Back Back
HIVR4P HIV Prevention
How the Power of Choice Impacts HIV Prevention: Evidence from HIVR4P

Released: November 04, 2024

Expiration: November 03, 2025

Elizabeth M. Irungu
Elizabeth M. Irungu, MBChB, MPH, PhD
Activity Information

Activity

Progress
1
Course Completed
Key Takeaways
  • Key studies at the HIVR4P 2024 meeting show that providing people with choices in HIV prevention, including long-acting PrEP, oral PrEP, and PEP, empowers them to choose a method that meets their individual needs and encourages engagement in HIV prevention.

The HIVR4P 2024 meeting in Lima, Peru, was an exciting one. At this meeting, healthcare professionals (HCPs) began to see what it looks like in the real world when people are offered a choice of HIV prevention therapy. Such choices include oral pre-exposure prophylaxis (PrEP), the monthly dapivirine vaginal ring (DPV-VR), and long-acting cabotegravir (CAB). 

A Matter of Choice
The CATALYST study, funded by the President’s Emergency Plan for AIDS Relief (PEPFAR)/United States Agency for International Development (USAID) through the Maximizing Options to Advance Informed Choice for HIV Prevention (MOSAIC) project, is being conducted in 5 African countries. At HIVR4P 2024, investigators described a substudy of 4000 participants, many of whom (45%) were under 24 years of age. Twenty-five percent reported doing sex work, and approximately two thirds were PrEP naive.

At enrollment, when given a choice of oral PrEP or the DPV-VR, 66% chose oral PrEP, and 30% chose the DPV-VR. DPV-VR uptake was approximately 15% among pregnant women and 21% among breastfeeding women.

Investigators then explored the factors associated with choosing the DPV-VR and found that people who reported multiple sex partners and who were currently using a contraceptive were more likely to choose the DPV-VR. By contrast, those who were younger (age <25 years), those who had never used PrEP before, and pregnant and breastfeeding women were less likely to choose the DPV-VR. A comparison of early returns for PrEP refills (1 month after treatment initiation) showed that persons who received the DPV-VR had slightly higher return rates than those who received oral PrEP. But PrEP retention or continuation at 1 month was quite low. 

Another study of the Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe (DREAMS) program in South Africa showed that, among women given a choice of oral PrEP or the DPV-VR, 66% chose oral PrEP and 30% chose the DPV-VR. In this study, the main factor associated with choosing the DPV-VR was age, as older women preferred it to oral PrEP. Women who reported transactional sex and who had a higher level of education were more likely to choose the DPV-VR.

While these 2 studies showed modest uptake of the DPV-VR, they also showed that oral PrEP is often preferred. These findings are important because they show that, as country officials begin to think about widespread implementation of PrEP, they must consider how to integrate all the methods offered, to accommodate women’s individual preferences and maximize PrEP uptake. Though the results are preliminary, they provide a glimpse into what may happen in the real world. 

More Choices = More Reach
Another team presented the results of a small pilot study conducted in 2 facilities in Zambia, studying implementation of long-acting CAB for PrEP. Over 4 months, more than 600 people initiated long-acting CAB. Most (70%) were PrEP naive, and only about 30% were people who transitioned from oral PrEP. I think this shows that the introduction of this long-acting PrEP allowed new access to HIV prevention and reached a population of people that oral PrEP previously did not.

Of those required to receive a second shot, 91% returned. This is remarkable in the HIV prevention field, because adherence is often a challenge in HIV prevention. This result shows that people who chose the injection were highly likely to return for their second shots, suggesting that an injectable option is one that people are willing to commit to. 

A Continuing Role for Postexposure Prophylaxis (PEP)
Postexposure prophylaxis-in-pocket is another innovative way of providing HIV prevention, and it was also discussed at HIVR4P 2024. PEP has been around for decades, and it is best for people with periods of high-risk exposure that are infrequent but require mitigation quickly. Traditionally PEP was intended for people with occupational exposure or those who have experienced gender-based violence, and is mainly accessed through specific healthcare facilities that provide it. Thus, access is restricted and difficult for many who would benefit from it, though demand remains high.

Postexposure prophylaxis-in-pocket allows people to receive pills in advance, so they can be taken as a preventative measure when a high-risk situation occurs. This is a really innovative way through which people can access HIV prevention. In fact, a pilot study conducted in Kenya that evaluated PrEP delivery in community pharmacies showed that people more often received PEP than PrEP. The high demand for PEP suggests that, when access is increased, people will use this intervention, suggesting that PEP is a critical strategy for HIV prevention that should not be restricted. 

Choice Improves HIV Prevention
I believe that providing a choice of prevention options brings in people who need HIV prevention by allowing them to choose a method that works for them. There also seems to be a good early return rate, at least after 1 month, for long-acting PrEP options, specifically the DPV-VR and CAB. However, oral PrEP is still a popular choice, with around 70% of people choosing it over the DPV-VR. This means that, even as new products are introduced, the challenges associated with oral PrEP faced over the years should still be addressed.

Long-acting products are not going to solve all problems of PrEP delivery, because people still want oral PrEP. Several issues have plagued oral PrEP implementation: those related to the healthcare system, stigma, lack of community education, provider bias, and complex delivery systems. The addition of new interventions does not solve this problem. There is still work to be done, and long-acting products help solve only a small part of it. Moreover, these products have not reached widespread availability. Very few countries have CAB available for PrEP, and very few doses have been administered. Most people are receiving new products through clinical trials, and some are not given options. 

PrEP options are limited for some populations. Some countries do not allow pregnant or breastfeeding women to use the DPV-VR or CAB, so even people who would like to try another method are unable to do so. The same is true for younger populations, because most studies are conducted in people at least 18 years of age. While some are beginning to be offered choices, others are not. 

Overall, HIVR4P 2024 stressed the need for diverse options that are accessible and delivery platforms that people can easily access without stigma. These platforms will need to be scaled up to increase the uptake of HIV prevention measures and reduce HIV transmissions. 

Your Thoughts?
What factors in your practice contribute to choice of HIV prevention? Get involved in the discussion by posting a comment below.