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Lessons From Brazil: Coordinating Rapid-Start PrEP

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Released: September 16, 2026

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The primary challenge of HIV prevention is not clinical efficacy, but reaching and engaging people most likely to benefit. Read on to learn how Brazil provides an example of how to simplify PrEP delivery with rapid starts and supportive public policy, and see how these principles may be applied to other low- and middle-income countries. 

Emilia M. Jalil
Emilia M. Jalil, MD, PhD
Rapid PrEP Brazil

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More than 4 decades into the HIV epidemic, the gap between what is possible and what is delivered in HIV prevention is striking. Globally, pre-exposure prophylaxis (PrEP) for HIV use has continued to increase, reaching approximately 9 million initiations by the third quarter of 2025. Nevertheless, 1.2 million people still acquired HIV in 2025, with a disproportional burden in low- and middle-income countries (LMICs). This mismatch highlights the primary challenge of contemporary HIV prevention: reaching and engaging people most affected by HIV. 

Rapid Starts for Equity
Rapid-start PrEP represents an important approach to minimize missed opportunities for HIV prevention by allowing PrEP initiation at first clinical contact, if clinically appropriate. This is further supported by the WHO recommendations for simplified and differentiated PrEP delivery. WHO guidance supports same-day PrEP initiation for most people following a negative HIV test result and appropriate clinical assessment, without delaying initiation for assessments that can be safely completed later. This approach may be especially relevant in LMICs, where requiring additional assessments before PrEP initiation can amplify existing structural barriers to health if people have difficulty accessing healthcare.

Going Beyond
Rapid-start strategies are helpful for deconstructing barriers to PrEP, but they also need to be part of a broader shift toward simplified, differentiated, and person-centered HIV prevention. This approach must be adapted to the local health system capacity and guided by national policies, with decentralized delivery and task shifting as important pillars. 

Brazil provides an example of the progressive simplification of PrEP delivery. Brazil’s unified health system, Sistema Único de Saúde, which provides universal health coverage, is a major national strength that has enabled the decentralization and scale-up of PrEP across the country under a single national guideline. The current guideline recommends same-day PrEP initiation through an individualized approach, moving away from risk-based eligibility criteria, and allowing initiation without waiting for kidney function results if clinically appropriate. Nurses and pharmacists, not just physicians, are empowered to evaluate people for PrEP and to prescribe it.  Brazil also aims to improve PrEP access by implementing delivery outside traditional health services, such as in community-based organizations.

Yet, despite how quickly PrEP can be initiated, PrEP implementation remains limited in many LMICs and has recently faced substantial disruptions in several settings. PrEP scale-up is constrained by the absence of national PrEP policies or implementation plans, by fragmented health systems, by limited resources, and by uneven service availability. Public policies committed to effective PrEP access are an urgent need. 

In addition to geographical differences among countries, access is also unequal within countries. Paradoxically, it is often more difficult for people in communities with higher HIV prevalence to access PrEP. This reflects broader social and structural inequities related to socioeconomic position, gender, race and ethnicity, sexual orientation, geography, and other intersecting factors.

Closing Gaps
Rapid-start PrEP is a feasible approach that can be incorporated into existing services without requiring substantial additional investments. Its adoption should be strongly encouraged as part of broader efforts to simplify and expand equitable access to HIV prevention. However, rapid-start alone cannot address the major systemic challenges that continue to limit the impact of PrEP. 

To meaningfully improve PrEP equity, the following factors must be addressed.

First, services must effectively reach the populations who could benefit most but continue to face the greatest barriers to access.

Second, countries must establish and sustain PrEP programs so that scientific advances extend beyond early-adoption settings. Despite the recent approval of several innovative PrEP agents, many are not readily available to the people who need them most. Meaningful choice requires that PrEP products be actually available to people who need them, and public policy must ensure that supply meets demand. Addressing these gaps alongside the adoption of rapid-start approaches will be essential for translating advances in PrEP into broader and more equitable population-level impact in LMICs.

Your Thoughts
Do you provide rapid-start PrEP in your practice? If not, what barriers are preventing you from using rapid-start PrEP?

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