PrEP public policies for HIV prevention in South America: an intersectional analysis

Abstract

BackgroundHIV pre-exposure prophylaxis (PrEP) is a highly effective biomedical prevention strategy, recommended by the World Health Organization since 2015. However, in South America, its adoption has been uneven, reflecting structural, political, and socio-cultural inequalities. This study maps and analyzes national PrEP policies across 13 South American countries through an intersectional lens, identifying challenges and opportunities for more equitable HIV prevention strategies.MethodsWe conducted a documentary survey of national PrEP-related policies, clinical guidelines, regulations, and public communications from Argentina, Bolivia, Brazil, Chile, Colombia, Ecuador, Guyana, French Guiana, Paraguay, Peru, Suriname, Uruguay, and Venezuela. Searches were performed on institutional websites in Portuguese, Spanish, English, and French using predefined keywords. In the absence of official policy documents, information was collected from media and civil society sources. Data from 118 documents were coded and analyzed using iterative summative content analysis, integrating intersectionality theory to assess how policies address (or neglect) structural inequalities.ResultsTen countries have formal national PrEP policies (Argentina, Brazil, Chile, Colombia, Ecuador, Guyana, French Guiana, Paraguay, Peru, Uruguay), with Brazil pioneering implementation in 2017. Three countries (Bolivia, Suriname, Venezuela) lack comprehensive national guidelines. Most countries recommend daily oral PrEP; on-demand dosing is approved in fewer contexts, often with restrictions. Long-acting injectable cabotegravir has been approved only in Brazil, French Guiana, and Peru, but remains largely unavailable. Geographic coverage ranges from national to highly localized models. Prioritized groups include men who have sex with men, transgender women, sex workers, serodifferent couples, and, in some countries, people who use drugs. Policy formulation involves ministries of health, academia, international organizations, and, variably, civil society. However, inclusion of marginalized populations and integration of intersectional approaches remain limited. There are inequalities in the incorporation of social markers of difference in PrEP policies across the region, with greater emphasis on sexuality, gender, class, and health conditions, and limited attention to race/ethnicity, territory, generation, and disability.ConclusionPrEP policy adoption in South America demonstrates significant heterogeneity, shaped by intersecting social, political, and institutional factors. While the region has made notable advances, access remains uneven, with structural barriers such as stigma, regulatory gaps, and geographic inequities limiting impact. Incorporating intersectional perspectives into policy design and implementation is essential to ensure that PrEP – in all its modalities – is accessible as a right to health, addressing differences across multiple social, geographic, and economic dimensions.