{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,30]],"date-time":"2026-09-30T04:04:12Z","timestamp":1790741052568,"version":"4.1.0"},"reference-count":29,"publisher":"AOSIS","issue":"1","license":[{"start":{"date-parts":[[2026,4,13]],"date-time":"2026-04-13T00:00:00Z","timestamp":1776038400000},"content-version":"unspecified","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"abstract":"<jats:p>Background:\u00a0Pre-exposure prophylaxis (PrEP) guideline implementation varies widely across countries as a result of differences in health systems, resources, and HIV priorities. Since 2016, oral PrEP has been available to key populations, yet limited evidence exists on how implementation challenges differ across contexts.\nObjectives:\u00a0This review aimed to explore the processes and challenges in the implementation of PrEP guidelines globally.\nMethod:\u00a0An integrative review method was used by searching electronic databases, including PubMed, Medline, EBSCOhost, CINAHL, and Google Scholar, to extract the data. We included qualitative, quantitative, and mixed-method studies relevant to the global implementation of PrEP published in peer-reviewed English journals from 2019 through 2025.\nResults:\u00a0This study emphasises that worldwide PrEP implementation is complex and adaptable, involving progressive provider engagement, task-shifting, and health system integration. Stigma and misunderstandings about PrEP, including structural barriers such as a lack of coverage recognition and supply chain difficulties at odds with the maintenance phase needed to scale up availability, are challenges.\nConclusion:\u00a0Progress on global PrEP coverage has been blunted by persisting challenges in dismantling structural, financial, and geopolitical blockades to universal access. The model will work if it is implemented with community outreach and creative service delivery, including education, training, and outreach. Structural inequalities need to be considered and crisis-affected communities prioritised to ensure that access is equitable and sustainable. Implemented at scale, PrEP could be a game changer for HIV prevention globally, especially in high-burden countries.\nContribution:\u00a0This study contributes by synthesising evidence on global PrEP guideline implementation, highlighting health system, structural, and societal challenges.<\/jats:p>","DOI":"10.4102\/curationis.v49i1.2817","type":"journal-article","created":{"date-parts":[[2026,4,13]],"date-time":"2026-04-13T14:20:12Z","timestamp":1776090012000},"update-policy":"https:\/\/doi.org\/10.4102\/crossmark-policy","source":"Crossref","is-referenced-by-count":2,"title":["Scaling up pre-exposure prophylaxis: A global analysis of processes and challenges regarding the implementation of the pre-exposure prophylaxis guidelines"],"prefix":"10.4102","volume":"49","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-0258-3038","authenticated-orcid":false,"given":"Junior M.","family":"Ntimani","sequence":"first","affiliation":[{"id":[{"id":"https:\/\/ror.org\/003hsr719","id-type":"ROR","asserted-by":"publisher"}],"name":"Sefako Makgatho Health Sciences University"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6156-6812","authenticated-orcid":false,"given":"Andile G.","family":"Mokoena-de Beer","sequence":"additional","affiliation":[{"id":[{"id":"https:\/\/ror.org\/003hsr719","id-type":"ROR","asserted-by":"publisher"}],"name":"Sefako Makgatho Health Sciences University"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9502-6486","authenticated-orcid":false,"given":"Deliwe R.","family":"Phetlhu","sequence":"additional","affiliation":[{"id":[{"id":"https:\/\/ror.org\/003hsr719","id-type":"ROR","asserted-by":"publisher"}],"name":"Sefako Makgatho Health Sciences University"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"2580","published-online":{"date-parts":[[2026,4,13]]},"reference":[{"key":"ref0","doi-asserted-by":"crossref","unstructured":"Atkins, K., Tengah, A., Musau, A., Mugambi, M., Odhiambo, G., Soud, M. et al., 2023, \u2018Health system opportunities and challenges for PrEP implementation in Kenya: A qualitative framework analysis\u2019, PLoS Global Public Health 3(4), e0001892. https:\/\/doi.org\/10.1371\/journal.pgph.0001892","DOI":"10.1371\/journal.pgph.0001892"},{"key":"ref1","doi-asserted-by":"crossref","unstructured":"Baron, D., Leslie, H.H., Mabetha, D., Becker, N., Kahn, K. & Lippman, S.A., 2024, \u2018Applying CFIR to assess multi-level barriers to PrEP delivery in rural South Africa: Processes, gaps and opportunities for service delivery of current and future PrEP modalities\u2019, Social Science & Medicine 361, 116663. https:\/\/doi.org\/10.1016\/j.socscimed.2024.116663","DOI":"10.1016\/j.socscimed.2024.117370"},{"key":"ref2","doi-asserted-by":"crossref","unstructured":"Barnighausen, K., Dalglish, S., Matse, S., Hughey, A., Hettema, A., Kahn, K. et al., 2020, \u2018PrEP in primary care; Health care worker adaptations to PrEP delivery in Eswatini\u2019, Research Square, viewed n.d., from https:\/\/doi.org\/10.21203\/rs.3.rs-73560\/v1","DOI":"10.21203\/rs.3.rs-73560\/v1"},{"key":"ref3","doi-asserted-by":"crossref","unstructured":"Bonett, S. et al., 2024, \u2018A qualitative descriptive evaluation of low-threshold PrEP service delivery models: Lessons for improving access and implementation\u2019, Implementation Science Communications 5, 4.","DOI":"10.1186\/s43058-023-00543-y"},{"key":"ref4","unstructured":"Centers for Disease Control and Prevention (CDC), 2021, Preexposure prophylaxis for the prevention of HIV infection in the United States-2021 update: A clinical practice guideline, CDC, Atlanta, GA."},{"key":"ref5","doi-asserted-by":"crossref","unstructured":"Chimoyi, L., Chikovore, J., Musenge, E., Mabuto, T., Chetty-Makkan, C.M., Munyai, R. et al., 2022, \u2018Understanding factors influencing utilization of HIV prevention and treatment services among patients and providers in a heterogeneous setting: A qualitative study from South Africa\u2019, PLoS Global Public Health 2(2), e0000132. https:\/\/doi.org\/10.1371\/journal.pgph.0000132","DOI":"10.1371\/journal.pgph.0000132"},{"key":"ref6","doi-asserted-by":"crossref","unstructured":"Eakle, R., Gomez, G.B., Naicker, N., Bothma, R., Mbogua, J., Cabrera Escobar, M. et al., 2019, \u2018HIV pre-exposure prophylaxis and early antiretroviral treatment among female sex workers in South Africa: Results from a prospective cohort demonstration project\u2019, PLoS Medicine 16(11), e1002890, https:\/\/doi.org\/10.1371\/journal.pmed.1002890","DOI":"10.1371\/journal.pmed.1002890"},{"key":"ref7","doi-asserted-by":"crossref","unstructured":"Gombe, M.M., Cakouros, B.E., Ncube, G., Zwangobani, N., Mareke, P., Mkwamba, A. et al., 2020, \u2018Key barriers and enablers associated with uptake and continuation of oral pre-exposure prophylaxis (PrEP) in the public sector in Zimbabwe: Qualitative perspectives of general population clients at high risk for HIV\u2019, PLoS One 15(1), e0227632. https:\/\/doi.org\/10.1371\/journal.pone.0227632","DOI":"10.1371\/journal.pone.0227632"},{"key":"ref8","doi-asserted-by":"crossref","unstructured":"Hicks, S., Odhiambo, B., Abuna, F., Dettinger, J.C., Ngumbau, N., G\u00f3mez, L. et al., 2023, \u2018Selecting implementation strategies to improve implementation of integrated PrEP for pregnant and postpartum populations in Kenya: A sequential explanatory mixed methods analysis\u2019, Implementation Science Communications 4, 93. https:\/\/doi.org\/10.1186\/s43058-023-00481-9","DOI":"10.1186\/s43058-023-00481-9"},{"key":"ref9","unstructured":"Higgins, J.P.T. & Green, S. (eds.), 2011, Cochrane handbook for systematic reviews of interventions, Version 5.1.0, The Cochrane Collaboration, viewed 27 August 2025, from http:\/\/handbook.cochrane.org."},{"key":"ref10","doi-asserted-by":"crossref","unstructured":"Irungu, E.M., Odoyo, J., Wamoni, E., Bukusi, E.A., Mugo, N.R., Ngure, K. et al., 2021, \u2018Process evaluation of PrEP implementation in Kenya: Adaptation of practices and contextual modifications in public HIV care clinics\u2019, Journal of the International AIDS Society 24(S3), e25799. https:\/\/doi.org\/10.1002\/jia2.25799","DOI":"10.1002\/jia2.25799"},{"key":"ref11","unstructured":"Irungu, E. & Baeten, J.M., 2020, \u2018PrEP rollout in Africa: Status and opportunities\u2019, Current HIV\/AIDS Reports 17, 24\u201331. https:\/\/doi.org\/10.1007\/s11904-019-00471-9"},{"key":"ref12","unstructured":"Joanna Briggs Institute, 2017, Critical appraisal tools for use in JBI systematic reviews: Checklist for quantitative studies, Joanna Briggs Institute, Adelaide."},{"key":"ref13","doi-asserted-by":"crossref","unstructured":"Killelea, A., Johnson, J., Dangerfield II, D.T., Beyrer, C., McGough, M., McIntyre, J. et al., 2022, \u2018Financing and delivering pre-exposure prophylaxis (PrEP) to end the HIV epidemic\u2019, Journal of Law, Medicine & Ethics 50(S1), 8\u201323.","DOI":"10.1017\/jme.2022.30"},{"key":"ref14","unstructured":"Ministry of health kenya, 2022, National guidelines on the use of anteretroviral drugs for treating and preventing HIV infection in Kenya, Ministry of Health, Nairobi."},{"key":"ref15","doi-asserted-by":"crossref","unstructured":"Nakambale, H.N., Roche, S.D., Mogere, P., Omollo, V., Kuo, A.P., Stergachis, A. et al., 2023, \u2018Barriers to and strategies for early implementation of pharmacy-delivered HIV PrEP services in Kenya: An analysis of routine data\u2019, Frontiers in Reproductive Health 5, 1023568. https:\/\/doi.org\/10.3389\/frph.2023.1023568","DOI":"10.3389\/frph.2023.1023568"},{"key":"ref16","unstructured":"National Department of Health (NDoH), 2023, National policy on HIV pre-exposure prophylaxis (PrEP) and test and treat (T&T), NDoH, Pretoria."},{"key":"ref17","doi-asserted-by":"crossref","unstructured":"Page, M.J., McKenzie, J.E., Bossuyt, P.M., Boutron, I., Hoffmann, T.C., Mulrow, C.D. et al., 2021, \u2018The PRISMA 2020 statement: An updated guideline for reporting systematic reviews\u2019, BMJ 372, n71. https:\/\/doi.org\/10.1136\/bmj.n71","DOI":"10.1136\/bmj.n71"},{"key":"ref18","doi-asserted-by":"crossref","unstructured":"Prager, E.M., Chambers, K.E., Plotkin, J.L., McArthur, D.L., Bandrowski, A.E., Bansal, N. et al., 2019, \u2018Improving transparency and scientific rigor in academic publishing\u2019, Cancer Reports 2(1), e1150. https:\/\/doi.org\/10.1002\/cnr2.1150","DOI":"10.1002\/cnr2.1150"},{"key":"ref19","doi-asserted-by":"crossref","unstructured":"Siegler, A.J., Mehta, C.C., Mouhanna, F., Giler, R.M., Pembleton, E.S., Guest, J.L. et al., 2021, \u2018Policy and insurance barriers to PrEP access in the United States: Implications for the \u201cEnding the HIV Epidemic\u201d initiative\u2019, American Journal of Public Health 111(8), 1520\u20131523, https:\/\/doi.org\/10.2105\/AJPH.2021.306398","DOI":"10.2105\/AJPH.2021.306398"},{"key":"ref20","doi-asserted-by":"crossref","unstructured":"Smith, A.K.J., Haire, B., Newman, C.E. & Holt, M., 2021, \u2018Challenges of providing HIV pre-exposure prophylaxis across Australian clinics: Qualitative insights of clinicians\u2019, Sexual Health 18(2), 187\u2013194. https:\/\/doi.org\/10.1071\/SH20208","DOI":"10.1071\/SH20208"},{"key":"ref21","doi-asserted-by":"crossref","unstructured":"Sullivan, P.S., Mena, L., Elopre, L. & Siegler, A.J., 2019, \u2018Implementation strategies to increase PrEP uptake in the south\u2019, Current HIV\/AIDS Reports 16(4), 259\u2013269. https:\/\/doi.org\/10.1007\/s11904-019-00447-4","DOI":"10.1007\/s11904-019-00447-4"},{"key":"ref22","unstructured":"UNAIDS, 2023, Global AIDS update 2023: the path that ends AIDS, UNAIDS, Geneva."},{"key":"ref23","unstructured":"UNAIDS, 2024, Global AIDS report \u2013 The urgency of now: AIDS at a crossroads, Joint United Nations Programme on HIV\/AIDS."},{"key":"ref24","unstructured":"UNAIDS, 2025, Global AIDS update 2025: Ending the AIDS epidemic by 2030, Joint United Nations Programme on HIV\/AIDS, viewed 12 September 2025, from https:\/\/www.unaids.org\/sites\/default\/files\/media_asset\/2025-global-aids-update-summaryen.pdf."},{"key":"ref25","doi-asserted-by":"crossref","unstructured":"Vanhamel, J., Rotsaert, A., Vanbaelen, T., Vuylsteke, B., Schim van der Loeff, M., Hensen, B. et al., 2023, \u2018HIV pre-exposure prophylaxis (PrEP) care in Belgium: A mixed-methods study on PrEP users\u2019 experiences and service delivery preferences\u2019, AIDS and Behavior 28(2), 393\u2013407. https:\/\/doi.org\/10.1007\/s10461-023-04232-8","DOI":"10.1007\/s10461-023-04232-8"},{"key":"ref26","doi-asserted-by":"crossref","unstructured":"Whittemore, R. & Knafl, K., 2005, \u2018The integrative review: Updated methodology\u2019, Journal of Advanced Nursing 52(5), 546\u2013553.","DOI":"10.1111\/j.1365-2648.2005.03621.x"},{"key":"ref27","unstructured":"World Health Organization (WHO), 2022a, Differentiated and simplified pre-exposure prophylaxis for HIV prevention: Update to WHO implementation guidance, World Health Organization, Geneva, viewed 15 June 2025, from https:\/\/www.who.int\/publications\/i\/item\/9789240061550."},{"key":"ref28","unstructured":"World Health Organization (WHO), 2022b, Implementing comprehensive HIV prevention programs with oral PrEP: A toolkit, WHO, Geneva, viewed 02 May 2025, from https:\/\/www.who.int\/publications\/i\/item\/9789240055597."}],"container-title":["Curationis"],"original-title":[],"link":[{"URL":"https:\/\/curationis.org.za\/index.php\/curationis\/article\/view\/2817\/4476","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,4,13]],"date-time":"2026-04-13T14:20:36Z","timestamp":1776090036000},"score":1,"resource":{"primary":{"URL":"https:\/\/curationis.org.za\/index.php\/curationis\/article\/view\/2817"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,4,13]]},"references-count":29,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2026,1,1]]}},"URL":"https:\/\/doi.org\/10.4102\/curationis.v49i1.2817","relation":{},"ISSN":["0379-8577","2223-6279"],"issn-type":[{"value":"0379-8577","type":"print"},{"value":"2223-6279","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,4,13]]},"article-number":"a2817"}}