Scientific research has gifted us with a range of
evidence-based options to protect ourselves from getting
infected with HIV. In 2012, US FDA had first approved
Pre-Exposure Prophylaxis (PrEP) daily oral medicines for HIV
prevention. More recently, long-acting injectable options of
PrEP are also approved. We at CNS listened to the experts on
both of these PrEP options so that we can make an informed
choice.
A lively debate was organised at the recently
concluded 10th Asia Pacific AIDS and Co-Infections
Conference (APACC 2025) in Tokyo, Japan, on “Should
Long-Acting Injectables (LAIs) Replace Oral Antiretrovirals
for Biomedical HIV Prevention in the Asia-Pacific Region?”
Also, 13th International AIDS Society Conference on HIV
Science (IAS 2025) and 2nd Asia Pacific Conference on
Point-of-Care Diagnostics for Infectious Diseases (POC25)
will open soon.
Arguments in favour of long-acting
injectable PrEP dwelt upon the current dismally low use of
oral PrEP in the Asia Pacific Region – as of end 2023,
around 204,000 individuals were actively using PrEP – just
2% of the 8.2 million target set for 2025. Also a
significant number of individuals discontinue PrEP within a
relatively short period of time after initiation. For
example, in Thailand, a programme serving over half of all
PrEP users, saw 47% of clients discontinuing within 12
months, according to the Institute of HIV Research and
Innovation (IHRI).
“I don’t fear the side
effects. I fear the side eyes”
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Varied reasons
were put forward by debater Jennifer Ho, a global health
advocate from Thailand, included “Oral PrEP is not reaching
those most at risk. Transgender women navigating stigma in
clinics, sex workers who cannot safely carry pills; men who
have sex with men and young men hiding their PrEP from
family; persons who use drugs facing criminalisation – all
of these find it difficult to take daily oral PrEP. Pill
shaming keeps people from starting or leads them to quietly
stop, because of ‘I don’t fear the side effects. I fear the
side eyes.’ On the other hand, long-acting injectables
remove structural and behavioural barriers and can reach
people outside formal systems. We need prevention tools that
meet people’s needs. Prevention works when it does not
depend upon disclosure, disability or perfect routine. Oral
PrEP stigmatises life because you have to take a pill daily.
Long-acting injectables are discreet, there is no daily pill
to remember, there is no need to hide. Long-acting
injectables are a prevention strategy that is realistic,
respectful and responsive.”
Dr Nagalingeswaran
Kumarasamy, a well known infectious disease expert from
India gave a doctor’s perspective on the necessity of
long-acting injectable PrEP. He serves as Chief and Director
of Infectious Diseases Medical Centre at Voluntary Health
Services Hospital in Chennai, India. He is also the
Secretary General of AIDS Society of India (ASI) – a
nationwide network of medical experts and researchers on
HIV, co-infections and co-morbidities.
Dr
Kumarasamy said that daily PrEP pill is not a suitable or
desirable prevention strategy for everyone. We need more
options as well as expanded access or use by key populations
(people who are at a heightened risk of HIV). Long-acting
PrEP will likely be a very cost-effective improvement over
standard PrEP but may require novel financing mechanisms
that bring short-term fiscal planning efforts into closer
alignment with longer-term societal objectives. Cost
effectiveness is different from cost of sale. Long-acting
injectables will be cost effective in the long run. It is
too much to expect daily adherence from people who are not
sick. Also studies have found that long-acting injectables
like cabotagravir and lenacapavir to be superior to oral
PrEP.
It is not about ‘either/or’
but expanding options for HIV
prevention
While conceding that long-acting
injectable PrEP is promising, Danvic Rosadiño, Co-Chair,
WHO Guidelines Development Group on Long-acting Injectable
Cabotegravir for HIV Prevention, firmly argued that
replacing oral PrEP is premature, impractical and
inequitable. Danvic heads programmes and innovations at
LoveYourself in the Philippines.
“It is not a question
of ‘either’, ‘or’. It is about expanding options,
and not eliminating them. In a socially, economically and
politically diverse region like the Asia Pacific, this will
risk undermining progress. The three core reasons why oral
PrEP should not be replaced is cost, convenience and
confidence,” he said.
“Long-acting injectable PrEP is
far more expensive than generic oral PrEP. How many
governments of this region will be able to afford
long-acting injectables? If we replace oral PrEP, we will be
leaving the most vulnerable behind. We have been able to
roll out PrEP in a very de-medicalised manner. We have built
our systems which allow oral PrEP to be accessed in
community clinics, in mobile clinics, in peer outreach
facilities. It is easy, discreet and empowering, especially
for those avoiding judgmental or stigmatising healthcare
settings. However long-acting injectables might bring us to
clinical dependence, and many of our clients do not feel
welcome in clinical facilities. We set up communities for
giving oral PrEP because the mainstream system was not built
for us. It excluded and stigmatised the community. We have
created alternate spaces where people could feel safe,
respected and seen not just as patients but as people. If we
shift HIV prevention back to clinical systems, we risk
destroying those safe spaces. Long-acting injectables might
require clients to go back to those places which they
actively avoided. Granted that long-acting injectables are
very promising, replacing oral PrEP with them would create
barriers and not bridges. We must protect choice. Different
people need different things-some will prefer pills, some
will prefer injectables. Let us invest in building a system
where these options co-exist and where everyone- no matter
where they live – can access HIV prevention that works for
them,” said Danvic.
Do not forget stigma,
inequity and costs
Dr Rayner Kay Jin Tan, an
Assistant Professor at the Saw Swee Hock School of Public
Health, National University of Singapore, supported Danvic.
He opined that “Stigma, inequity and costs are very
important considerations when we think about PrEP and other
HIV prevention products. Keeping these things in mind, we
should not replace oral PrEP with long-acting injectables.
Oral PrEP has been de-medicalised to a large extent and
distribution is community driven, thus bringing access to
communities. And the cost of long-acting injectables is
still not known. No generic manufacturer has given any idea
of what it would cost. And most of the HIV infections are in
countries that will not be able to meet the high cost of
long-acting injectables. Except for Australia, no other
countries in the Asia-Pacific have approved any long-acting
injectable PrEP.
However, both sides agreed that not
everyone needs the same prevention options, but everyone
deserves what works best for them. Speed, scale,
implementation, and equity must be at the core of
translating exciting scientific tools into public health
impact.
Give real choices to people to choose
from full range of HIV combination prevention
options
It is now for the readers to decide
which premise do they support- long-acting injectables or
daily oral PrEP -till science develops more exciting HIV
prevention tools. And above all, expanding the range of
prevention options to protect ourselves from HIV should
always remain the mainstay – and trusting people to have
real choices if all combination prevention options are
offered to them.
Oral PrEP or pre-exposure
prophylaxis is an HIV medicine taken daily by HIV negative
individuals that reduces their risk of acquiring HIV through
sex by about 99% and from injection drug use by at least
74%. PrEP should be used with condoms when possible. There
are newer approved PrEP options that also protect us against
few STIs, like Doxy PrEP (which provides reasonable
protection against getting infected with STIs like syphilis,
chlamydia, and gonorrhoea).
Know
more about long-acting injectable PrEP
Since
2022, one of the long-acting injectable PrEP has a medicine
called cabotegravir which has shown high efficacy in
protecting us from HIV. It involves injections administered
intramuscularly, with the first two injections given four
weeks apart, followed thereafter by an injection every 8
weeks.
Studies have shown it to be safe and superior
to daily oral PrEP (which uses medicines like tenofovir and
emtricitabine) for HIV prevention among cisgender women,
cisgender men who have sex with men, and transgender women
who have sex with men. It offers a promising alternative to
daily oral PrEP, particularly for individuals who may face
challenges with adherence to daily medication. It was
recommended by the WHO in 2022 as an additional HIV
prevention option for people at substantial risk of HIV
infection.
However, its current high cost of US$
22,000 per year per user jeopardises its potential for
public health benefits. In July 2022, its manufacturer ViiV
Healthcare announced a voluntary license with the Medicines
Patent Pool, allowing 90 countries to buy generic versions
of cabotegravir for HIV prevention. The cost of generic
version is expected to be potentially around US$ 16-34 per
person per year. However, generic versions will not be out
before 2027.
Long-acting
Lenacapavir
Long-acting lenacapavir PrEP
given as a subcutaneous injection once every 6 months, has
been found to be highly effective. In 2024, two landmark
clinical studies- PURPOSE 1 and PURPOSE 2- showed it to be
100% efficacious in preventing HIV among cisgender women and
96% efficacious among men who have sex with men, transgender
and gender non-binary individuals, and was found superior to
oral PrEP.
It is currently priced at US$ 42,250 per
year per person in the US, but is expected to become much
more affordable to around US$ 200-300 per year per person
with the introduction of generic versions, that are expected
to be available by 2027.
Shobha Shukla – CNS
(Citizen News Service)
(Shobha Shukla is the
award-winning founding Managing Editor and Executive
Director of CNS (Citizen News Service) and is a feminist,
health and development justice advocate. She is a former
senior Physics faculty of prestigious Loreto Convent College
and current Coordinator of Asia Pacific Regional Media
Alliance for Health and Development (APCAT Media) and
Chairperson of Global AMR Media Alliance (GAMA received AMR
One Health Emerging Leaders and Outstanding Talents Award
2024). She also coordinates SHE & Rights initiative
(Sexual health with equity &
rights).
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