Interest in Long-Acting Injectable Pre-exposure Prophylaxis (LAI PrEP) Among Women in the Women's Interagency HIV Study (WIHS): A Qualitative Study Across Six Cities in the United States

A Mixed Methods Evaluation of Pharmacists' Readiness to Provide Long-Acting Injectable HIV Pre-exposure Prophylaxis in California

BACKGROUND

Pre-exposure prophylaxis (PrEP) uptake remains low among people who could benefit, some of whom may prefer alternatives to oral PrEP, such as long-acting injectable pre-exposure prophylaxis (LAI-PrEP). We evaluated the potential for LAI-PrEP provision in pharmacies through a mixed methods study of pharmacists in California, where Senate Bill 159 enables pharmacists to independently provide oral PrEP.

METHODS

In 2022-2023, we conducted an online cross-sectional survey of California pharmacists and pharmacy students (n = 919) and in-depth interviews with pharmacists (n = 30), both of which included modules assessing attitudes about PrEP provision. Using log-binomial regression, we estimated prevalence ratios (PRs) comparing survey participants' willingness to provide LAI-PrEP by pharmacy- and individual-level characteristics. Qualitative interview data were analyzed using Rapid Qualitative Analysis to identify factors that may affect pharmacists' provision of LAI-PrEP.

RESULTS

Half of the survey participants (53%) indicated that they would be willing to administer LAI-PrEP using gluteal injection in their pharmacy. Willingness was higher among participants who worked in pharmacies that provided vaccinations or other injections (56% vs. 46%; PR: 1.2; 95% confidence interval: 1.0-1.4) and/or oral PrEP under Senate Bill 159 (65% vs. 51%; PR: 1.3; 95% confidence interval: 1.1-1.5) than among participants whose pharmacies did not. Interviewed participants reported barriers to LAI-PrEP provision, including the need for increased training and staffing, a private room for gluteal injections, better medication access, and payment for services.

CONCLUSION

Pharmacies offer a promising setting for increased LAI-PrEP access. However, pharmacists may require additional training, resources, and policy changes to make implementation feasible.

Interest in and Willingness to Use PrEP: A Cross-Sectional Study of Individuals with Problematic Substance Use Residing in a High HIV Prevalence Jurisdiction

Although it is an effective HIV prevention method, pre-exposure prophylaxis (PrEP) is underutilized in the Southern US. Many people who use drugs (PWUD) have increased susceptibility to HIV which could be lessened by using PrEP. Potential barriers to PrEP use include lack of awareness of PrEP, low knowledge about HIV prevention, low self-efficacy for HIV prevention, inaccurate risk perceptions, and anticipated stigma. The current study examined predisposing, enabling, and reinforcing factors that may predict interest in PrEP. The purpose of the current study was to explore factors associated with interest in and willingness to use daily oral and long acting injectable PrEP among sexually active adult PWUD. The data were collected from adult participants (n = 270) residing in Harris County, TX, who self-reported problematic substance use and who reported oral, anal, or vaginal sex in the six months prior to completing the survey. The survey was distributed and completed online via Qualtrics Panels in March of 2022 and included measures of PrEP and HIV knowledge, PrEP stigma, sexual health self-efficacy, experiences of discrimination, health literacy, and medical mistrust. The majority of participants reported circumstances or behaviors that increased their susceptibility to HIV. Findings indicated that PrEP user stereotypes and PrEP anticipated disapproval by others were associated with interest in using daily oral PrEP and willingness to use long acting injectable PrEP. These results provide insight into reasons for low PrEP uptake among PWUD who live in a high HIV prevalence jurisdiction. Implications for HIV prevention intervention are discussed.

Identification of Determinants and Implementation Strategies to Increase Long-Acting Injectable PrEP for HIV Prevention Among Latino Men Who Have Sex with Men (MSM)

BACKGROUND

Latino men who have sex with men (LMSM) are disproportionally affected by HIV infections in the USA. The uptake rate of pre-exposure prophylaxis (PrEP) for HIV prevention has remained low among LMSM. Long-acting injectable PrEP (LAI-PrEP) may have the potential to improve structural, behavioral, and cognitive barriers to adherence. Given the potential benefits of LAI-PrEP and the limited data with this population, the aim of our study was to explore experiences and attitudes of LAI-PrEP among LMSM and identify implementation barriers compared to the standard oral presentation, align proposed implementation strategies, and propose outcomes to monitor and assess impact.

METHODS

In this qualitative study, guided by the Consolidated Framework for Implementation Research, we explored health care providers perspectives on facilitators and barriers to LAI-PrEP implementation strategies for LMSM. Interviews were recorded, transcribed, and analyzed using thematic content analysis.

RESULTS

Fear of immigration policies, ability to conceal PrEP medication, health insurance coverage, health information fatigue, lack of culturally adapted information, and provider's lack of knowledge were among the main barriers to LAI-PrEP. Most providers discussed the need for adapted and/or tailored training materials for and suggested designing marketing materials and specific clinical recommendations for LAI-PrEP.

CONCLUSION

In order to ensure an effective adaptation process that encompasses local and national goals of HIV prevention, future interventions should be designed in a way that incorporates culturally relevant information for LMSM. This study provides an implementation research logic model to guide future studies.

Effectiveness of a culturally tailored HIV intervention in promoting PrEP among black women who use drugs in community supervision programs in New York City: a randomized clinical trial

BACKGROUND

In the U.S. there are significant racial and gender disparities in the uptake of pre-exposure prophylaxis (PrEP). Black Americans represented 14% of PrEP users in 2022, but accounted for 42% of new HIV diagnoses in 2021 and in the South, Black people represented 48% of new HIV diagnoses in 2021 but only 21% of PrEP users in 2022. Women who use drugs may be even less likely than women who do not use drugs have initiated PrEP. Moreover, women involved in community supervision programs (CSP) are less likely to initiate or use PrEP, More PrEP interventions that focus on Black women with recent history of drug use in CSPs are needed to reduce inequities in PrEP uptake.

METHODS

We conducted a secondary analysis from a randomized clinical trial with a sub-sample (n = 336) of the total (N = 352) participants from the parent study (E-WORTH), who tested HIV negative at baseline were considered PrEP-eligible. Black women were recruited from CSPs in New York City (NYC), with recent substance use. Participants were randomized to either E-WORTH (n = 172) an HIV testing plus, receive a 5-session, culturally-tailored, group-based HIV prevention intervention, versus an HIV testing control group (n = 180). The 5 sessions included an introduction to PrEP and access. This paper reports outcomes on improved awareness of PrEP, willingness to use PrEP, and PrEP uptake over the 12-month follow-up period. HIV outcomes are reported in a previous paper.

RESULTS

Compared to control participants, participants in this study assigned to E-WORTH had significantly greater odds of being aware of PrEP as a biomedical HIV prevention strategy (OR = 3.25, 95% CI = 1.64-6.46, p = 0.001), and indicated a greater willingness to use PrEP as an HIV prevention method (b = 0.19, 95% CI = 0.06-0.32, p = 0.004) over the entire 12-month follow-up period.

CONCLUSIONS

These findings underscore the effectiveness of a culturally-tailored intervention for Black women in CSP settings in increasing awareness, and intention to initiate PrEP. Low uptake of PrEP in both arms highlight the need for providing more robust PrEP-on-demand strategies that are integrated into other services such as substance abuse treatment.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02391233 .

HPTN 083-02: factors influencing adherence to injectable PrEP and retention in an injectable PrEP study

INTRODUCTION

HPTN 083 demonstrated the superiority of long-acting cabotegravir (CAB-LA) versus daily oral emtricitabine/tenofovir disoproxil fumarate (TDF/FTC) as pre-exposure prophylaxis (PrEP) among cisgender men and transgender women who have sex with men (MSM/TGW). HPTN 083 provided the first opportunity to understand experiences with injectable PrEP in a clinical trial.

METHODS

Participants from two US sites (Chicago, IL and Atlanta, GA) and one international site (Rio de Janeiro, Brazil) were purposively sampled for individual qualitative interviews (N = 40), between November 2019 and March 2020, to explore trial experiences, barriers to adherence and other factors that may have impacted study implementation or outcomes. The blinded phase ended early due to efficacy; this analysis includes interviews conducted prior to unblinding with three groups defined by adherence (i.e. injection visit attendance): adherent (n = 27), non-adherent (n = 12) and early discontinuers (n = 1). Data were organized using NVivo software and analysed using content analysis.

RESULTS

Participants (mean age: 27) were primarily cisgender MSM (90%) and Black/African American (60%). Reasons for trial enrolment and PrEP use included a preference for using HIV prevention medication versus treatment in the event of HIV acquisition; the ability to enhance health via study-related education and services; access to a novel, convenient HIV prevention product at no cost; and contributing to MSM/TGW communities through research. Participants contrasted positive experiences with study staff with their routine clinical care, and emphasized increased scheduling flexibility, thorough communication, non-judgemental counselling and open, affirming environments (e.g. compassion, less stigma) as adherence facilitators. Injection experiences were positive overall; some described early injection-related anxiety, which abated with time and when given some measure of control (e.g. pre-injection countdown), and minimal injection site discomfort. Some concerns and misperceptions about injectable PrEP were reported. Barriers to adherence, across all adherence categories, included structural factors (e.g. financial constraints, travel) and competing demands (e.g. work schedules).

CONCLUSIONS

Respondents viewed injectable PrEP trial participation as a positive experience and a means of enhancing wellbeing. Study site flexibility and affirming clinic environments, inclusive of non-judgemental counselling, were key facilitators of adherence. To support injection persistence, interventions that address structural barriers and promote flexible means of injection delivery may be most effective.

Perspectives on Injectable HIV Pre-Exposure Prophylaxis: A Qualitative Study of Health Care Providers in the United States

The introduction of injectable HIV pre-exposure prophylaxis (PrEP) has the potential to significantly change the biomedical HIV prevention landscape. However, effective implementation will require health care providers to adopt, prescribe, and administer injectable PrEP within clinical settings. This study qualitatively examined challenges and benefit of injectable PrEP implementation from the perspective of health care providers. From April to August 2022, we conducted 19 in-depth interviews with current PrEP-prescribing health care providers in New York State, including 3 physician assistants, 5 physicians, and 11 nurse practitioners. Interviews were audio-recorded, transcribed verbatim, and thematically analyzed to report semantic-level themes regarding injectable PrEP implementation. More than half of participants (61%) were aware of injectable PrEP; only 21% had experience prescribing it. Qualitative findings highlighted five themes. Three themes represented implementation challenges, including speculative concerns about side effects, appointment compliance, and practical and logistical considerations. The remaining two themes described benefits of injectable PrEP relative to oral PrEP, which included greater convenience and enhanced privacy. Findings from this qualitative study make significant applied contributions to the sparse knowledge on health care provider perspectives of injectable PrEP post-US Food and Drug Administration approval and their concerns and considerations regarding implementation in real-world clinical settings.

A Qualitative Exploration of PrEP Interests, Barriers, and Interventions Among Black and Latina Cisgender Women in the U.S

Black and Latina cisgender women (BLCW) are disproportionally affected by HIV, particularly in the southern U.S. In Austin, Texas, Black women contract HIV 18.4 times more and Latinas 2.6 times more compared to White women. Pre-exposure prophylaxis (PrEP) is a medication that prevents contracting HIV; however, PrEP adoption among women is low. The current qualitative study aimed to explore PrEP awareness, interest, preferred PrEP administration methods, barriers to PrEP adoption, and future programs to increase PrEP adoption and adherence among BLCW. A total of 18 BLCW at high risk for HIV were enrolled. Participants completed 3 semi-structured interviews across 3 months. Interviews were transcribed verbatim, coded, and analyzed using thematic content analysis. Results demonstrated that BLCW had low PrEP awareness, high initial PrEP interest, and were interested in a long-acting injectable form of PrEP. Barriers to PrEP adoption included concerns regarding side effects, concerns about adherence to the currently available daily pill, and difficulty with insurance. Participants proposed different ideas for interventions, including support groups, education, community-level programs, and structural interventions. Future studies should focus on increasing PrEP awareness and HIV risk, consider alternative forms of PrEP, educate providers and medical staff on PrEP, and consider tailored interventions to reduce HIV risk among BLCW.

Barriers to Oral PrEP: A Qualitative Study of Female Sex Workers, PrEP Prescribers, Policymakers, and Community Advocates in Morocco

In 2017, Morocco became the first Arab country to incorporate pre-exposure prophylaxis (PrEP) in its HIV-prevention program. Yet no research has been published on PrEP from Morocco. Although female sex workers are one of the target populations of PrEP in Morocco, their enrollment in PrEP is lower than men who have sex with men. In this study, we conducted 38 semi-structured interviews with female sex workers, physicians who prescribe PrEP, policymakers, and community advocates to identify problems associated with access to and use of PrEP. We also investigated preferences for daily oral, vaginal ring, and long-acting injectable PrEP. A reflexive thematic analysis revealed seven themes: PrEP stigma; stigmatization and criminalization of sex work; one size doesn't fit all; knowledge and misconceptions about PrEP; economic burden; inconvenience of PrEP pills; and preferred PrEP modalities. This paper discusses the implications of the findings for increasing access and use of PrEP in Morocco.

Preference for long-acting injectable for ART and PrEP among people with and without HIV: a cross-sectional study in Argentina

Background

Little is known about the preferences for antiretroviral therapy (ART) administration methods, such as oral daily pills or long-acting injectable (LAI) options, as well as preferences for pre-exposure prophylaxis (PrEP) administration methods among people without HIV in Latin America.

Objectives

This study aimed to assess the preferences for ART administration methods among people with HIV and PrEP methods among those without HIV, as well as to examine the correlations and reasons for these preferences.

Design

We conducted a cross-sectional web-based questionnaire between April and July 2021, using social media accounts of a HIV non-governmental organization. The questionnaire was open to all adults living in Argentina, irrespective of their sexual orientation or gender identity.

Methods

The questionnaire included questions on substance use, depression, chronic treatment, previous experiences with injectable medication, and HIV status. Those with HIV answered questions about ART adherence and their preferences for ART methods, while those without HIV were asked about condom use, awareness of PrEP, and their preferences for PrEP methods.

Results

Out of 1676 respondents, 804 had HIV, and 872 did not. Among those with HIV, 91.5% expressed a high preference for LAI-ART, with significantly higher preferences among participants with higher educational levels, cisgender gay, bisexual, and queer men, younger individuals, and those with prior injectable medication experience. Among those without HIV, 68% preferred LAI-PrEP, and this preference was positively associated with previous positive experiences with injectable medication.

Conclusion

The strong preference for LAI-ART suggests the potential for improved adherence and well-being among people with HIV. Additionally, the preference for LAI-PrEP among those without HIV emphasizes the importance of considering this option for HIV prevention strategies. This study highlights the need to offer diverse methods for ART and prevention to accommodate different preferences and improve health care outcomes in Latin America.

Methodological issues in qualitative research on HIV prevention: an integrative review

In view of the growing concern about the use of qualitative approach in health research, this article aims to analyze how the qualitative theoretical-methodological framework of HIV prevention is presented in empirical research. We conducted an integrative literature review with the following guiding questions: "How is the qualitative theoretical-methodological framework expressed in empirical research on HIV prevention?"; "What are the limits and potentials of the qualitative methodological designs employed?". In the qualitative methodological discussion, five dimensions guided the methodological course and the presentation of findings, from the analysis of the characterization of qualitative studies to the contextualization of the studies and the methodological approaches used, highlighting the use of semi-structured interviews with thematic content analysis. We also examined social categories and analytical references, drawing attention to the plurality of these theoretical-conceptual references and to the authors' polyphony, and identified the limits and potentials of qualitative research. This study focuses on a scientific topic that is related to a wide variety of social groups and analyzes how they are affected by it, examining issues related to social inequality and other analytical possibilities surrounding HIV prevention, and providing resources for a comprehensive methodological discussion. Hence, avoiding the risk of conducting qualitative research based on checklists that limit inventiveness and openness to different designs and forms of execution and analysis is as pivotal as ensuring that the research is consistent and detailed in publications.

Willingness to use long-acting injectable PrEP among HIV-negative/unknown men who have sex with men in mainland China: A cross-sectional online survey

BACKGROUND

Men who have sex with men (MSM) are at high risk of HIV acquisition. Long-acting injectable-pre-exposure prophylaxis (LAI-PrEP), requiring less frequent dosing, is being studied as an alternative method to daily oral HIV PrEP. With the addition of this potential new prevention method, it expands the scope for a wider user choice and is expected to increase the acceptability and uptake of HIV prevention measures. The aim of our study was to explore the willingness to use LAI-PrEP and associated influential factors.

METHODS

Participants were recruited from December 2020 to March 2021 through banner advertisements on web- and mobile app-based platforms on Blued, a large gay Chinese social media platform. MSM in our cross-sectional study was HIV-negative and currently lived in mainland China. Participants were asked about their willingness to use LAI-PrEP and reasons why they might be or not be willing to use LAI-PrEP. Multivariable logistic regression was used to analyze the factors associated with the willingness to use LAI-PrEP.

RESULTS

In total, 969 participants met the inclusion criteria and finished the survey. Nearly twenty percent (19.5%) of participants had never tested for HIV; 66.8% of MSM had multiple male partners; and 51.6% of MSM engaged in condomless sex with their partner. About three-fifths (66.3%) of MSM were aware of PrEP, and only 3.9% of MSM had used PrEP before. The willingness to use LAI-PrEP among MSM was 74.0% (95% CI: 71.4%-76.6%). MSM with higher education levels were less likely to show a willingness to use LAI-PrEP (AOR = 0.56, 95%CI: 0.38-0.84). Participants who had a history of HIV test (AOR = 1.68, 95%CI: 1.11-2.55), were willing to use daily oral PrEP (AOR = 10.64, 95%CI:7.43-15.21), had multiple male sexual partners (AOR = 1.33, 95%CI:0.93-1.90), who used rush popper(AOR = 1.49, 95%CI:1.05-2.13), and who were aware of PEP (AOR = 1.66, 95%CI: 1.02-2.70) were more likely to show willingness to use LAI-PrEP.

CONCLUSIONS

In our study, MSM had quite high awareness but low uptake of PrEP. As LAI-PrEP is expected to be approved for use in China in the future, our study of MSM highlights the need for key population-focused education programs about PrEP and healthy sexual behavior. This study also provides some evidence for LAI-PrEP use among the Chinese MSM population in the future.

A Note on Preexposure Prophylaxis Preferences Among Women Who Inject Drugs

ABSTRACT

We informed women who inject drugs about different preexposure prophylaxis (PrEP) formulations; they then ranked their preferences. Daily oral PrEP was most preferred, followed by injectable PrEP and vaginal rings/gels, especially among women of color. Multiple PrEP options should be discussed with women who inject drugs to increase uptake.

Systematic review of the values and preferences regarding the use of injectable pre-exposure prophylaxis to prevent HIV acquisition

INTRODUCTION

Pre-exposure prophylaxis (PrEP) is an important HIV prevention option. Two randomized trials have provided efficacy evidence for long-acting injectable cabotegravir (CAB-LA) as PrEP. In considering CAB-LA as an additional PrEP modality for people at substantial risk of HIV, it is important to understand community response to injectable PrEP. We conducted a systematic review of values, preferences and perceptions of acceptability for injectable PrEP to inform global guidance.

METHODS

We searched nine databases and conference websites for peer-reviewed and grey literature (January 2010-September 2021). There were no restrictions on location. A two-stage review process assessed references against eligibility criteria. Data from included studies were organized by constructs from the Theoretical Framework of Acceptability.

RESULTS

We included 62 unique references. Most studies were observational, cross-sectional and qualitative. Over half of the studies were conducted in North America. Men who have sex with men were the most researched group. Most studies (57/62) examined injectable PrEP, including hypothetical injectables (55/57) or placebo products (2/57). Six studies examined CAB-LA specifically. There was overall interest in and often a preference for injectable PrEP, though there was variation within and across groups and regions. Many stakeholders indicated that injectable PrEP could help address adherence challenges associated with daily or on-demand dosing for oral PrEP and may be a better lifestyle fit for individuals seeking privacy, discretion and infrequent dosing. End-users reported concerns, including fear of needles, injection site pain and body location, logistical challenges and waning or incomplete protection.

DISCUSSION

Despite an overall preference for injectable PrEP, heterogeneity across groups and regions highlights the importance of enabling end-users to choose a PrEP modality that supports effective use. Like other products, preference for injectable PrEP may change over time and end-users may switch between prevention options. There will be a greater understanding of enacted preference as more end-users are offered anti-retroviral (ARV)-containing injectables. Future research should focus on equitable implementation, including real-time decision-making and how trained healthcare providers can support choice.

CONCLUSIONS

Given overall acceptability, injectable PrEP should be included as part of a menu of prevention options, allowing end-users to select the modality that suits their preferences, needs and lifestyle.

Factors Associated with Preferences for Long-Acting Injectable Antiretroviral Therapy Among Adolescents and Young People Living with HIV in South Africa

Long-acting injectable anti-retroviral therapy (LAART) may overcome barriers to long-term adherence and improve the survival of adolescents and young people living with HIV (AYLHIV). Research on the acceptability of LAART for this age-group is limited. We asked 953 AYLHIV about their preferred (theoretical) ART mode of delivery (pill, injectable, or other) in 2017-2018, before LAART was available or known to AYLHIV in South Africa. One in eight (12%) AYLHIV preferred LAART over single or multiple pill regimens. In multivariate analyses, six factors were associated with LAART preference: medication stock-outs (aOR = 2.56, 95% CI 1.40-4.68, p = 0.002), experiencing side-effects (aOR = 1.84, 95% CI 1.15-2.97, p = 0.012), pill-burden (aOR = 1.88, 95% CI 1.20-2.94, p = 0.006), past-year treatment changes (aOR = 1.63, 95% CI 1.06-2.51, p = 0.025), any HIV stigma (aOR = 2.22, 95% CI 1.39-3.53, p ≤ 0.001) and recent ART initiation (aOR = 2.02, 95% CI 1.09-3.74, p = 0.025). In marginal effects modelling, 66% of adolescents who experienced all factors were likely to prefer LAART, highlighting the potential high acceptability of LAART among adolescents and young people living with HIV struggling to adhere and have good HIV treatment outcomes. Adolescent boys who reported high ART pill burden were more likely to prefer LAART than their female peers in moderation analyses, suggesting that LAART may be particularly important to improve treatment outcomes among male AYLHIV as they become older. Adding LAART to existing treatment options for AYLHIV, particularly higher risk groups, would support AYLHIV to attain and sustain viral suppression-the third 95, and reduce their risk of AIDS-related mortality.

PrEP awareness and use among reproductive age women in Miami, Florida

BACKGROUND

Miami, Florida is an epicenter of the HIV epidemic in the US, with 20% of new HIV infections occurring in women. Despite effectiveness of Pre-Exposure Prophylaxis (PrEP) in preventing HIV, only 10% of eligible women benefit from its use.

SETTING

This study evaluates PrEP awareness and use, and factors associated with PrEP awareness among sexually active women in Miami, Florida.

METHODS

Results reported in this study included cross-sectional data that were collected as part of a baseline visit from a parent study. Cis-gender, HIV-negative, 18-45-year-old, sexually active women were recruited as part of a study evaluating recurrent bacterial vaginosis and HIV risk. Participants completed questionnaires assessing socio-demographics, HIV risk factors, prior history of HIV testing and reproductive tract infections, PrEP awareness and use. Relationships between variables and PrEP awareness were analyzed and multivariable logistic regression identified variables strongly associated with PrEP awareness.

RESULTS

Among the 295 women enrolled, median age was 31 (24-38) years, 49% Black, 39% White, and 34% Hispanic. Of 63% who knew about PrEP, only 5% were on PrEP. Women with income below poverty line (OR = 2.00[1.04,3.87];p = 0.04), more male sexual partners in past month (OR = 1.30[1.01,1.68];p = 0.04), lifetime HIV testing (OR = 6.42[2.83,14.52];p<0.01), and current bacterial vaginosis (OR = 2.28[1.18,4.40];p = 0.01) were more likely to be aware of PrEP. Lower odds of PrEP awareness were associated with being Black (OR = 0.38[0.15,0.96];p = 0.04), Hispanic (OR = 0.18[0.08,0.39];p<0.01), heterosexual (OR = 0.29[0.11,0.77];p<0.01), and reporting inconsistent condom use during vaginal sex (OR = 0.21[0.08,0.56];p<0.01).

CONCLUSION

PrEP awareness is low among reproductive age women in a high-risk setting. Culturally tailored interventions are needed to increase PrEP awareness and uptake, especially among Black and Hispanic women with inconsistent condom use during vaginal sex with male partners.

High Interest in Long-acting Injectable Pre-exposure Prophylaxis (LAI-PrEP) for HIV Prevention Among Men Who Have Sex With Men (MSM): Result From A Nationwide Survey in Malaysia

The recent approval of long-acting injectable cabotegravir (CAB-LA) as PrEP for HIV prevention could be an attractive alternative for MSM, particularly among those who face barriers to adherence using the oral pill. This study reports on the awareness of long-acting injectable PrEP (LAI-PrEP) and factors associated with interest in LAI-PrEP use among a nationwide sample of MSM in Malaysia. An online cross-sectional survey was conducted between August and September 2021 to explore perspectives on PrEP modalities among Malaysian MSM (N = 870). Convenience sampling was used to recruit participants using ads on two platforms hornet and facebook. While only 9.1% of the study participants were aware of LAI-PrEP, the majority had heard of oral PrEP (80.9%). After giving a description of it, a large majority (86.6%) expressed interest in using it if made accessible. Those who had a prior history of HIV testing (aOR = 1.9; 95% CI = 1.2-3.2) were more likely to use LAI-PrEP. Interestingly, despite the concerns related to potential high cost (aOR = 3.4; 95% CI = 2.1-5.5) and long-term side effects (aOR = 1.9; 95% CI = 1.2-3.1), the majority of the participants were interested in using LAI-PrEP. Those who were afraid of (or disliked) syringes were less interested in using it (aOR = 0.2; 95% CI; 0.1-0.4). In the recent context that LAI-PrEP was shown to be safe and effective at preventing HIV, our results indicate its potential relevance as an additional PrEP option that could accelerate the uptake and scale-up of PrEP. However, it is crucial to conduct future research urgently to improve the understanding of strategies that could enhance the accessibility, acceptability, and affordability of LAI-PrEP for MSM in low- and middle-income countries, including Malaysia.

Characterizing Twitter Content About HIV Pre-exposure Prophylaxis (PrEP) for Women: Qualitative Content Analysis

BACKGROUND

HIV remains a persistent health problem in the United States, especially among women. Approved in 2012, HIV pre-exposure prophylaxis (PrEP) is a daily pill or bimonthly injection that can be taken by individuals at increased risk of contracting HIV to reduce their risk of new infection. Women who are at risk of HIV face numerous barriers to HIV services and information, underscoring the critical need for strategies to increase awareness of evidence-based HIV prevention methods, such as HIV PrEP, among women.

OBJECTIVE

We aimed to identify historical trends in the use of Twitter hashtags specific to women and HIV PrEP and explore content about women and PrEP shared through Twitter.

METHODS

This was a qualitative descriptive study using a purposive sample of tweets containing hashtags related to women and HIV PrEP from 2009 to 2022. Tweets were collected via Twitter's API. Each Twitter user profile, tweet, and related links were coded using content analysis, guided by the framework of the Health Belief Model (HBM) to generate results. We used a factor analysis to identify salient clusters of tweets.

RESULTS

A total of 1256 tweets from 396 unique users were relevant to our study focus of content about PrEP specifically for women (1256/2908, 43.2% of eligible tweets). We found that this sample of tweets was posted mostly by organizations. The 2 largest groups of individual users were activists and advocates (61/396, 15.4%) and personal users (54/396, 13.6%). Among individual users, most were female (100/166, 60%) and American (256/396, 64.6%). The earliest relevant tweet in our sample was posted in mid-2014 and the number of tweets significantly decreased after 2018. We found that 61% (496/820) of relevant tweets contained links to informational websites intended to provide guidance and resources or promote access to PrEP. Most tweets specifically targeted people of color, including through the use of imagery and symbolism. In addition to inclusive imagery, our factor analysis indicated that more than a third of tweets were intended to share information and promote PrEP to people of color. Less than half of tweets contained any HBM concepts, and only a few contained cues to action. Lastly, while our sample included only tweets relevant to women, we found that the tweets directed to lesbian, gay, bisexual, transgender, queer (LGBTQ) audiences received the highest levels of audience engagement.

CONCLUSIONS

These findings point to several areas for improvement in future social media campaigns directed at women about PrEP. First, future posts would benefit from including more theoretical constructs, such as self-efficacy and cues to action. Second, organizations posting on Twitter should continue to broaden their audience and followers to reach more people. Lastly, tweets should leverage the momentum and strategies used by the LGBTQ community to reach broader audiences and destigmatize PrEP use across all communities.

Overcoming barriers to patient adherence: the case for developing innovative drug delivery systems

Poor medication adherence is a pervasive issue with considerable health and socioeconomic consequences. Although the underlying reasons are generally understood, traditional intervention strategies rooted in patient-centric education and empowerment have proved to be prohibitively complex and/or ineffective. Formulating a pharmaceutical in a drug delivery system (DDS) is a promising alternative that can directly mitigate many common impediments to adherence, including frequent dosing, adverse effects and a delayed onset of action. Existing DDSs have already positively influenced patient acceptability and improved rates of adherence across various disease and intervention types. The next generation of systems have the potential to instate an even more radical paradigm shift by, for example, permitting oral delivery of biomacromolecules, allowing for autonomous dose regulation and enabling several doses to be mimicked with a single administration. Their success, however, is contingent on their ability to address the problems that have made DDSs unsuccessful in the past.

Exploring preferences and decision-making about long-acting injectable HIV pre-exposure prophylaxis (PrEP) among young sexual minority men 17-24 years old

Intramuscular cabotegravir for long-acting injectable HIV pre-exposure prophylaxis (i.e., LAI-PrEP) was approved by the U.S. FDA in 2021. We sought to explore LAI-PrEP decision-making among a nationwide sample of young sexual minority men (YSMM) 17-24 years old. In 2020, HIV-negative/unknown YSMM (n = 41) who met CDC criteria for PrEP were recruited online to participate in synchronous online focus groups eliciting preferences and opinions about LAI-PrEP, as well as the impact of a potential self-administered option. Data were analyzed using inductive and deductive thematic analysis with constant comparison. Preferences and decision-making about LAI-PrEP varied widely among YSMM, with participants frequently comparing LAI-PrEP to oral PrEP regimens. We identified five key themes related to LAI-PrEP decision-making including concerns about adherence to PrEP dosing and clinic appointments, awareness and knowledge of PrEP safety and efficacy data, comfort with needles, minimizing PrEP stigma, and considerations of self-administration. YSMM acknowledged more PrEP options as beneficial to supporting uptake and persistence.

Considerations for the Use of Long-Acting and Extended-Release Agents During Pregnancy and Lactation

Long-acting agents hold significant promise for treating and preventing common illnesses, including infections. Pharmacokinetic and safety data during pregnancy and lactation are often unavailable for new drugs; these data are vital to facilitate optimal drug use by pregnant and lactating women and women who may conceive. In this commentary, we summarize the circumstances in which pregnant and lactating women are likely to use and benefit from long-acting agents. We focus on long-acting formulations of small molecules (rather than biologics such as monoclonal antibodies) and on several infections of global importance (human immunodeficiency virus, tuberculosis, malaria, and hepatitis C). We discuss pregnancy pharmacokinetic/pharmacodynamic and potential safety and efficacy considerations pertaining to the use of long-acting agents in pregnancy and lactation. Finally, we summarize existing preclinical and pregnancy pharmacokinetic data that are available (or expected in the near future) for several agents that are under development or approved, and how key research gaps may be addressed.

Barriers to Uptake of Long-Acting Antiretroviral Products for Treatment and Prevention of Human Immunodeficiency Virus (HIV) in High-Income Countries

Long-acting injectable antiretroviral therapy (LAI-ART) for the treatment and prevention of human immunodeficiency virus (HIV) holds great potential to shift treatment paradigms by offering an alternative to daily oral medication. However, significant challenges at the drug, patient, and system levels risk impeding the uptake and implementation of LAI-ART. This review aims to describe the known and anticipated barriers to uptake of LAI-ART in high-income countries, as well as the ongoing research addressing some of these barriers to improve the delivery and uptake of LAI-ART products.

PrEP service delivery preferences of black Cis-gender women living in the Southern United States

To assess PrEP service delivery preferences among Black cis-gender women living in urban and rural settings in Alabama, we conducted a cross-sectional discrete choice experiment survey. Discrete choice experiments included five attributes. Hierarchical Bayes (HB) modeling and latent class analyses (LCA) were used to evaluate attribute preferences. Among 795 Black cis-gender HIV-negative women, almost two-thirds lived in urban settings and reported having at least some college; about a third reported a household income less than $25,000 annually; and reported willingness to use PrEP. Respondents placed the greatest importance on PrEP medication formulation and healthcare facility. LCA showed the group with the highest rural proportion preferred for on-line visits. Black women in the Deep South had distinct preferences regarding PrEP service delivery. These findings can inform tailored interventions to improve PrEP uptake among Black cis-gender women across diverse settings in the South.

A Patient Decision Aid (i.ARTs) to Facilitate Women's Choice Between Oral and Long-Acting Injectable Antiretroviral Treatment for HIV: Protocols for its Development and Randomized Controlled Pilot Trial

BACKGROUND

Many women with HIV (WWH) have suboptimal adherence to oral antiretroviral therapy (ART) due to multilevel barriers to HIV care access and retention. A long-acting injectable (LAI) version of ART was approved by the US Food and Drug Administration in January 2021 and has the potential to overcome many of these barriers by eliminating the need for daily pill taking. However, it may not be optimal for all WWH. It is critical to develop tools that facilitate patient-provider shared decision making about oral versus LAI ART modalities to promote women's adherence and long-term HIV outcomes.

OBJECTIVE

This study will develop and pilot test a web-based patient decision aid called i.ART+support (i.ARTs). This decision aid aims to support shared decision making between WWH and their providers, and help women choose between oral and LAI HIV treatment.

METHODS

The study will occur in 3 phases. In phase 1, we will utilize a mixed methods approach to collect data from WWH and medical and social service providers to inform i.ARTs content. During phase 2, we will conduct focus groups with WWH and providers to refine i.ARTs content and develop the web-based decision aid. In phase 3, i.ARTs will be tested in a randomized controlled trial with 180 women in Miami, Florida, and assessed for feasibility, usability, and acceptability, as well as to evaluate the associations between receiving i.ARTs and viral suppression, ART pharmacy refills, and clinic attendance.

RESULTS

This study was funded in March 2021. Columbia University's IRB approved the study protocols (approval number IRB-AAAT5314). Protocols for phase 1 interviews have been developed and interviews with service providers started in September 2021. We will apply for Clinicaltrials.gov registration prior to phase 3, which is when our first participant will be enrolled in the randomized controlled trial. This is anticipated to occur in April 2023.

CONCLUSIONS

This study is the first to develop a web-based patient decision aid to support WWH choices between oral and LAI ART. Its strengths include the incorporation of both patient and provider perspectives, a mixed methods design, and implementation in a real-world clinical setting.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/35646.

Cabotegravir: The first long-acting injectable for HIV pre-exposure prophylaxis

DISCLAIMER

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

PURPOSE

The purpose of this article is to review the pharmacology, efficacy, and safety of the integrase inhibitor cabotegravir for HIV pre-exposure prophylaxis, including data from clinical trials.

SUMMARY

A narrative review was performed by searching PubMed/MEDLINE databases to identify relevant articles published between March 2014 and December 2021 using the keyword terms cabotegravir and Apretude and the search strings "long-acting injectable AND human immunodeficiency virus" and "pre-exposure prophylaxis AND human immunodeficiency virus." All relevant English-language articles evaluating the pharmacology, efficacy, or safety of cabotegravir in humans for HIV pre-exposure prophylaxis were included. Additional data were obtained from prescribing information, references of identified articles, and abstracts from scientific meetings. Cabotegravir has been approved by the Food and Drug Administration and is considered both safe and effective for HIV pre-exposure prophylaxis. It is the first long-acting injectable medication approved for this indication. Phase 3 clinical trials have demonstrated the noninferiority of cabotegravir to currently recommended oral once-daily dosing regimens. Injection-site reactions were common in clinical trials of cabotegravir and occurred in up to 81% of trial participants. Costs associated with the long-acting injectable formulation must also be considered.

CONCLUSION

Cabotegravir is a novel bimonthly, injectable option for pre-exposure HIV prophylaxis for high-risk adolescents and adults weighing at least 35 kg.

Preferences for HIV Preexposure Prophylaxis Products Among Black Women in the U.S

In a nationwide sample of Black women in the U.S., we assessed preferences for HIV preexposure prophylaxis (PrEP) products, including long-acting injectable (LAI) PrEP and once-daily oral PrEP. Among 315 respondents, 32.1% were aware of PrEP and 40.6% were interested in using it; interest increased to 62.2% if PrEP were provided for free. Oral PrEP was the preferred option (51.1%), followed by LAI PrEP (25.7%), vaginal gel (16.5%), and vaginal ring (6.7%). When examining oral and LAI PrEP alone, most (62.7%) preferred oral PrEP. LAI PrEP was more likely to be preferred among respondents with concerns about healthcare costs or PrEP-related stigma, and among those who reported inconsistent condom use and multiple sexual partners. Although most Black women preferred oral PrEP, LAI PrEP may be appealing to a subset with social and structural barriers to PrEP use, such as cost and stigma, and those at increased risk of HIV infection.

Promises and challenges: cabotegravir for preexposure prophylaxis

PURPOSE OF REVIEW

Tenofovir-based oral PrEP has been effective in reducing population-level HIV incidence in multiple settings, although disparities remain. Injectable cabotegravir-based PrEP is an alternative that may be attractive to individuals with adherence challenges or who do not desire to take a daily medication. We review promises and challenges of cabotegravir-based PrEP.

RECENT FINDINGS

Cabotegravir has demonstrated higher effectiveness than oral PrEP in two randomized trials, with a hazard ratio of 0.31 for HIV incidence among MSM and transgender women across multiple settings [95% confidence interval (CI) 0.18-0.62] and 0.11 for cisgender women in sub-Saharan Africa (95% CI 0.040.32). Cabotegravir was also highly effective among populations with disproportionate HIV incidence. Although cabotegravir breakthrough was rare, diagnosis was delayed with use of antigen/antibody-based HIV tests, and resistance occurred with breakthrough infections. Implementation will need to overcome several challenges, including HIV RNA laboratory monitoring not being widely available, requirement for additional staff time and clinic space, and need to provide oral medication during interruptions in dosing.

SUMMARY

Cabotegravir-based PrEP is a highly effective additional PrEP option that will expand HIV prevention options. For successful roll-out, strategies for streamlined and accessible delivery of cabotegravir in real-world settings will need to be developed.

A Layer Plus Approach to Implementation Research and Collaboration for Long-Acting Injectable Pre-Exposure Prophylaxis for HIV Prevention

In 2020, the HIV prevention clinical trials, HPTN (HIV Prevention Trials Network) 083 and 084, reported that long-acting injectable cabotegravir (CAB-LA) for HIV prevention was statistically superior to daily oral tenofovir disoproxil fumarate/emtricitabine (TDF/FTC) for pre-exposure prophylaxis (PrEP) in cisgender men and transgender women who have sex with men, and cisgender women. However, clinical efficacy does not translate to real-world effectiveness and clinical practice as evidenced by current global use of oral PrEP. There are ~626,000 users of PrEP, which is significantly below the 3 million goal set by UNAIDS for 2020. Implementation will be key to ensuring that CAB-LA reaches those who desire to use it. We describe the Layer Plus Approach for CAB-LA for PrEP dissemination and implementation. The "Layer" is focused on integrating CAB-LA into existing PrEP models of care and understanding the best delivery channels that could be established in existing programs. Important implications of layering include preparing health professionals to provide CAB-LA, improving access for potential users, and addressing existing PrEP structural and facility barriers. "Plus," which accounts for the existing disparities in PrEP access and use, means expanding CAB-LA to reach individuals for whom HIV prevention options have not been accessible or who have lapsed on oral PrEP. Implications for Plus include the development of new structures, systems, policies, and processes. A key aspect to the Approach is building collaborations to aid successful implementation. The Layer Plus Approach is a simple but strategic framework or a tailored approach to guide dissemination research and implementation.

Barriers to HIV Pre-Exposure Prophylaxis Uptake and Ways to Mitigate Them: Perspectives of Ghanaian Immigrants in the United States

African immigrants in the United States experience disparities in HIV incidence. Pre-exposure prophylaxis (PrEP) effectively prevents HIV infection, yet uptake is low among racial and ethnic minorities. To better understand PrEP adoption among African immigrants, in March 2020, we conducted interviews with Ghanaian immigrants (N = 40) to explore the barriers and ways to overcome these barriers to PrEP adoption. Participants described several barriers (e.g., low HIV knowledge and risk perception, fear of social judgment, cultural values, and norms), which may impede PrEP adoption. We categorized these barriers according to the levels of the socioecological model (individual, interpersonal, community, and organizational/structural factors). Participants also identified strategies to overcome the barriers, such as providing comprehensive education on HIV and PrEP. Our research provides foundational knowledge that can inform future PrEP research with Ghanaian and other African immigrants and offers important insights into factors that may impact PrEP adoption in this population.

Key population perceptions and opinions about long-acting antiretrovirals for prevention and treatment: a scoping review

PURPOSE OF REVIEW

Key populations are disproportionately affected by human immunodeficiency virus (HIV). Access, retention, and adherence are important barriers for the efficacy of preexposure prophylaxis (PrEP) and HIV treatment among these populations. Long-acting (LA) antiretrovirals hold the promise to solve some of these backdrops. The objective of the current review is to update the perceptions of key populations and PLWH about LA, based on their opinion, acceptability, and willingness to use it.

RECENT FINDINGS

According to the review preferences for LA vary with the population studied. Regarding people living with HIV (PLWH), male having sex with men are interested in having different options, adolescents are interested in LA (strong preference for implants), yet also perceive substantial obstacles to using biomedical prevention; transgender women aimed to nonvisible small implants, with long-lasting effects or LA injections that can be applied in other areas than buttocks, and women who experienced history of medical injections might increase preference for LA (except for history of people who inject drugs [IDU]). Female sex workers and IDU both showed interest in LA-PrEP. Regarding antiretroviral therapy, LA increased treatment satisfaction and acceptance, mainly among those receiving injections every 2 months. LA helped overcome pill fatigue, stigma, and adherence issues.

SUMMARY

Knowing preferences for biomedical interventions will contribute to better understanding and developing effective strategies for these populations.

Long-Acting Injectable ART and PrEP Among Women in Six Cities Across the United States: A Qualitative Analysis of Who Would Benefit the Most

Long-acting injectable (LAI) modalities have been developed for ART and PrEP. Women face unique barriers to LAI use yet little research has examined women's perceptions of potential LAI HIV therapy candidates. We conducted 89 in-depth interviews at six Women's Interagency HIV Study (WIHS) sites with women living with HIV (n = 59) and HIV-negative women (n = 30) from 2017 to 2018. Interviews were recorded, transcribed, and analyzed using thematic content analysis. Participants identified specific sub-populations who could most benefit from LAI over daily pills: (1) young people; (2) women with childcare responsibilities; (3) people with adherence-related psychological distress; (4) individuals with multiple sex partners; and (5) people facing structural insecurities such as homelessness. Women are underserved by current HIV care options and their perspectives are imperative to ensure a successful scale-up of LAI PrEP and LAI ART that prioritizes equitable access and benefit for all individuals.

Promise, perils and cautious optimism: the next frontier in long-acting modalities for the treatment and prevention of HIV

PURPOSE OF REVIEW

This paper provides a critical review of recent therapeutic advances in long-acting (LA) modalities for human immunodeficiency virus (HIV) treatment and prevention.

RECENT FINDINGS

LA injectable antiretroviral therapy (ART) has been approved in the United States, Canada and Europe; the United States also has approved LA injectable preexposure prophylaxis (PrEP) and the World Health Organization has recommended the vaginal PrEP ring. Current LA PrEP modalities in clinical trials include injections, films, rings, and implants; LA ART modalities in trials include subcutaneous injections and long-term oral pills. Although LA modalities hold incredible promise, global availability is inhibited by long-standing multilevel perils including declining multilateral funding, patent protections and lack of political will. Once available, access and uptake are limited by factors such as insurance coverage, clinic access, labor markets, stigma, and structural racism and sexism. These must be addressed to facilitate equitable access for all.

SUMMARY

There have been tremendous recent advances in the efficacy of LA ART and PrEP modalities, providing renewed hope that 'ending the HIV epidemic' is within reach. However, pervasive socio-structural inequities limit the promise of LA modalities, highlighting the need for cautious optimism in light of the embedded inequities in the trajectory of research, development, and population-level implementation.

Pharmacy-Based Interventions to Increase Use of HIV Pre-exposure Prophylaxis in the United States: A Scoping Review

HIV pre-exposure prophylaxis (PrEP) remains underutilized in the U.S. Since greater than 85% of PrEP prescriptions are filled at commercial pharmacies, pharmacists are uniquely positioned to increase PrEP use. This scoping review explores pharmacy-based initiatives to increase PrEP use. We searched PubMed, PsycINFO, CINAHL, and Scopus for peer-reviewed studies on pharmacist-led interventions to increase PrEP use or pharmacy-based PrEP initiatives. Forty-nine articles were included in this review. Overall, studies demonstrated that patients expressed strong support for pharmacist prescription of PrEP. Three intervention designs compared changes in PrEP initiation or knowledge pre- and post-intervention. Commentary/review studies recommended PrEP training for pharmacists, policy changes to support pharmacist screening for HIV and PrEP prescription, and telemedicine to increase prescriptions. Pharmacists could play key roles in improving PrEP use in the U.S. Studies that assess improvements in PrEP use after interventions such as PrEP prescription, PrEP-specific training, and adherence monitoring by pharmacists are needed.

"I had Made the Decision, and No One was Going to Stop Me" -Facilitators of PrEP Adherence During Pregnancy and Postpartum in Cape Town, South Africa

PrEP is safe and effective but requires adherence during potential HIV exposure, yet the facilitators of long-term maternal adherence are not well understood. We conducted semi-structured interviews with 25 postpartum women who reported high adherence (PrEP use ≥ 25 days in last 30-days and never missed a PrEP prescription in pregnancy/postpartum period) within a PrEP service for pregnant and postpartum women. A thematic approach guided an iterative process of coding and analysis. Themes identified as drivers of optimal PrEP use were HIV risk perception, mainly because of partner’s behaviors and unknown serostatus, and a strong desire to have a baby free of HIV. Reported disclosure of PrEP use facilitated PrEP adherence. Women discussed having partner and family support, which included reminders to take PrEP daily. Primary barriers were anticipated or experienced stigma, overcome through education of partners and family about PrEP. Pregnant women experienced transient side-effects, but found ways to continue, including taking PrEP at night. PrEP programs for pregnant and postpartum women should integrate strategies to assist women with realistic appraisals of risk and teach skills for disclosure and securing support from significant others.

Predictors of Anticipated PrEP Stigma among Women with Self-Reported Problematic Substance Use: Implications for Engaging Women in the PrEP Care Continuum

Pre-exposure prophylaxis (PrEP) is an effective HIV prevention method, but it has been underutilized by women. Anticipated stigma regarding use of PrEP is a contributing factor in the underutilization of this prevention strategy. The current study explored the relationships among PrEP stigma, sex risk (i.e., inconsistent condom use, condomless sex with persons of unknown serostatus, or sex in exchange for money or drugs), substance use, attitudes toward HIV testing, and medical mistrust. Participants were 106 primarily ethnic-minority women who reported recent substance use and agreed to participate in a study exploring HIV prevention attitudes. Within this sample, the majority of participants had one or more CDC-defined PrEP indications. Findings indicate that medical mistrust was associated with perceived PrEP stereotypes and HIV testing attitudes. These results provide some insight into reasons for low PrEP uptake among women at risk for HIV. Implications for HIV prevention with women are discussed.

A Qualitative Exploration of Women's Interest in Long-Acting Injectable Antiretroviral Therapy Across Six Cities in the Women's Interagency HIV Study: Intersections with Current and Past Injectable Medication and Substance Use

Medications for antiretroviral therapy (ART) and preexposure prophylaxis (PrEP) are currently daily pill regimens, which pose barriers to long-term adherence. Long-acting injectable (LAI) modalities have been developed for ART and PrEP, but minimal LAI-focused research has occurred among women. Thus, little is known about how women's history of injection for medical or nonmedical purposes may influence their interest in LAI. We conducted 89 in-depth interviews at 6 sites (New York, NY; Chicago, IL; San Francisco, CA; Atlanta, GA; Chapel Hill, NC; Washington, DC) of the Women's Interagency HIV study. Interviews occurred with women living with HIV (n = 59) and HIV-negative women (n = 30) from November 2017 to October 2018. Interviews were recorded, transcribed, and analyzed using thematic content analysis. Women's prior experiences with injections occurred primarily through substance use, physical comorbidities, birth control, or flu vaccines. Four primary categories of women emerged; those who (1) received episodic injections and had few LAI-related concerns; (2) required frequent injections and would refuse additional injections; (3) had a history of injection drug use, of whom some feared LAI might trigger a recurrence, while others had few LAI-related concerns; and (4) were currently injecting drugs and had few LAI-related concerns. Most women with a history of injectable medication would prefer LAI, but those with other frequent injections and history of injection drug use might not. Future research needs to address injection-related concerns, and develop patient-centered approaches to help providers best identify which women could benefit from LAI use.