Long-Acting Injectables as PrEP Therapy

Segment Description: The benefits and risks of using long-acting injectables as PrEP therapy.

Joseph Eron, MD: Let’s discuss the issue of cabotegravir alone as an injectable prevention. Julia, what is the benefit, risk, and how might that fit into the prevention world?

Julia Marcus, PhD, MPH: Yes, in some ways there are parallels with treatment, stigma, and will it solve adherence but then create other issues. And what impact will it have in overall prevention?

If the only people who are interested in long-acting PrEP [pre-exposure prophylaxis] are people who are already taking daily PrEP and they switch, it’s not going to have any population-level effectiveness. The hope is that long-acting PrEP will cater to a population of the PrEP market that’s not interested in taking daily PrEP but is interested in taking long-acting PrEP.

Joseph Eron, MD: There is an issue of people who start on oral PrEP and they say they’re ready for oral PrEP, but then they don’t persist. This population could benefit from injectables, right?

Julia Marcus, PhD, MPH: Yes. It depends what their barriers to persistence are. If their barriers are that they don’t want to be coming into the clinic every 3 months, long-acting injectables may not help them. They may have to come in even more.

Joseph Eron, MD: Yes, if the barrier is that they forget.

Julia Marcus, PhD, MPH: That’s right, and it could be perfect.

Joseph Eron, MD: The other groups that I’m worried about are people that are in unequal power relationships or in maybe commercial sex work or some other situations where they just can’t afford either because of bodily or emotional risk to have a pill in their hands or in their drawer or wherever.

Julia Marcus, PhD, MPH: Or their pills get stolen because they’re homeless. There are populations where long-acting PrEP could be really useful. And people who don’t have power and also in addition to homelessness, people who inject drugs who may have a difficult time taking a pill every day, but may be coming in to syringe change frequently.

Joseph Eron, MD: Right, or methadone maintenance.

Julia Marcus, PhD, MPH: Yes.

Julia Marcus, PhD, MPH: I think about how to co-locate them could be really powerful.

Joseph Eron, MD: Sure.

Allison Agwu, MD, ScM: There’s a stigma of having that blue pill that you take every day. People assume that you are positive and there’s some risk to taking PrEP, in certain communities. It’s about expanding options in the armamentarium. And for different people, or the same person at different times, a different modality may work for them. If a patient has to go abroad for 2 months, maybe that’s the time to get your shot, right? You don’t have to worry about taking your pills to Morocco, right?

It’s about choice and options, and it’s exciting to have them, and I think we are going to have to work out the systems issues, the administration issues, and the opportunity to have more people at the table. We’re not the only ones that need to give shots—the nurse or the pharmacist can. How do we make our practices work for people? How do we get over those barriers?

Joseph Eron, MD: One thing you hear about PrEP a lot is to demedicalize it.

Julia Marcus, PhD, MPH: Yes, that’s huge. When we first introduced PrEP, it was highly medicalized and it stuck. PrEP care is more intensive than HIV care.

Julia Marcus, PhD, MPH: Yes, these are healthy people taking a very safe, effective medication.

Joseph Eron, MD: It is important to point out that we don’t know that this injectable is going to work. It’s being studied. There are at least 2 large randomized trials, 1 in predominantly men who have sex with men, and transgender women, and another in high-risk women in Africa that are exploring a comparison between injectable and pills. It’s an active control, which would be the TDF/FTC [tenofovir/emtricitabine]. We’re excited about it. But we don’t know whether it’s going to work or not. Some of these long, really long-acting alternatives could also make a difference that Allison mentioned.

Allison Agwu, MD, ScM: Absolutely.

Joseph Eron, MD: And potentially for therapy too. We need 2 drugs that have similar durations of activity in order to use them together.