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Long-Acting PrEP at AIDS 2024
Long-Acting PrEP at AIDS 2024: Perspectives From Africa

Released: August 20, 2024

Expiration: August 19, 2025

Kenneth Ngure
Kenneth Ngure, MPH, MSc, PhD
Activity Information

Activity

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Key Takeaways
  • Long-acting PrEP, such as lenacapavir and long-acting cabotegravir, are effective and safe options for many people, including men, women, and pregnant individuals.
  • Innovative delivery mechanisms, such as differentiated service delivery models with private pharmacies, will be key for widespread implementation of long-acting PrEP in Africa.

Twice-Yearly Lenacapavir for HIV Prevention
One of the key highlights of the AIDS 2024 conference were the results from the PURPOSE 1 trial, presented by Dr Linda Gail-Bekker, at the co-chairs’ choice session. This landmark study was conducted among adolescent girls and young women without HIV in South Africa and Uganda. Participants received either twice-yearly lenacapavir, daily oral emtricitabine (FTC)/tenofovir alafenamide (TAF), or daily oral FTC/tenofovir disoproxil fumarate (TDF).

Among the 55 incident HIV infections observed, there were 0 infections among the 2134 participants in the lenacapavir arm, translating to an efficacy of 100%, but 39 infections among the 2136 participants in the FTC/TAF arm and 16 infections among the 1068 participants in the FTC/TDF arm.

To me, these data demonstrate that twice-yearly pre-exposure prophylaxis (PrEP has the potential to overcome adherence and persistence challenges, especially those associated with daily oral regimens. This is of particular importance to people in settings where HIV is prevalent, such as sub-Saharan Africa, and could also appeal to those desiring discreet PrEP options, such as adolescent girls and young women in that region.

Long-Acting Cabotegravir in Pregnancy
Continuing with this theme, injectable long-acting cabotegravir (LA CAB) was another PrEP option highlighted at AIDS 2024, with several abstracts reporting data showing that LA CAB is safe and highly effective for HIV prevention: The HPTN 084 open-label extension investigated whether LA CAB is safe and effective for pregnant people. Dr Sinead Delany-Moretlwe reported that among the 2472 participants, there were 351 confirmed pregnancies where the women were offered a choice of LA CAB or FTC/TDF.

Among participants with active CAB exposure, prior CAB exposure, and no CAB exposure, maternal and pregnancy outcomes (including preterm birth, stillbirth/intrauterine fetal demise, and spontaneous abortion) were consistent with expected background rates. In addition, the composite rate of poor pregnancy outcomes was similar across the nonrandomized exposure groups and driven by spontaneous abortion rates.

These data provide reassurance that CAB can safely be used during pregnancy, which is a period of high HIV risk, especially in regions of Africa where HIV is endemic.

Widespread Implementation of LA PrEP
Additional findings from the SEARCH Dynamic Choice HIV prevention trial, conducted in rural Uganda and Kenya, showed that more than one half of participants who were offered a choice of oral PrEP/postexposure prophylaxis or LA CAB chose and started LA CAB during the first 48 weeks. LA CAB was a popular, feasible choice for both men and women, with high level of satisfaction. In particular, participants in this setting cited ease of use and avoiding the stigma of oral PrEP as major reasons for preferring LA CAB.

However, for LA PrEP to reach enough people to have a lasting impact on HIV prevention, innovative delivery mechanisms will be key. To this end, Dr Stephanie Roche presented the results of a formative study, in which  pharmacy clients, providers, and stakeholders were interviewed to understand key considerations for implementing injectable PrEP at private pharmacies in Kenya.

All interviewees supported the idea of pharmacy delivery, but they identified several gaps or gray areas that could hinder implementation. In particular, many participants reported concerns regarding unqualified PrEP providers, who may not be competent at counseling patients, administering injections, managing drug reactions, or assessing adverse effects. As a solution, participants suggested implementing an injectable PrEP certification program, similar to existing courses on delivery of injectable contraceptives.

Finally, a PROTECT survey conducted in Europe to investigate the interest and intention to use LA PrEP among men who have sex with men reported that survey responders in Europe are interested and intend to use LA PrEP if it is made available.

I believe that LA PrEP has the potential to help address unmet HIV prevention needs and that the results of these studies in Africa can offer lessons to other regions of the world on how to improve access to PrEP, enact public health policies, and tailor messaging to reach a broader population.

Your Thoughts?
How do you think these studies from Africa can help inform implementation of LA PrEP in your practice? Leave a comment to join the discussion!