Global adoption of guidelines on and use of oral pre-exposure prophylaxis (PrEP): current situation and future projections

Background: With the 2020 global target of three million oral pre-exposure prophylaxis (PrEP) users set during the UN General Assembly in 2016 at an end, we assessed global trends in the adoption of World Health Organization (WHO) PrEP recommendations into national guidelines and numbers of PrEP users, and estimated future trajectories of PrEP users.  Methods: Data obtained through the Global AIDS Monitoring (GAM) and WHO regional offices was collated to report numbers of PrEP users and WHO PrEP recommendations adoption by country for 2016-2019. To forecast PrEP user numbers until 2023, model countries were selected in each region. PrEP use growth rates observed in these model countries were applied to countries in corresponding regions under different scenarios, including a COVID-19 disruption scenario with static global PrEP use in 2020.  Findings: In 2019, there were 630,000 PrEP users across 76 countries (41% in Americas and 36% in African region), a 70% increase from 2018. 121 countries had adopted the WHO PrEP recommendations in national guidelines: 33 countries in 2018 and 23 in 2019. Without COVID-19 disruptions, 1·0-1·1 million global PrEP users by the end of 2020 and 2·4-5·2 million by 2023 were projected. If COVID-19 disruptions result in no PrEP user growth in 2020, there would be 0·7-1·6 million fewer PrEP users in 2023 (vs. no disruptions).  Interpretation: Widespread adoption of WHO PrEP recommendations coincided with a global increase in PrEP use. While the 2020 global PrEP target will be missed, we estimated future growth in PrEP use. In many countries, PrEP user numbers are small relative to new HIV infections and PrEP recommendations are not implemented at scale. New PrEP products could expand the PrEP user base and, with greater oral PrEP use through simplified delivery, PrEP could significantly contribute to ending AIDS by 2030.  Funding Statement: We thank Unitaid for providing the funding necessary to this work. Declaration of Interests: The authors declare no conflict of interests.