake and use: to be considered by ISG in the wider context of other HIV research gaps in 2024 to 2025.

Action 2.3

Review existing work to deliver and improve equitable access, uptake and use of PrEP, and draw on findings to make actionable recommendations and suggest ways forward using a place-based approach.

Action 2.3.1

Local areas to utilise UKHSA-facilitated HIV care pathway workshops to identify service improvement actions related to optimising delivery of PrEP. Work to be led by UKHSA in 2024 to 2025.

Action 2.3.2

EHSHCG research to inform future work to improve uptake of PrEP among key population groups, including black African women, trans and non-binary people, and sex workers. This may include making every contact count (MECC), accessibility of SHSs for key populations, use of increased cultural sensitivity, and co-production in advice and guidance. Work to be led by EHSHCG in 2024 to 2025.

Action 2.3.3

BASHH and BHIVA to review practice examples and existing work in 2024 to 2025 to make actionable recommendations to help improve equitable access, uptake and use of PrEP, including in detained settings.

Action 2.3.4

Review of genitourinary medicine (GUM) access, including HIV testing uptake and PrEP use, in prisons following on from the publication of the BASHH prison standards. Work to be led by BASHH, NHSE and UKHSA in 2024 to 2025.

Action 2.3.5

DHSC to bring together NHSE, UKHSA, local government colleagues and NHS professional bodies in 2024 to 2025 to clarify arrangements for PrEP in prisons, including data collection.

Action 2.3.6

BASHH and BHIVA to work with commissioners in 2024 to 2025 to establish suitable and acceptable pathways for access to current and future PrEP therapies or treatments, including second line emtricitabine and/or tenofovir alafenamide and prescribing by non-NHS providers.

Action 2.4

Review evidence of novel PrEP approaches. 

Action 2.4.1

HIV PrEP horizon scanning looking at innovative models of care along the HIV PrEP continuum and innovative PrEP access using technology. Work to be led by BASHH in 2024 to 2025.

Action 2.4.2

Horizon scanning for new HIV PrEP drugs. This work in ongoing and led by BASHH and NHSE.

Action 2.5

ISG PrEP working group to assess opportunities for PrEP delivery in other settings.

In 2024 to 2025, DHSC and system partners to consider the available evidence, regulatory and delivery or system issues, and funding needed to enable potential future delivery in other settings beyond specialist sexual health clinics.

Action 2.6

Reporting and publication of HIV PrEP data.

Action 2.6.1

UKHSA to continue publishing HIV PrEP data in existing HIV surveillance outputs - using indicators in UKHSA’s:

• monitoring and evaluation framework for PrEP

• annual publication of HIV official statistics

• annual publication of HIV Action Plan monitoring and evaluation framework

Action 2.6.2

DHSC to explore adding PrEP indicators to the Public Health Outcomes Framework in 2024 to 2025.

Action 2.7

Implement measures to improve PrEP performance evaluation.

Action 2.7.1

EHSHCG, with support from UKHSA, to raise awareness among commissioners in 2024 to 2025 of UKHSA PrEP monitoring and evaluation framework, including PrEP indicators reported through the genitourinary medicine clinic activity data set (GUMCAD) STI surveillance system, and consider aggregated service-level data to inform key performance indicators (KPI).

Action 2.7.2

UKHSA to continue ongoing and routine work with commissioners and providers in 2024 to 2025 to improve data quality and ensure PrEP indicators are as useful as possible. Explore opportunities for collecting information on local interventions aimed at improving access, uptake and use of PrEP through existing evaluation frameworks. 

Action 2.7.3

Local areas to continue strengthening the use of routine commissioning data to understand why people with a HIV PrEP need (at significant HIV risk and who could benefit from PrEP) attending specialist SHSs are not getting PrEP, and address bottlenecks along the HIV care pathway to improve services at local level. EHSHCG to lead on this work with support from UKHSA in 2024 to 2025.

Action 2.8

ISG to monitor and review progress on action areas in PrEP roadmap - work to be led by ISG PrEP working group in 2023 to 2024 and 2024 to 2025.  

Action 2.8.1

PrEP working group comprising of key ISG delivery partners, including civil society, to oversee the implementation of this roadmap.

Action 2.8.2

Ongoing monitoring and review of action areas and actions in regular ISG meetings.

Action 2.8.3

ISG to review progress on improving equitable access, uptake and use of PrEP, including through possible future provision in other settings.

Action area 3: promoting awareness of PrEP among key groups

Greater awareness of PrEP and demand creation among key groups most at risk of HIV is likely to be needed alongside improved access pathways in specialist SHSs, as highlighted under action area 4, and potential access to PrEP through other settings under action area 5.

Action 3.1

Promote PrEP in partnership with users and target populations, and consider options for national and local PrEP campaigns.

Action 3.1.1

DHSC to work with system partners to improve available information on HIV PrEP, including on nhs.uk, and suggestions to make sure PrEP information is comprehensive, culturally competent and relevant. Work to be led by the ISG PrEP working group in 2024 to 2025.

Action 3.1.2

DHSC will continue to promote PrEP nationally through HIV Prevention England in partnership with key stakeholders in 2024 to 2025.

DHSC will consider PrEP awareness when preparing options for ministers for the successor to the current HIV Prevention England programme.

Action 3.1.3

Local government to continue to promote PrEP as appropriate to their target populations - using data from UKHSA and in collaboration with users and target populations as appropriate.

EHSHCG to develop examples of PrEP campaigns in 2024 to 2025 and invite commissioners to incorporate into local, regional and national health promotion strategies.

Action area 4: improving access pathways in specialist SHSs

As part of our work to improve access to PrEP for those most at risk of HIV, we will explore and consider opportunities to improve PrEP access pathways in specialist SHSs as well as PrEP provision in other settings (action area 5).

Increasing awareness of eligibility and enabling wider services to refer people to existing PrEP clinics (specialist SHSs) is likely to be an important part of achieving equitable access to HIV PrEP for those that could benefit the most from PrEP.

Action 4.1

Revise professional guidelines on the use of HIV PrEP, including recommendations on the following.

Action 4.1.1

Routine discussion of PrEP with service users attending specialist SHSs to ensure everyone who needs PrEP is aware of it and PrEP is prescribed as appropriate. Work to be led by BASHH and BHIVA in 2024.

Action 4.1.2

Six-month PrEP prescriptions to be issued where appropriate (permitted as per PrEP patient group direction (PDF, 314KB)) to reduce service demand from existing PrEP users and increase capacity for complex patients. Work to be led by BASHH and BHIVA in 2024.

Action 4.1.3

Develop service standards for PrEP delivery through guideline development by BASHH and BHIVA - with support from UKHSA on use of surveillance data to measure service standards. Work to be led by BASHH and BHIVA in 2024, with support from UKHSA.

Action 4.2

ISG Workforce Task and Finish Group to consider opportunities for upskilling the sexual health workforce, including on PrEP - building on available evidence and existing work in specialist SHSs to deliver PrEP.

Action 4.2.1

Gather resources to do a gap analysis on available resources. Work to be led by ISG Workforce Task and Finish Group in 2024 to 2025.

Action 4.2.2

Develop a sexually transmitted infection foundation (STIF) course for all providers. Work to be led by ISG Workforce Task and Finish Group in 2024 to 2025.

Action 4.3

ISG PrEP working group to explore in 2024 to 2025 opportunities for piloting HIV PrEP referrals in primary care to access PrEP at specialist SHSs, drawing on existing work (for example, in Manchester) and elsewhere.

Action 4.4

Online training for health professionals on PrEP criteria. 

Action 4.4.1

NHSE workforce leads to implement a centralised online training programme for sexual health clinic staff on PrEP prescription criteria to minimise missed opportunities for prescribing PrEP. Work to be led by ISG Workforce Task and Finish Group in 2023 to 2024.

Action 4.4.2

Consider the need for upskilling other health professionals on PrEP prescription criteria using a centralised online training programme. Work to be led by ISG Workforce Task and Finish Group in 2023 to 2024.

Action 4.5

Explore opportunities for expanded use of PrEP outreach programmes and online models.

Action 4.5.1

Local government to continue to consider the benefits of local and targeted outreach programmes to identify people who could benefit from PrEP but are not currently accessing it (guided by lessons emerging from action area 3 to promote awareness of PrEP among key groups, and HIV surveillance data showing the need to focus efforts on black heterosexual women, heterosexual women from other ethnic minority groups and GBMSM).

EHSHCG and ADPH to lead, and local government to consider implementing PrEP outreach programmes as appropriate in their local context and subject to availability of funding.

Action 4.5.2

BASHH and BHIVA to promote successful online models (for example, the Brighton PrEP EmERGE project), including underlying evidence-base and funding requirements for implementation. Presentations at BHIVA spring conference in 2024.

Action 4.5.3

EHSHCG to raise awareness in 2024 to 2025 among commissioners of use of virtual PrEP follow-up through phone apps (for example, the Brighton PrEP EmERGE project).

Action 4.6

BASHH and BHIVA to use available information and data on HIV PrEP to make recommendations to inform more person-centred models of PrEP provision along the PrEP continuum. Work to be taken forward in 2024 to 2025.

Action 4.7

BASHH to deliver professional standards of HIV PrEP in prisons delivered by specialist SHSs.

Publication of BASHH standards for the management of sexual health in UK prisons in 2024.

Action area 5: improving access pathways in other settings

HIV PrEP is currently only prescribed at specialist SHSs, but as we work to improve equitable access, uptake and use of PrEP, we will explore opportunities for making PrEP accessible outside specialist SHSs and in a variety of settings.

Action 5.1

ISG PrEP working group to consider opportunities for PrEP delivery or pilots outside specialist SHSs.

PrEP working group to draw on information and further evidence as outlined under action area 2.

Action 5.1.1

ISG PrEP working group to assess available evidence and regulatory and delivery or system issues, and funding needed to deliver PrEP in other settings. Make recommendations, as appropriate, on opportunities to pilot PrEP delivery in local areas with extremely high, high and low HIV prevalence levels.

Action 5.1.2

DHSC and local commissioning bodies to consider availability of funding to support the implementation of PrEP pilots as appropriate.

Action 5.1.3

The inclusion of and co-production with populations who use or could benefit from PrEP should be considered as part of the development of any future pilots.

Action 5.2

Explore opportunities for PrEP service delivery in reproductive health services with the aim to improve access to PrEP for women.

Action 5.2.1

ISG PrEP working group to explore in 2024 to 2025 opportunities for providing PrEP in reproductive health services, including those services integrated with specialist SHSs and reproductive health services in primary care, women’s health hubs, independent abortion clinics and so on.

Action 5.2.2

BASHH and BHIVA to engage the Faculty of Sexual and Reproductive Healthcare in 2024 to 2025 on missed opportunities to test for HIV and prescribe PrEP in reproductive health services integrated with specialist SHSs.

Action 5.3

ISG PrEP working group to explore in 2024 to 2025 the feasibility and possible benefits of undertaking online PrEP clinic pilot at local or national levels to complement other digital services - considering a range of issues, including clinical implications and governance.

Conclusion

In line with our commitment in the HIV Action Plan, we will continue to invest in HIV PrEP and take forward actions in this roadmap to improve equitable PrEP access, uptake and use for key population groups and in settings other than specialist SHSs.

We know that PrEP is extremely effective at preventing HIV and that access, uptake, and use of PrEP varies significantly among key groups most at risk of HIV. However, there is potential to improve access to HIV PrEP for all population groups at high risk of HIV, including GBMSM, women, trans and non-binary people, black African communities, and sex workers.

The HIV Action Plan ISG will work towards achieving the government’s vision of equitable access to PrEP so that access, uptake and use of PrEP meet the needs of at-risk groups. This includes individuals and groups who could benefit from PrEP irrespective of their gender, age, ethnicity, sexual orientation, disability, geographic area of residence or socio-economic background.

We know that more work needs to be done to ensure PrEP is accessible for all groups, including concerted action from across the health system and civil society organisations representing key groups. We also know that we need to improve our knowledge of tackling inequalities in PrEP access, uptake and use, and how potential barriers could be overcome.

More evidence is needed on the effectiveness of providing PrEP outside SHSs and whether this will reach populations who could benefit from it, but are not currently accessing it. As part of our work, we will explore and consider opportunities to improve PrEP access pathways in specialist SHSs as well as PrEP provision in other settings. Provision of a wider choice of PrEP methods may improve uptake, acceptability and adherence in the future as evidence to support their effectiveness becomes available.

We will implement the 5 action areas in this roadmap in collaboration with key delivery partners across the public health system, to be reviewed in 2025, and continue to be taken forward as appropriate beyond this timeframe.

Throughout the implementation of the roadmap, we will work closely with stakeholders to amend key priority areas and adjust key actions as our knowledge, resources and opportunities to take effective action evolve. This roadmap will help guide our efforts to improve equitable PrEP access, uptake and use, reflecting evolving priorities, funding availability and policy changes to ensure we achieve our ambitions in the most efficient way possible.

The HIV Action Plan ISG will monitor the implementation of this roadmap on an ongoing basis and will also convene all implementing partners once a year to review progress on improving PrEP access, uptake and use for those at significant risk of HIV and who could benefit from receiving PrEP.

Annex A: recommendations of the PrEP Access and Equity Task and Finish Group

The following recommendations were developed by the PrEP Access and Equity Task and Finish Group and were used to inform the development of the PrEP roadmap. They are presented here to provide transparency, however, you should refer to the main document to see the work being taken forward as part of the roadmap.

Group 1: overarching funding recommendations 

1. Targeted work to improve PrEP access and reduce inequality must be funded by the system as a whole, not solely the PHG. At the same time, funding for local authority public health must explicitly reflect increased work on PrEP and sexual health to meet the national HIV Action Plan and recommendations. Without funding, these recommendations will not be delivered.

2. One-off central funding must be provided to support sexual health clinics to recover activity displaced by unpaid mpox work.

3. Any unspent 2021 to 2022 and 2022 to 2023 HIV Innovation Fund should be used to fund pilots to tackle PrEP access and inequalities.

Group 2: commissioning recommendations 

4. National health bodies, in partnership with local commissioners, should commission a series of pilots providing PrEP in a variety of settings outside specialist sexual health clinics, including online, pharmacies, GPs, a community setting, a contraceptive clinic and a non-specialist sexual health setting. Areas of high, medium and low HIV prevalence should all be represented. Pilots must be supported by funding for promotion and gathering learnings to expand PrEP provision nationally. Co-production with populations who use or who could benefit from PrEP should be prioritised.

5. National health bodies, in partnership with local authority commissioners, should pilot a national online PrEP clinic.

6. DHSC must commit to swiftly consider the findings of PrEP pilots and, if successful, commission PrEP beyond sexual health services nationally.

Group 3: improving knowledge 

7. A registrar or BASHH fellow should be tasked to complete and publish a review of best practice and existing work tackling inequalities in PrEP access.

8. A research roundtable should be convened in spring 2024 to discuss gaps in current evidence and potential for further research, including opportunities and harms identified through pilots for PrEP beyond sexual health services.

Group 4: promoting awareness 

9. DHSC and NHSE should review and revise all NHS web content and literature on sexual health and reproductive health to identify new opportunities to promote PrEP in these forums. These should be co-designed with users and target populations.

10. A national PrEP campaign to be launched (or support for local campaigns) to promote that PrEP is freely available and signpost where it can be accessed. This should be co-designed with users and target populations and evaluated.

Group 5: improving access, pathways and retention

11. Local targeted outreach programmes must be funded to identify people who could benefit from PrEP but are not accessing it currently. These programmes should be guided by lessons emerging from group 3 recommendations.

12. Six-month PrEP prescriptions should be promoted, where appropriate, to reduce service demand from existing PrEP users and increase capacity for complex patients.

13. PrEP guidance should recommend routine discussion of PrEP with everyone attending a sexual health clinic, to ensure everyone who needs PrEP is aware of it and can access it.

14. Introduce a national PrEP access target with a maximum wait time. A task and finish group led by commissioners should be established to facilitate this and appropriate funding must be provided.

15. PrEP KPIs for commissioners should be revised and broadened to include measures to improve equity. Reviewing KPIs and consideration of additional GUMCAD codes to inform the KPI data should be within the remit of the task and finish group identified in recommendation 14.

16. A centralised online training programme for sexual health clinic staff on PrEP eligibility should be launched to minimise missed opportunities for prescribing PrEP.

17. Everyone with a PrEP need who attends a sexual health clinic should be seen by a nurse or clinician who is qualified to counsel on PrEP.

18. We strongly recommend that co-production and co-design underpin all actions and recommendations and inform a continuous improvement approach.

Annex B: supplementary recommendations

The following recommendations were developed by the PrEP Access and Equity Task and Finish Group and were used to inform the development of the PrEP roadmap. They are presented here to provide transparency, however, you should refer to the main document to see the work being taken forward as part of the roadmap.

Following an initial workshop (7 March 2023) on an early draft of the PrEP Action Plan, the Task and Finish Group reconvened for an additional meeting in March 2023.

In response to the draft plan, the group agreed to make a set of additional recommendations to supplement the Task and Finish Group’s report submitted to the HIV Action Plan Implementation Steering Group in January 2023.

Introduction of a national PrEP access or waiting target

The group recommends a revision of action on national PrEP access or waiting target, to read:

Local authorities to report on the feasibility of how national PrEP access targets can be introduced, which cover access to and waiting times for initiation of treatment and ongoing access. Task and finish group to be made up of commissioners with input from UKHSA on the feasibility of monitoring this target.

The PrEP Action Plan should seek to influence the upcoming update to the PrEP Public Health Outcomes Framework and promote a PrEP-related target.

PrEP pilots

It is concerning that the current proposal for PrEP pilots is marked as ‘possible future opportunities’, describes a single pharmacy pilot and does not include primary care. PrEP pilots beyond sexual health services must be tailored to local need and capacity.

An additional working group - consisting of DHSC, the community sector, NHSE and clinicians - should meet for a discrete workshop to produce guidelines and recommendations to ICSs on determining the most appropriate settings locally for PrEP delivery beyond sexual health clinics. This exercise must happen simultaneously to the pilots recommended in the Task and Finish Group’s report in January.

PrEP in prisons

Accelerate and advise on the PrEP pilots in prisons committed in the HIV Action Plan. 

Engagement with reproductive health clinicians

Opt-out HIV testing in emergency departments in Manchester alone has identified 3 women living with previously undiagnosed HIV who had accessed sexual health services for coils fitting in the last year but had not been tested for HIV. It is clear that a number of the commitments in the PrEP Action Plan must include engagement with reproductive health services.

DHSC should engage the Faculty for Sexual and Reproductive Health on the delivery of relevant actions in the PrEP Action Plan, including to:

• set up a roundtable to identify gaps in evidence and research needs
• review existing work to tackle inequalities in PrEP access
• revise professional guidelines on routine PrEP discussions
• ensure professionals are qualified to counsel on PrEP at specialist SHSs

BASHH and BHIVA should engage the Faculty for Sexual and Reproductive Health on missed opportunities to test for HIV and prescribe PrEP in reproductive health services.

The Association of Directors of Public Health to discuss with members the potential for a pilot on PrEP provision from reproductive health services.