Person-centred HIV prevention in an era of innovation and uncertainties

Abstract

Person-centred care (PCC) is a healthcare approach that focuses on understanding and respecting clients’ preferences, values and beliefs. It aims to empower clients by actively involving them in their own care and highlighting the importance of effective communication and relationships between providers and clients [1-3]. Person-centred health systems are widely endorsed in political and policy statements as essential for addressing health system challenges, promoting equity in access, delivering quality and effective care, and ensuring that no one is left behind [4]. Despite widespread recognition of these PCC principles, current healthcare delivery models often fall short of these ideals because they tend to be disease-focused, fragmented and siloed, emphasising specific programmatic outputs, putting pressure on health workers and jeopardising client-centred care delivery [5]. There is an urgent need to transition from disease-focused health systems to those centred on individuals because nearly half of the global population lacks equitable access to essential healthcare services.

This transformation requires innovative solutions that meet client needs while maintaining accessibility and continuity of care. Recent advances in HIV prevention, including long-acting injectables for pre-exposure prophylaxis (LAI-PrEP), create unprecedented opportunities for PCC. In 2024, the ground-breaking PURPOSE 1 trial reported 100% efficacy among young women receiving twice-yearly lenacapavir​ [6]. Similarly, the PURPOSE 2 trial demonstrated that HIV incidence was 96% lower with lenacapavir compared to the background incidence [7]. For the first time, individuals can choose from multiple PrEP options—pills, rings or injectables—that align with their sexual behaviours, needs, preferences and life circumstances. Health providers need to educate and counsel individuals about these options, providing evidence-based information about their effectiveness, side effects and requirements (such as adherence to daily dosing or injection schedule) to facilitate autonomous and informed decision-making.

HIV self-testing (HIVST) utilisation can be improved through PCC approaches and complement PrEP. A meta-analysis of 33 studies from around the globe found that HIVST kit distribution by sexual partners, peers or through online platforms achieved higher testing rates than facility-based testing [8]. Significantly, it expanded testing coverage in key populations without reducing test accuracy or safety. Recent evidence suggests that HIVST streamlines HIV screening for people on PrEP and promotes PrEP uptake by individuals not accessing care. It can be leveraged to support PrEP initiation, continuation and re-engagement in care [9]. Technological innovations, such as LAI-PrEP and HIVST, represent only one component of effective prevention. To maximise their effectiveness, it is crucial to adopt comprehensive policies that integrate biomedical strategies with behavioural and structural interventions, implement multi-sectoral programmatic approaches and develop community-responsive service delivery models. This supplement synthesises evidence from PCC intervention research conducted across Africa, Asia, the Caribbean and North America. It includes four research articles, two short reports, a systematic review, a viewpoint and a debate article. Three main themes emerged from the research included in this supplement.

The first theme centres on strategies designed to overcome structural and health system barriers that impede access to HIV prevention services. Australia's approach highlights the importance of person-centred HIV prevention at a national level, driven by partnerships among community organisations, policymakers and researchers that reflect the experiences of local communities, as illustrated in the Viewpoint by Bavinton et al [10]. Despite progress in eliminating HIV among gay and bisexual men who have sex with men, there was a 55% rise in HIV cases among overseas-born individuals from 2010 to 2023. Addressing these disparities requires principles like accessibility and cultural responsiveness, along with enabling access and choices for PrEP. Efforts to expand PrEP options, integrate services into primary healthcare and expand multicultural peer navigation services demonstrate how prioritising dignity and autonomy can improve reach and retention in HIV prevention programmes. McLemore and Amon present the experience of the Global Fund's Breaking Down Barriers initiative, which targeted structural and health system barriers affecting key populations, who account for 70% of new HIV acquisitions worldwide [11]. The authors highlight the experience of Jamaica, Mozambique and Indonesia, which all incorporated a human rights-based approach to improve access to health services. In Indonesia, nearly 900 transgender individuals obtained their national ID cards to enhance access to healthcare and social services. Meanwhile, in Mozambique, community members received support from legal professionals and peers to address human rights issues related to HIV services, successfully resolving 90% of the 6018 cases reported. In Jamaica, civil society organisations have improved legal literacy initiatives, known as “Know your rights,” and formed multi-institutional coalitions to tackle stigma and discrimination. Thus, combining community-led human rights efforts with person-centred HIV prevention and treatment has the potential to overcome structural barriers to care.

The second theme focuses on delivering integrated services beyond conventional health models to reach populations who infrequently seek HIV preventive services due to multi-level barriers, including stigma and discrimination, such as key populations and youth. In India, the Mitr clinics provide a comprehensive approach for transgender women, combining gender-affirming services with HIV testing and PrEP. Services such as laser hair removal and hormone therapy attract clients, facilitating access to HIV prevention services (Shaikh et al.) [12]. As a result, 62% of eligible clients received HIV testing, and among 585 clients interested in PrEP, nearly all (98%) took it. These interventions demonstrate the value of integrated, client-centred care for underserved populations. A qualitative study in Canada examined the experiences of both service providers and care recipients regarding integrated HIV/HCV care and the safer supply programme for people who use drugs (Guta et al.) [13]. This programme, managed by healthcare professionals, focused on providing services in a person-centred, non-punitive and trauma-informed manner.

Providers noted that the safer supply model facilitated discussions with people who use drugs about preventing HIV, HCV, and other sexually transmitted and bloodborne infections. In South Africa, community-based peer navigation reached 75% of youth enrolled in a stepped-wedge, cluster-randomised trial, with high acceptability for support; 93% tested for HIV, while 63% tested for curable sexually transmitted infections (STIs), revealing an STI prevalence of 29%, with 85% linked to treatment (Busang et al.) [14]. Males were more likely than females to be offered PrEP, indicating that tailored interventions addressing men's specific PrEP needs and preferences can improve uptake. These diverse examples demonstrate how the discourse can shift from labelling populations as “hard-to-reach” to focusing on what comprehensive services can be offered to them alongside HIV preventive services.

The third theme includes papers focusing on new technologies, including digital health solutions, data health systems, and point-of-care (POC) testing. At the global level, the World Health Organisation has proposed guidelines on person-centred HIV strategic information, with an emphasis on strengthening digital data systems to harmonise and increase the use of essential data elements for national health information systems, thereby improving the HIV response, including HIV prevention [15]. Dalal et al. surveyed 21 countries to gather data on the implementation of these guidelines at the national level. Among the 18 participating countries (82%), all of them included the recommended HIV testing data elements, and nearly all addressed vertical transmission [16]. However, only half provided the necessary data to calculate PrEP coverage. Harm reduction services, such as opioid-agonist maintenance therapy (OAMT), were available in only eight countries due to legal barriers; of these, 75% collected the required OAMT data elements. These findings highlight significant gaps in global implementation of WHO digital health guidelines, particularly in PrEP monitoring and harm reduction data collection, underscoring the importance of ongoing technical support in strengthening HIV surveillance systems. In a similar vein, technology is being utilised to improve oral PrEP use. Recent research has focused on identifying evidence-based interventions to improve adherence and retention in PrEP programmes. A systematic review conducted by Rotsaert et al. found that two-way text reminders or POC tenofovir testing combined with HIV biofeedback counselling improved oral PrEP continuation rates among pregnant and postpartum women [17]. While POC STI testing did not influence PrEP initiation or continuation rates, STI diagnosis was a predictor for PrEP uptake. Future research on PCC interventions should explore the interplay between risk perception, STI diagnosis, PrEP usage and drug-level feedback.

Two papers from Asia demonstrate how digital interventions can be incorporated to deliver real-time individualised HIV prevention messaging and identify predictive attributes for PrEP adherence. Mobile health (mHealth) applications designed to support adherence or self-care can tailor information, advice, and reminders based on user-provided data and preferences. mHealth apps that include self-monitoring and visual feedback have the potential to increase PrEP use. The “Stand by You” initiative in Thailand used a mobile app to provide person-centred support for young people, especially sexual and gender minorities, by ensuring privacy while delivering HIVST kits and non-judgemental text-based real-time counselling (Sripanidkulchai et al.) [18]. The programme's effectiveness was demonstrated through high engagement: 56% were first-time testers, the prevalence of undiagnosed HIV was 3.6%, and among them, 60.2% were linked to care. This success highlights how digital tools, community involvement, TikTok influencers and tailored messaging can effectively overcome barriers such as stigma and limited access to healthcare. Building on this evidence of mHealth engagement strategies, researchers have also leveraged machine learning techniques to better understand and predict user behaviour patterns within digital health platforms. A machine learning study of a mobile health app found that age, cumulative PrEP use, condom use and anal sex events with HIV-negative partners not on PrEP predicted PrEP utilisation among men in Taiwan (Liao et al.) [19]. The use of digital health person-centred interventions is rapidly evolving, and new scientific research questions will emerge on how to incorporate them into routine clinical care and assess their sustained effects on PrEP persistence.

The year 2025 has been marked by extraordinary changes in the HIV response globally following the unprecedented funding cuts and reorganisation of the US global health programme. This disruption will significantly impact PCC, leading to service cuts, lower quality, increased client burden and weakened healthcare system capacity. Evidence from low- and middle-income countries shows worsened client experiences, higher out-of-pocket costs and disrupted care continuity [20]. UNAIDS projects that the permanent discontinuation of HIV programmes currently supported by PEPFAR will lead to 6.6 million new HIV acquisitions between 2025 and 2029 [21]. Within this environment, advocacy for increased resources, global and domestic support, funding for HIV prevention efforts and alignment of donor resources with local requirements is critical [22]. Striking a balance between the demand for comprehensive care and fiscal constraints necessitates innovative strategies and collaborative partnerships. Prioritising high-impact, cost-efficient and community-led interventions is key to sustainability for PCC [23].

Bringing people-centred HIV prevention interventions to scale requires a comprehensive strategy that integrates biomedical, behavioural and social interventions into existing healthcare systems [22, 25], while actively involving communities in the design and delivery of services. Additionally, implementing a combination of evidence-based HIV prevention strategies at the individual, community and policy levels—such as integrating PrEP, antiretroviral treatment and behavioural support to improve uptake and adherence—is essential for improving population-level impact [25]. It is also important to address stigma and discrimination that hinder access to care [26]. Advocacy for increased resources, support for HIV prevention efforts, increasing domestic funding sources and ensuring that donor resources align with local requirements can help secure the sustainability of PCC interventions. Despite these strategies for sustaining person-centred HIV interventions, such as mHealth apps, peer navigation, two-way texting and POC testing, challenges such as chronic underfunding, drastic funding reductions, and pervasive multi-level stigma continue to pose significant barriers to care.

AM, IA and M-CL have no competing interests to report.

All authors have contributed to the conception and writing of the manuscript. All authors reviewed and approved the final version.

No funding was received for this work.