Disrupted access and diverging pathways to sexual health services during COVID-19: insights from the PrEP impact trial in England

Abstract Background Using data from the HIV pre-exposure prophylaxis (PrEP) Impact trial, an implementation trial of PrEP across sexual health services to inform routine PrEP commissioning in England, we examined sexual health service use and PrEP need during UK COVID-19 social restrictions (March-November 2020) to assess the pandemic’s impact on PrEP delivery in England. This is the first analysis extending trial data beyond February 2020. Methods We collated monthly aggregate data from 157 PrEP Impact Trial clinics in England (October 2017–November 2020), focusing on gay, bisexual, and other men who have sex with men (MSM). For trial participants and non-trial attendees (NTA), we examined trends in service use, STI/HIV test positivity, PrEP need, and prescriptions (30, 60, 90, ≥ 120 tablets). We also assessed changes in the enrolment patterns of key subgroups (aged 16–24, ethnic minority background, and bacterial STI history) over time. COVID-19 restrictions were defined as March–July and September–November 2020. Results Attendances markedly decreased between February and April 2020 (-34% for trial participants; -78% for NTA). By July 2020, trial participant attendances had nearly returned to pre-lockdown levels, while NTA attendances remained more than 50% lower than in January. HIV and STI test positivity increased more among NTA than trial attendees during restrictions, reaching 0.95% [95% CI 0.51–1.63] and 18.9% [95% CI 17.0-20.9] respectively. This suggests triage towards higher risk individuals but also highlights likely unmet need among others. The proportion of clinic attendees with PrEP need also increased during the pandemic, and short-lived increases to longer term prescriptions were observed. Demographic shifts during restrictions showed decreased in-person enrolment among younger people and increased representation of ethnic minority groups. Conclusions Structured PrEP delivery preserved access among trial participants during COVID-19-related disruptions, but non-trial attendees, despite persistent risk, faced greater barriers and slower recovery. These disparities underscore the need for resilient, flexible delivery models that can sustain HIV prevention in periods of major service disruptions. With continued PrEP scale-up, addressing equity gaps for those outside established care pathways will be essential to prevent widening disparities and ensure the success of HIV prevention efforts. Trial registration The study is registered with ClinicalTrials.gov (Prospective, non-interventional trial NCT03253757; registered 06/16/2017).