Closing the PrEP access gap in Europe: a strategic framework for equity and innovation among difficult-to-reach populations

HIV/AIDS remains a global health challenge with significant disparities in access to prevention strategies, particularly among underserved populations. Pre-exposure prophylaxis (PrEP) has proven to be an effective intervention in reducing HIV transmission, yet its uptake remains suboptimal in Europe. This report examines the current state of PrEP implementation in Spain, identifies key barriers to its access and proposes strategies for overcoming these obstacles, with a focus on equity and innovation. Despite PrEP being available since 2019, challenges such as centralized, hospital-based distribution, stigmatization, rigid eligibility criteria, excess medicalization and insufficient healthcare provider education persist. This study highlights the disproportionate underutilization of PrEP among populations with difficulty accessing prevention programmes, including women, migrants, sex workers, transgender individuals and people who inject drugs. Moreover, the introduction of long-acting injectables (LAI) and their endorsement by WHO represent a promising solution to improve PrEP efficacy, adherence and reduce the burden of frequent clinic visits. Drawing on successful international models, such as the 56 Dean Street clinic in London, this paper advocates for a decentralized, de-medicalized, community-based approach to PrEP delivery alongside policy reforms to simplify eligibility criteria and integrate PrEP into broader healthcare services. These solutions aim to address geographical and socio-cultural barriers, ultimately facilitating more equitable access to HIV prevention across Europe. The findings emphasize the importance of flexibility, community engagement and innovation to ensure that those most at need are ultimately offered PrEP, contributing to global efforts to close the HIV prevention gap.