IMPLEMENTATION AND EXPANSION OF PREP IN BRAZIL: REGIONAL INEQUALITIES IN ACCESS, ADHERENCE, AND VULNERABILITY TO HIV
Abstract
Given the persistence of the AIDS epidemic and the limitations of antiretroviral therapy, Pre-Exposure Prophylaxis (PrEP) has emerged as an important biomedical prevention strategy. In Brazil, the implementation of PrEP within the Unified Health System (SUS) began in 2017 and was progressively expanded across the national territory. By 2018, significant disparities had already become evident in the distribution of Drug Dispensing Units (UDMs) among Brazilian regions. Evidence indicates that regions with stronger health infrastructure, such as the Southeast, concentrated on a larger share of services, whereas historically more vulnerable regions, such as the Northeast, faced structural, logistical, and programmatic barriers that limited the decentralization of prophylaxis services. In 2019, the expansion of PrEP availability in strategic municipalities resulted in a substantial decline in new HIV cases. However, between 2020 and 2025, fluctuations in the number of new infections were observed, with annual variations marked by increases and decreases in cases, depending on the region. This pattern may be associated with the growing number of users discontinuing PrEP, as well as with the effects of the COVID-19 pandemic in 2020 and 2021. This scenario suggests that vulnerability to HIV is not determined solely by the structural availability of UDMs but is also closely related to adherence to care. Although the expansion of PrEP represents a significant advancement in combined HIV prevention in Brazil, further efforts are needed to strengthen health education initiatives, improve long-term user follow-up, and promote the decentralization of services. Such measures are essential to ensure greater regional equity and to enhance the impact of PrEP in controlling the HIV epidemic.
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