Contemporary challenges in human immunodeficiency virus pre-exposure-prophylaxis in Belgium

Human Immunodeficiency Virus (HIV) pre-exposure prophylaxis (PrEP) is effective in reducing HIV incidence and improving sexual health. Despite its increasing adoption globally and in Belgium, PrEP coverage remains insufficient, posing challenges for both PrEP care and users. Our thesis explores some of these challenges and interventions to address them. We first focus on PrEP discontinuation and the persistent HIV risk upon discontinuation. Factors contributing to discontinuation include monogamous relationships, reduced sexual activity, consistent condom use, but also barriers to care such as difficult access. To address these, we emphasize a differentiated, client-centered, and low-threshold PrEP delivery model, aligned with the World Health Organization's recommendations. Considering individual HIV risk beyond retention metrics is crucial. Subsequently, we delve into a syndemic affecting PrEP users, particularly challenges posed by chemsex and non-consensual sex. A substantial proportion of Belgian PrEP users engage in chemsex and express a willingness to reduce its associated risks, mostly through online applications and face-to-face counseling with a healthcare professional. Non-consensual sex is frequently reported, with a low rate of help seeking, emphasizing the need for improved support services, potentially within PrEP clinics familiar to users. Our research also explores antimicrobial resistance (AMR) in bacterial STIs, most particularly in Neisseria gonorrhoeae. Increasing AMR is mostly due to high antimicrobial consumption. Reduced screening intensity for Neisseria gonorrhoeae and Chlamydia trachomatis in PrEP cohorts is one way to decrease antimicrobial consumption. We also recommend ceftriaxone mono-therapy for Neisseria gonorrhoeae, and we caution against widespread doxycycline prophylaxis use due to the risk of AMR emergence. In conclusion, PrEP positively impacts HIV reduction and sexual health, but challenges in PrEP care, including coverage and discontinuation, must be addressed. The chemsex and non-consensual sex syndemic requires attention and enhanced support services within PrEP clinics. Addressing emerging AMR in bacterial STIs is crucial. Our research provides insights for optimizing PrEP programs and tackling associated challenges.