CATIE NEWS
JULY 7, 2023
Some views on injectable long-acting HIV pre-exposure prophylaxis (PrEP)
- Canadian researchers interviewed 42 people about their views on long-acting injectable PrEP
- Many people were excited about the possibility of accessing injectable PrEP once it is approved
- Participants raised concerns about potential costs and other barriers to access injectable PrEP
A highly effective method of reducing one’s risk of HIV infection through sex is the use of HIV pre-exposure prophylaxis (PrEP). In Canada, PrEP consists of using one of the following combinations of anti-HIV drugs available in one pill:
- Truvada and generic formulations – tenofovir DF + FTC (emtricitabine)
- Descovy – tenofovir alafenamide (TAF) + FTC
According to Canadian researchers, these are usually taken as one pill daily, though some people use a different schedule that is “on-demand.” Further information about PrEP is available here.
In addition to taking medicines, PrEP involves regular screening for HIV and other sexually transmitted infections (STIs) and monitoring of kidney health. This screening may involve periodic visits to a lab or clinic. Prescriptions for PrEP also need to be renewed, which usually requires a visit to a clinic.
Long-acting PrEP
In December 2021, an injectable long-acting formulation of PrEP was approved in the U.S. (it has also been approved in some other countries). It is sold under the brand name Apretude and consists of a long-acting formulation of the anti-HIV drug cabotegravir. This drug is injected deep into muscles in the buttocks every two months and requires a healthcare professional to administer the injections. Long-acting cabotegravir is not yet approved in Canada for the prevention of HIV, however, it may be approved sometime in 2024.
To find out what some people think about long-acting PrEP and issues regarding its availability and use, a team of researchers in Ontario and British Columbia conducted interviews with 22 community members, some of whom used oral PrEP and some of whom did not. All community members identified as gay, bisexual, queer or other men who have sex with men. In addition, researchers gathered feedback from 20 key stakeholders, including healthcare providers, public health officials and staff of non-governmental organizations (NGOs). All 42 study participants were in Ontario and were interviewed between June and October 2021.
Key results
The researchers’ main findings were distributed as follows:
Views of community members
- 33% of community members had heard of injectable PrEP.
- Researchers described people’s views about injectable PrEP as generally “enthusiastic.”
- Researchers said that many users of oral PrEP would be interested in switching to injectable PrEP, as it is viewed as more convenient and would enhance adherence.
- Some people did not expect that they would use injectable PrEP because of discomfort from needles.
Views of key stakeholders
- In general, injectable PrEP was seen as promising, as it could improve access to PrEP and, in particular, allow marginalized populations access to highly effective HIV prevention.
- Some people were concerned that the potential demand for injectable PrEP would place a burden on clinics, which may need more time and/or personnel.
- The potential cost of injectable PrEP was raised as an issue; if the future price of injectable PrEP was too high, that could act as a barrier to access.
Bear in mind
The approval of injectable PrEP would be a major advance for HIV prevention in Canada. However, there will likely be challenges with implementing injectable PrEP in clinics and making it available to the full range of populations that could benefit from it. Further research is needed to understand issues that could hamper people’s access to long-acting PrEP once it is approved.
Study details
At the time of the interviews, 13 of the 22 community members currently used PrEP, three previously used PrEP and six had never used PrEP. Most of the men were between 19 and 49 years old. Twenty of them identified as cisgender and two were transgender.
Results – Community members
Current and former users of PrEP
Current and former users of PrEP generally held favourable views of injectable PrEP. Many were interested in using it. According to the research team, “many PrEP users expressed enthusiasm about injectable PrEP and interest in switching to injectable PrEP due to its perceived convenience.” One person told the researchers that “the idea of a dose that lasts a couple of months at a time does sound really good.”
Some community members described daily pill-taking as a “chore.” Furthermore, some current PrEP users disclosed that they found it difficult to find a regular time each day to take PrEP. Participants mentioned that obtaining prescription refills can sometimes be time consuming.
Participants were unsure if injectable PrEP would require more healthcare visits than being on a regimen of oral PrEP. If more visits would be needed for injectable PrEP, this would be perceived as a barrier.
Two people with experience using oral PrEP appreciated the technological advance represented by injectable PrEP. However, they felt that having to take a pill offered an advantage; they argued that they would feel more in control of protecting themselves if they used oral rather than injectable PrEP (which has to be administered by healthcare personnel).
According to the researchers, “many PrEP users” stated that having access to an injectable formulation of PrEP with its infrequent dosing would enhance their ability to adhere to PrEP. Participants noted that injectable PrEP would offer an advantage over oral PrEP in the following situations:
- forgetting to take pills
- having an irregular schedule
- when travelling
One PrEP user stated: “I take one injection [for allergies] a month. It’s just so much easier and you wouldn’t have to think about it that much. With PrEP, every time I want to sleep over at somebody else’s place […] or I want to travel, I always have to think about like, ‘don’t forget PrEP, don’t forget PrEP, don’t forget PrEP,’ and just kind of having one less thing to think about is a good thing.”
People who never used oral PrEP
Researchers found that even people who had never used oral PrEP viewed injectable PrEP somewhat favourably as a technological advance. They quickly grasped the potential benefits of injectable PrEP. However, some people who had never used PrEP expressed reluctance to consider using injectable PrEP in the future for the following reasons:
- wanting to avoid injections
- confidence in their safer-sex strategies
- feeling that they are at very low risk for HIV
Results – Key stakeholders
As a group, key stakeholders were optimistic about the promise of injectable PrEP. Specifically, they saw it as more effective than oral PrEP and said it would likely enhance adherence to PrEP. Some healthcare providers thought that it could lead to more contact with patients and thereby strengthen relationships between clinicians and patients.
Some stakeholders felt that injectable PrEP had the potential to better fit into the lives of marginalized populations than oral PrEP. However, according to the researchers, stakeholders noted that people who used injectable PrEP would “still need to adhere to healthcare visits by returning to the clinic every two months.” Several healthcare providers were concerned about some patients’ ability to maintain this frequency of visit for PrEP injections.
Cost issues
Concerns were raised by both community members and key stakeholders about the possible cost of injectable PrEP. Some participants were concerned that injectable PrEP would be relatively expensive for the average person who could benefit from PrEP.
In Canada, each province and territory has a list of medicines that it subsidizes. This list is commonly called a formulary. Once a drug is approved by regulatory authorities, Canada’s provinces and territories negotiate with pharmaceutical companies about what price they are willing to pay so a drug can be made available via formulary access. Injectable PrEP needs to be priced responsibly so that the budgets of provincial and territorial formularies are not stressed, as they pay for many different drugs for millions of people, while still allowing pharmaceutical companies to make a profit.
Having injectable PrEP on provincial and territorial formularies would be a good step to making it more widely available. However, in some provinces, accessing the formulary comes at a cost for patients where a deductible and/or a co-payment is required. For some people, such out-of-pocket payments can serve as a barrier to access.
Implementation issues
Cabotegravir is made by ViiV Healthcare. A long-acting formulation of cabotegravir is currently part of a two-drug injectable treatment for HIV. This two-drug combination meant for treatment is sold under the brand name Cabenuva.
ViiV has funded a patient support program for Cabenuva users. A simplified summary of the program is as follows: If a doctor and patient agree on Cabenuva as a treatment and the use of the Cabenuva support program, the doctor enrolls the patient into the support program. Along with the patient, the program will determine the choice of pharmacy to dispense Cabenuva and the best place for them to go to receive the injections via one of the program nurses. These services are provided to the patient at no cost.
As injectable PrEP has not been approved in Canada, it is not known if ViiV will also offer a patient support program for people who will be prescribed it in the future.
Factors that make life more difficult
Some people struggle with one or more issues—drug dependency, homelessness, mental health conditions, poverty—that challenge their ability to maintain appointments and access medical care and medicines. Comprehensive support programs are needed to address these issues. Such support would not only help vulnerable members of society but would also make it easier for them to access injectable PrEP and participate in helping to reduce the spread of HIV.
Clinics that provide PrEP services
If injectable PrEP is going to reach more people, clinics that provide sexual health services would need additional funding to make dedicated staff available and to teach providers about the issues related to the use of injectable PrEP.
Promotion in the community
The researchers stated that once injectable PrEP has been approved in Canada it will need to be promoted in order to increase community awareness about this option for HIV prevention.
For the future
Injectable PrEP is an exciting HIV prevention option that will hopefully become available in Canada sometime in 2024. However, much work remains to be done to pave the way for injectable PrEP and to ensure that a wide range of people at risk for HIV and their healthcare providers can consider it as an option.
—Sean R. Hosein
Resources
HIV pre-exposure prophylaxis (PrEP) – CATIE
Summary: HIV antiretroviral medication coverage in Canada – Public Health Agency of Canada
REFERENCES:
- Grace D, Gaspar M, Wells A, et al. Injectable pre-exposure prophylaxis for HIV prevention: Perspectives on the benefits and barriers from gay, bisexual, and queer men and health system stakeholders in Ontario, Canada. AIDS Patient Care STDS. 2023; in press.
- ViiV Healthcare. APRETUDE (cabotegravir extended-release injectable suspension). U.S. Product Monograph. December 2021.
- ViiV Healthcare. ViiV Healthcare announces FDA approval of Apretude (Cabotegravir extended-release injectable suspension.), the first and only long-acting injectable option for HIV prevention. Press Release. 21 December, 2021.
- World Health Organization. WHO recommends long-acting cabotegravir for HIV prevention. Press Release. 28 July, 2022.
From Canadian AIDS Treatment Information Exchange (CATIE).
This content was originally published by CATIE, Canada’s source for HIV and hepatitis C information.
Source: https://www.catie.ca/catie-news/some-views-on-injectable-long-acting-hiv-pre-exposure-prophylaxis-prep
For more information visit CATIE's Information Network at www.catie.ca
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