Targeted universalism for long-acting PrEP: an urgent need to avoid risk targeting and build population-level impact

New long-acting HIV prevention product choices, including lenacapavir, cabotegravir, and investigational monthly oral MK‑8527, usher in promise for ending HIV as a public health threat. Decisions taken at a product's launch determine who will access it and shape its population-level impact. We argue that targeted universalism should be used to organise the roll‑out of pre-exposure prophylaxis (PrEP) choices. Targeted universalism means setting the goal of universal access for anyone who wants effective prevention and then tailoring functional supports, such as convenient delivery points and improved provider capacity for supportive interactions, to: 1) guide distribution of limited supply, and 2) help groups facing the steepest barriers to engage with prevention on an equal footing. As a policy framework, targeted universalism thus seeks to avoid mistakes that have restricted the population-level impact of oral PrEP by eliminating epidemiologically driven risk targeting, reckoning with the social resistance associated with stigmatised interventions and populations, and facilitating equitable coverage through systems strengthening.