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LA PrEP IDWeek EACS
Adding Long-Acting Injectables to the PrEP Menu

Released: November 14, 2023

Darrell H S Tan
Darrell H S Tan, MD, FRCPC, PhD
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Key Takeaways
  • Receipt of long-acting injectable PrEP was low among patients prescribed it because of barriers and inequities such as drug cost, payor coverage, transportation issues, patient tracking, and provider misperceptions about appropriate candidates for administration.
  • Although patient and provider interest in long-acting PrEP is high, more tools are needed to improve access for patients who are not already receiving oral PrEP.

One of the most exciting advances in the field of HIV prevention in recent years has been the emergence of long-acting (LA) injectable cabotegravir (CAB) as a safe and effective pre-exposure prophylaxis (PrEP) option. The HPTN 083 trial among men who have sex with men and transgender women and the HPTN 084 trial in cisgender women demonstrated that this agent is superior to daily oral tenofovir disoproxil fumarate with emtricitabine at preventing HIV. Although Canada was the first country in the world to gain regulatory approval for injectable CAB plus rilpivirine as treatment, injectable CAB as PrEP is not yet approved in Canada and cannot be readily accessed for off-label use since it is not available as a standalone product. As we eagerly await its regulatory approval, there are instructive lessons to be learned from other contexts where rollout is already underway, including findings from several poster presentations at the 2023 IDWeek and EACS conferences.

Inequities to Access in the CAN Community Health Network
An important priority as we plan for injectable PrEP in Canada will be to ensure access, given the troubling potential for oral PrEP to exacerbate health inequities. In a study of 293 HIV-negative adults who were prescribed injectable PrEP within CAN Community Health, a US outpatient clinic network, it was sobering to find that only 52.9% of the prescriptions actually resulted in at least 1 injection, reflective of persistent challenges in accessing this product.

Of note, there was an overrepresentation of Black patients in the group who never received the agent. Among those who did, gaps in insurance coverage were among the barriers to persistence on injectable PrEP. Because lack of medication insurance is a well-documented barrier to oral PrEP use in Canada, it will be critical that injectable PrEP be adequately financed, ideally through universal coverage programs but, at minimum, through listing on public formularies, with supplemental strategies to assist with copayments.

Healthcare Staff Perceptions
Related issues were addressed in posters at IDWeek from the PILLAR and EBONI studies, a pair of US implementation science projects evaluating the implementation of LA CAB to Black men (including cisgender and transgender men) and Black women (including cisgender and transgender women), respectively. A very high proportion of study staff (85% in PILLAR, 93% in EBONI) felt positive or extremely positive about implementing LA CAB in their setting, but they identified multiple challenges.

In EBONI, 62.4% of study staff mistakenly believed that specific demographics of individuals are more appropriate for LA CAB than others, most often including transgender women (95.9%), men who have sex with men (93.2%) and Black people (91.8%). Such perceptions may inadvertently perpetuate stigma, limit access among others who could benefit from PrEP, and oversimplify the multiple reasons that any person may stand to benefit from LA CAB. The authors interpreted these results to mean that more tools are needed to change healthcare staff perceptions and to support them in identifying people who could benefit from injectable PrEP.

In PILLAR, the top-cited barriers to delivering LA CAB included drug costs (51%), patients’ ability to keep appointments (32%), patients’ willingness to travel to injection appointments (26%), and clinics’ ability to flag missed injection visits in a timely fashion (23%). These issues are likely to be directly applicable to the Canadian context as well and can inform planning for implementation programs tailored to the specific needs of key populations.

Realizing the Full Potential of Injectable PrEP
The population-level impact of injectable PrEP on Canada’s HIV epidemic will be greatest if it fills an unmet need—in particular, if it attracts people at risk who are not already using oral PrEP. In this regard, it is noteworthy that among the 293 people prescribed injectable PrEP in the CAN Community Health Network study, only 18.4% were “new” to PrEP.

The other unmet need that injectable PrEP could fill is for those who are struggling to adhere to oral PrEP. In data presented at EACS from the French ANRS-PREVENIR cohort of men who have sex with men using either daily or on-demand oral PrEP, 18% found their current regimen difficult to follow, a characteristic that was associated with greater interest in injectable PrEP with a relative risk ratio of 2.44 (95% CI: 1.52-3.92).

Optimizing the delivery of injectable PrEP in Canada will require deliberate efforts to ensure equitable access, coupled with tailored social marketing campaigns that raise awareness and interest, especially among communities with high HIV incidence and those with difficulty adhering to oral PrEP.

Your Thoughts?
What barriers have you encountered to successfully implementing injectable PrEP? See more studies from IDWeek 2023 and EACS 2023 and get involved by posting a comment below.