While the world has focused on the Covid pandemic for nearly three years,less and less attention is being paid to HIV. However, HIV is still a globalproblem. In 2021, according to the United Nations, 38.4 million people wereliving with HIV, over 6,50,000 died from AIDS-related illnesses, and 1.5million became newly infected.
Nearly 70% of infections occur in key groups: sex workers and theirclients, men who have sex with men, people who inject drugs, and transgenderpeople and their sexual partners. Adolescent girls and young women insub-Saharan Africa are another important group with nearly 5,000 getting HIVevery week.
For many years, options for HIV prevention were quite limited. Earlycampaigns consisted of the ABCs – abstinence, being faithful, and condoms. Inthe early 2000s, male circumcision was added, but multiple attempts atdeveloping a vaccine have been disappointing.
In 2012, however, much excitement surrounded the introduction of HIVpre-exposure prophylaxis, or PrEP. The initial form of PrEP was a combined oralpill consisting of two medications used to treat HIV – emtricitabine andtenofovir. When taken regularly, PrEP is highly effective in preventing HIVinfection and very safe. PrEP was seen as a game-changer by enabling people totake charge of their sexual health, particularly for those who could notnecessarily control when or how they had sex.
Oral PrEP has worked well for many, particularly for men who have sex withmen in high-income settings and for serodifferent couples (couples in which oneperson has HIV and the other does not).
For others – like young people – it’s hard to take a pill consistently duringperiods of risk for getting HIV. The interest is there, but lots of things getin the way. Some relate to the person, like forgetfulness, transport to aclinic, and alternative priorities. Other factors relate to stigma and lack ofsupport.
PrEP administered via a vaginal ring is another safe option that’s beendeveloped. It’s not yet clear how many people will want to use it as it becomesmore widely available.
Access to PrEP has been slow and mostly limited to high-income countries.Some countries like Kenya, Uganda, South Africa, Zambia, and Nigeria, have beenmore proactive than others, but it is still hard for many to get PrEP.
Now that injectable PrEP is an option, it’s poised to make a hugedifference in HIV prevention – as long as some key issues can be overcome.
Benefits of injectable PrEP
The latest version of PrEP is an injection of another HIV drug –cabotegravir (called CAB-LA for cabotegravir-long acting). It is given in thebuttocks and lasts for two months. It is even more effective than oral PrEP andsafe.
Another injectable drug – lenacapavir – would only need to be given onceevery six months, and would be easier to inject because it only needs to gointo the skin; but it is still in clinical trials.
In many ways, injectable PrEP seems like a perfect solution. It’s discreet,there’s no burden of frequent pill taking, and it can be combined with otherservices and injections, like contraception for women. People in the CAB-LAtrials in many parts of the world, including sub-Saharan Africa, South America,and the US, really liked it. Although some public health officials andhealthcare workers have worried about the pain and any swelling due to theinjection itself, most people do very well.
Drawbacks of injectable PrEP
Several issues, however, may get in the way of injectable PrEPrevolutionising HIV prevention.
First, most people can’t get it. The United States was the first country toapprove CAB-LA in December 2021. The next was Zimbabwe in October 2022. Thenecessary paperwork is being processed in other countries in sub-SaharanAfrica, but regulatory processes are slow and access is likely to be achallenge for some time.
Second, it is expensive. CAB-LA is priced at over $22,000 per person peryear in the US. It could be covered to some extent by health insurancecompanies, but not everyone has health insurance. The drug manufacturer willlower the price for the markets in low- and middle-income countries, but theexact cost is not yet known. Some estimates are around $250 per person peryear. That’s still about five times as much as oral PrEP costs. The increasedeffectiveness may be worth it for people at high risk of getting HIV, butbringing it to those people will be challenging for health ministries.
Third, logistical issues complicate the delivery of injectable PrEP,including the need for refrigerators to store the drug and nurses to give theinjections. Clinics may not be set up to provide many injections on a givenday, and limited availability may mean people can’t get the shots when theyneed them.
Finally, continuing to get injections over time is still likely to be aproblem. The experience with injectable contraception has taught us that up tohalf of the people who select that form of family planning, stop it within ayear. Injectable PrEP does not solve the other barriers people face, liketransport to the clinic and prioritisation of HIV prevention.
The lack of access raises important ethical concerns. Most of the thousandsof people in the CAB-LA trials live in countries without access to it,including Botswana, Eswatini, Kenya, Malawi, South Africa, Uganda, and Zimbabweamong others. Processes to enable access are unacceptably slow, although thedrug is available in the US (and just recently Zimbabwe).
Where to go from here?
Despite these challenges, injectable PrEP is a huge advantage for the HIVprevention toolbox. The choice is critical for most interventions to work, andHIV prevention is no different. PrEP use increases when people are giveneffective options and can choose what works best for them.
PrEP needs to be easier for people to take, for instance by making it moreconvenient and less medical. Programmes are starting to do this throughcommunity delivery. That approach may be more challenging with injections, butit may get easier with time and with injections in the skin, like lenacapavir.
Advocacy will be critical for expediting the regulatory process andnegotiating with pharmaceutical companies to license other companies to producemore affordable generics.
