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Universal PrEP
A United Front for Universal PrEP: The Right Choice

Released: November 21, 2025

Linda-Gail Bekker
Linda-Gail Bekker, MBChB, DTMH, DCH, FCP(SA), PhD
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Key Takeaways
  • Framing PrEP discussions around HIV risk stigmatizes PrEP and excludes many potential candidates who may not see themselves as engaging in “risky” behavior.
  • Enabling people to choose PrEP based on their own needs and preferences is empowering, rather than stigmatizing, and actually increases PrEP uptake and persistence.

The advent of antiviral-based pre-exposure prophylaxis (PrEP) revolutionized primary HIV prevention. When used consistently and at scale, PrEP has the potential to largely quell the HIV epidemic through substantial reductions in HIV incidence. But it is not enough to only bring PrEP to people who are “at risk.”

Studies in Africa, where the epidemic is still largely generalized, showed that assessing eligibility for PrEP using risk criteria may reduce its impact: It excludes many who could benefit, and it potentially stigmatizes PrEP.

The studies showed that in communities where HIV is prevalent and HIV viral suppression is not universal (signifying viral transmission), the greatest number of HIV infections are averted when PrEP is offered to all who may benefit. Its impact then depends on accessibility, uptake, effective usage, and persistence.

How can we make this happen? I believe that sexual and reproductive health is an important component of primary healthcare. When encountering a person who is sexually active, we must explore whether HIV prevention may be indicated. Individuals who may be interested in PrEP can then be taken through the different available modalities to choose whichever best suits them. We now have PrEP options that include oral PrEP, a vaginal ring, and 2 types of long-acting injectable PrEP. Each modality has unique characteristics, including mode of action and dosing interval.

In our setting, a structured counseling script is offered, which is enhanced with pamphlets and digital tools that offer more information, weighing the pros and cons and helping potential PrEP users to identify their preferences before even making contact with their healthcare professional (HCP). This information is then assessed by their HCP in terms of clinical eligibilities for various PrEP options, overall streamlining PrEP initiation. 

The Importance of Choice
Data from East Africa illustrated the importance of offering people PrEP options that suit their individual needs. Investigators offered participants a choice between long-acting cabotegravir (LA CAB), oral PrEP, and postexposure prophylaxis, with the option to change over time (the SEARCH dynamic choice prevention intervention). They found that offering choices increased biomedical sexual exposure covered time to 69.7%, compared to 13.3% with standard-of-care HIV prevention. It also reduced HIV incidence to 0%, compared to 1.8% with standard of care.

We have also learned some key points in our PrEP implementation programs in low-socioeconomic, high-burden areas in Cape Town.

  1. Offering choice is feasible with structured counseling that includes a fun self-assessment quiz to gauge preferences. Choice counseling can be effective when conducted by trained lay counselors with a nurse-led final assessment to ensure HIV negativity.

In our project, we offered LA CAB, the dapivirine vaginal ring, and oral PrEP. Most young people 16-29 years of age chose injectable PrEP, and fewest chose the vaginal ring. The main reasons were considerations of lifestyle with less importance given to side effects and effectiveness.

  1. Choice is dynamic, not only in the long term but even over a short period of time. We found that after a few weeks, many people moved from choosing oral PrEP to wanting injectable PrEP, presumably when they felt more comfortable with the concept of PrEP.
  2. Choice increases uptake and coverage. In South Africa, we have shown that adding more PrEP choices has increased the overall uptake of PrEP as prevention.
  3. Choice leads to better persistence: when people are sure about their selection, they have better persistence with their PrEP choice.
  4. Digital tools can augment decision-making and reduce burden on counselors and nurses.
  5. There may be choice trade-offs associated with modes of delivery. For example, a PrEP user who really wants discretion and privacy may opt for oral or ring PrEP, which can be delivered to a private venue, rather than attending a clinic or drop-in center for an injectable, which needs to be administered by an HCP.

Ultimately, framing PrEP discussions around risk stigmatizes PrEP and excludes many potential candidates who may not see themselves as engaging in “risky” behavior. Instead, HCPs should present PrEP as a normal aspect of preventive healthcare. Enabling people to choose based on their own needs and preferences is empowering, rather than stigmatizing. In all, uniting behind universal PrEP for all, based on individual preference and choice rather than risk, is critical to making a significant impact on the HIV epidemic.

Your Thoughts
How do you initiate discussions about PrEP in your practice? What do you think is the best way to discuss PrEP with a person who thinks they don’t need it? Leave a comment to join the discussion!

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