The Long-Acting Cabotegravir Tail as an Implementation Challenge: Planning for Safe Discontinuation

Baseline variables associated with subsequent HIV seroconversion among gay, bisexual and other men who have sex with men and transgender women: a prospective, multicenter PrEP demonstration study (ImPrEP)

Background

Ongoing implementation of HIV pre-exposure prophylaxis (PrEP) in Latin America should consider lessons learned from implementation projects such as ImPrEP (Brazil/Mexico/Peru, 2018-2021). In this analysis we assessed the effect of variables ascertained in early appointments on HIV seroconversion among ImPrEP participants.

Methods

ImPrEP enrolled HIV-negative men who have sex with men and transgender women (MSM/TGW) aged 18+ years reporting recent condomless anal sex, anal sex with HIV-positive partners, transactional sex, or sexually transmitted infections (STI). Participants received a 30-day PrEP supply; at the 30-day visit and quarterly thereafter they completed behavioural assessments, underwent HIV testing, and received 3-month PrEP supplies if HIV-negative. PrEP adherence was measured using the medication possession ratio (MPR) at the 30-day visit. We used Cox's proportional hazards regression to examine the effect of our sociodemographic, behavioural, STI, and early PrEP care engagement variables of interest on time to HIV seroconversion.

Findings

Compared to participants in Brazil, the hazard ratio for HIV seroconversion was higher among those in Peru (HR = 7.91, 95% CI: 4.74-13.20). Compared to participants aged ≥35 years, the HR for HIV seroconversion was higher for those aged 18-24 (aHR = 4.84, 95% CI: 2.55-9.17 and 25-34 (aHR = 2.43, 95% CI: 1.21-4.91). HIV seroconversion was also associated with transgender identity (aHR = 2.28, 95% CI: 1.12-4.66), transactional sex (aHR = 1.88, 95% CI: 1.18-2.99), receptive condomless anal sex (aHR = 2.42, 95% CI: 1.42-4.12), STI diagnosis (aHR = 1.93, 95% CI: 1.25-2.99), and a MPR < 0.6 (aHR = 2.64, 95% CI: 1.52-4.60).

Interpretation

While moderate-high, HIV incidence among ImPrEP participants represented a considerable reduction from figures observed among MSM/TGW not using PrEP/PEP. Interventions to improve PrEP adherence are needed among new Latin American PrEP users, especially if baseline factors associated with seroconversion are present. Long-acting injectable PrEP can also become useful for this population.

Funding

This study was funded by UNITAID.

Preference for Long-Acting Injectable PrEP Compared With Daily Oral PrEP Among Transgender Women in the U.S.: Findings From a Multisite Cohort

Introduction

Pre-exposure prophylaxis (PrEP) use among transgender women in the U.S. has not reached levels optimal to change the trajectory of the HIV epidemic owing to multilevel barriers. Long-acting injectable PrEP received Food and Drug Administration approval in 2021 and may potentially address some of the barriers experienced in initiating and adhering to daily oral PrEP (e.g., pill fatigue, medication storage). However, preferences for long-acting injectable PrEP compared with daily oral PrEP have not been well studied among transgender women.

Methods

The authors analyzed data collected from transgender women not living with HIV in eastern and southern U.S. in 2020-2022. Using multivariable Poisson regression with robust standard errors, the authors estimated prevalence ratios and 95% CIs for factors associated with preference for long-acting injectable PrEP.

Results

The study sample (N=789) was racially and ethnically diverse, with 42.6% identifying as Black, Latina, and/or multiracial and 12% using daily oral PrEP. Fifty-eight percent preferred long-acting injectable PrEP to daily oral PrEP. In multivariable regression analyses, preference for long-acting injectable PrEP was associated with residence in Midwest (reference group=Northeast, adjusted prevalence ratio=1.33; 95% CI=1.10, 1.60), current PrEP indications (adjusted prevalence ratio=1.14; 95% CI=1.01, 1.30), and history of gender-affirming hormone injection (adjusted prevalence ratio=1.36; 95% CI=1.18, 1.57).

Conclusions

Transgender women may prefer long-acting injectable PrEP to daily oral PrEP, especially those with current PrEP indications and experience with gender-affirming hormone injections. Increasing availability and access to long-acting injectable PrEP may improve PrEP uptake in transgender women, particularly in combination with other interventions to reduce multilevel PrEP barriers.

HIV Prevention in Syringe Service Programs Since the Start of COVID-19: Where Do We Go From Here?

PURPOSE

This narrative review addresses post-2020, specific, complex challenges for use of and adherence to pre-exposure prophylaxis (PrEP) for HIV prevention among out-of-treatment people who use drugs (PWUD) at syringe services programs (SSPs).

RECENT FINDINGS

The COVID-19 pandemic and its associated changes to the provision of healthcare have significantly impacted HIV prevention, especially for PWUD. Through a synthesis of literature and clinical experience, we (1) characterize the operational changes imposed by the pandemic on SSPs that shaped the current HIV prevention landscape; (2) describe three levels of current challenges for PWUD, including consumer attitudes, non-medical and medical provider attitudes, and structural and scalability barriers; (3) characterize current models for PrEP in SSPs; and (4) offer practical recommendations for HIV prevention in harm reduction programs. PrEP is a highly effective prevention tool if taken as prescribed. It has been enthusiastically promoted by members of the research, public health and provider communities. Despite its efficacy, PWUD struggle to engage with the PrEP care continuum. We highlight opportunities to advance HIV prevention for PWUD by enhancing tailored, whole-person approaches that may set aside PrEP in favor of other risk reduction routes. For most PWUD who receive services at SSPs, PrEP is a single tool and not realistic until other social and structural determinants of health are addressed.

Brief Report: Stated Preferences for Long-Acting Injectable ART Among Mobile Men Living With HIV in Malawi: A Qualitative Study

BACKGROUND

Long-acting injectable (LAI) antiretroviral medications are as effective as daily oral antiretroviral therapy (ART) and offer discreet, less frequent dosing. LAIs may be ideal treatment options for people who experience challenges with adherence to daily oral ART, including mobile men living with HIV (MLHIV).

METHODS

We conducted a qualitative substudy within two parent trials in 24 health facilities in Malawi that enrolled MLHIV ≥15 years not on ART. We conducted in-depth interviews with a stratified random sample of participants who had taken oral ART and self-reported mobility (travel) during the 6-month study (≥1 trip of ≥3 nights). Interviews described cabotegravir/rilpivirine and asked about clients' stated preferences for LAI vs. oral ART and their reasoning. Interviews were translated, transcribed, coded in Atlas.ti, and analyzed using framework analysis.

RESULTS

We interviewed 29 mobile MLHIV from July 1, 2022, to August 30, 2022, median age 36 years (interquartile range: 31-41), mean 28 nights away in the past 6 months (SD: 40). Nearly all participants (26/29) expressed a preference for LAI over daily oral ART because LAI would reduce the risks of forgetting to take pills and unwanted disclosure. Three men preferred oral ART primarily because of fear of side effects from a new medication. A few men reported they would change their preference if injection site reactions prevented them from working.

CONCLUSIONS

Mobile MLHIV in Malawi with previous ART adherence challenges expressed strong stated preferences for LAI over daily oral ART. Further research is needed to understand implementation challenges and potential effectiveness of LAI among harder-to-reach populations.

HIV Pre-Exposure Prophylaxis

Pre-exposure prophylaxis (PrEP) of human immunodeficiency virus (HIV) represents the most significant breakthrough in the HIV prevention field over the past decade. PrEP is an effective strategy in preventing the transmission of HIV across all populations, providing high adherence. The current PrEP options include oral daily and on-demand tenofovir-based regimens, long-acting injections of cabotegravir, and a 1-month dapivirine vaginal ring. As a component of a multifaceted prevention approach, extensive deployment of PrEP holds the promise to significantly reduce the global HIV epidemic. Nonetheless, barriers still exist in terms of uptake, adherence, and persistence, while disparities in PrEP accessibility remain a concern.

N-Substituted Bicyclic Carbamoyl Pyridones: Integrase Strand Transfer Inhibitors that Potently Inhibit Drug-Resistant HIV-1 Integrase Mutants

HIV-1 integrase (IN) is an important molecular target for the development of anti-AIDS drugs. A recently FDA-approved second-generation integrase strand transfer inhibitor (INSTI) cabotegravir (CAB, 2021) is being marketed for use in long-duration antiviral formulations. However, missed doses during extended therapy can potentially result in persistent low levels of CAB that could select for resistant mutant forms of IN, leading to virological failure. We report a series of N-substituted bicyclic carbamoyl pyridones (BiCAPs) that are simplified analogs of CAB. Several of these potently inhibit wild-type HIV-1 in single-round infection assays in cultured cells and retain high inhibitory potencies against a panel of viral constructs carrying resistant mutant forms of IN. Our lead compound, 7c, proved to be more potent than CAB against the therapeutically important resistant double mutants E138K/Q148K (>12-fold relative to CAB) and G140S/Q148R (>36-fold relative to CAB). A significant number of the BiCAPs also potently inhibit the drug-resistant IN mutant R263K, which has proven to be problematic for the FDA-approved second-generation INSTIs.

Implementation and resource needs for long-acting PrEP in low- and middle-income countries: a scoping review

INTRODUCTION

Several low- and middle-income countries (LMICs) are preparing to introduce long-acting pre-exposure prophylaxis (LAP). Amid multiple pre-exposure prophylaxis (PrEP) options and constrained funding, decision-makers could benefit from systematic implementation planning and aligned costs. We reviewed national costed implementation plans (CIPs) to describe relevant implementation inputs and activities (domains) for informing the costed rollout of LAP. We assessed how primary costing evidence aligned with those domains.

METHODS

We conducted a rapid review of CIPs for oral PrEP and family planning (FP) to develop a consensus of implementation domains, and a scoping review across nine electronic databases for publications on PrEP costing in LMICs between January 2010 and June 2022. We extracted cost data and assessed alignment with the implementation domains and the Global Health Costing Consortium principles.

RESULTS

We identified 15 implementation domains from four national PrEP plans and FP-CIP template; only six were in all sources. We included 66 full-text manuscripts, 10 reported LAP, 13 (20%) were primary cost studies-representing seven countries, and none of the 13 included LAP. The 13 primary cost studies included PrEP commodities (n = 12), human resources (n = 11), indirect costs (n = 11), other commodities (n = 10), demand creation (n = 9) and counselling (n = 9). Few studies costed integration into non-HIV services (n = 5), above site costs (n = 3), supply chains and logistics (n = 3) or policy and planning (n = 2), and none included the costs of target setting, health information system adaptations or implementation research. Cost units and outcomes were variable (e.g. average per person-year).

DISCUSSION

LAP planning will require updating HIV prevention policies, technical assistance for logistical and clinical support, expanding beyond HIV platforms, setting PrEP achievement targets overall and disaggregated by method, extensive supply chain and logistics planning and support, as well as updating health information systems to monitor multiple PrEP methods with different visit schedules. The 15 implementation domains were variable in reviewed studies. PrEP primary cost and budget data are necessary for new product introduction and should match implementation plans with financing.

CONCLUSIONS

As PrEP services expand to include LAP, decision-makers need a framework, tools and a process to support countries in planning the systematic rollout and costing for LAP.