Long-term, injectable pre-exposure prophylaxis (PrEP) has proven to be 89% more effective in protecting cisgender women from HIV than single-pill-a-day regimens, according to a study run by the HIV Prevention Trials Network. The reason that this injectable PrEP, cabotegravir, has proven so effective is that it provides about two months of protection, which makes adherence far easier for patients to maintain.
Cabotegravir PrEP has not yet been approved for use in the U.S. by the Food and Drug Administration. While waiting for that approval, it is important for community health organizations and care providers to think about what it will take to administer the drug effectively to women who are interested in using it.
According to Meera Shah, M.D., M.P.H., chief medical officer at Planned Parenthood Hudson Peconic, the drug is a welcome milestone. Especially because Descovy (emtricitabine/tenofovir alafenamide), the most recent pill form of PrEP, is not approved for cisgender women or transgender men to use.
A primary concern about cabotegravir’s efficacy is whether a trained medical professional will be required to administer the drug. If scheduling appointments is the only means of access, then it is possible that providers will see a decline in adherence. Shah has faith that this will not be the case, based upon her experience with Depo-Provera (medroxyprogesterone acetate), an injectable form of contraception that is administered every three months.
“It’s a great option that many patients choose to use because it’s a lot better for their lifestyle,” she says. “I haven’t read if the cabotegravir will be approved for self-administration, but with Depo-Provera, we give patients a year’s prescription, and they administer it on their own every three months, which is really nice, because it minimizes the number of times that the patient has to come into the health center. I know that cabotegravir would require about eight injections a year. So I hope that patients can give it to themselves.”
With PrEP, many patients are unable to get more than a 30-day supply at a time because insurance companies will not reimburse that cost for care providers. “It’s not really tailored to the individual life experience, which I find to be a problem,” Shah says. “That’s why I would encourage the option—if patients select injectable self-administration—to provide a year supply to be given.”
Adherence is impeded when it interferes with a person’s schedule, she explains. “Some people have busy lives. With work and childcare, getting to doctor’s appointments can be really challenging. Throw in the [COVID-19] pandemic, and people are really trying to stay home and avoid going out into the community. And the reality of missing a doctor’s appointment and getting another one can be challenging. Care providers try to be as efficient as possible, but the reality is it doesn’t always happen as smoothly as we would hope.”
Looking at other considerations that health care providers should keep in mind about cabotegravir, Shah says, “It is important to recognize that vaginal tissue requires PrEP to be in the system for 20 to 21 days before it becomes protective in that tissue. For anal tissue, it is only seven days. It’s important to be mindful about these periods of time where PrEP will become effective based on the body parts that are being used for sex. And be mindful of people’s lifestyles and what works for them and what doesn’t. There is a reason we are always coming up with new ways to help our patients. For example, because condoms aren’t for everyone. If condoms worked for all people, we wouldn’t have had to come up with a different way to prevent HIV. I always advocate for them, but I also understand the realities of people’s lives.
“Similarly, for some people, taking a pill every day just doesn’t work,” she says. “That’s why I’m so happy to know that this injectable PrEP is on the horizon, because it can really meet our patients’ needs. Particularly because many of the patients that I take care of are really high risk. Whether they’re exchanging sex for money, have a partner who is living with HIV, have two jobs, or multiple children that they’re caring for on their own, they can’t always worry about taking a pill every day. We really have to recognize that and see what we can do to meet our patients where they are.”
Focusing on meeting patients where they are in their lives and helping them to find the harm-reduction solution that works for their lifestyle is the only effective way that we will eliminate new seroconversions. Hopefully, cabotegravir will be deployed with this idea in mind.