Objectives:
HIV Pre-Exposure Prophylaxis (PrEP) is highly effective in preventing HIV acquisition. In England, NHS availability was limited to participants of the PrEP Impact Trial until late 2020. Some key populations at greater risk of HIV were underrepresented in the trial suggesting inequities in trial PrEP access. We used the PrEP-to-need ratio (PnR; number of PrEP users divided by new HIV diagnoses) to investigate whether PrEP access improved following routine commissioning in Oct-2020 and identify populations most underserved by PrEP.

Methods:
Aggregated numbers of people receiving ≥1 PrEP prescription and non-late new HIV diagnoses (epidemiological proxy for PrEP need) were taken from national surveillance datasets. We calculated the PnR across socio-demographics during Impact (Oct-2017 to Feb-2020; pre-COVID-19 pandemic) and post-commissioning PrEP era (2021) in England.

Results:
PnR increased >11-fold, from 4.2 pre-commissioning to 48.9 in 2021, due to a 4-fold reduction in non-late new HIV diagnoses and near 3-fold increase in PrEP users. PnR increased across genders, however the men’s PnR increased 12-fold (from 5.4 pre-commissioning to 63.9 post-commissioning) while the women’s increased 7-fold (0.5 to 3.5). This increasing gender-based inequity was observed across age, ethnicity, and region of residence: white men had the highest PnR, increasing >13-fold (7.1 to 96.0), while Black African women consistently had the lowest PnR, only increasing slightly (0.1 to 0.3) post-commissioning, suggesting they were the most underserved group. Pre-commissioning, the PnR was 78-fold higher among white men than Black women, increasing to 278-fold post-commissioning.

Conclusions:
Despite the overall increase in PrEP use, substantial PrEP Impact trial inequities widened post-commissioning in England, particularly across gender, ethnicity and region of residence. This study emphasises the need to guide HIV combination prevention based on equity metrics relative to the HIV epidemic. The PnR could support the optimisation of combination prevention to achieve zero new HIV infections in England by 2030.