Understanding the benefits of multiple options for PrEP therapy

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Dr. Frank J. Palella Jr.: Thinking about the multiple modalities that are available for PrEP, this gives us the opportunity to further personalize therapy. There are people for whom intermittent PrEP might be appropriate, and certainly for some people, taking daily oral pills might be the right thing to do. However, the bar has clearly been raised by the availability of injectable PrEP, as evidenced by the data from HPTN 083 and 084, and I think it has set a new standard for various types of patients, for MGM [transgender men] and cisgender men, for cisgender women, for people of color, for transgender women in 083. It’s wonderful that we have different types of PrEP to offer patients, but in terms of effectiveness, tolerability, and adherence, the proven new option for injectable PrEP with cabotegravir, with Apretude, you have set a new standard.

The challenges associated with the need to take daily PrEP pills, tablets, and oral capsules have to do with adherence. Often the people we target most for use or PrEP initiation and use and PrEP retention and care are people who don’t need to take other pills for other conditions, meaning they don’t have other comorbidities. The presence of their HIV risk is the only medical indication to take pills that they have. Taking pills daily for an anticipated patient of a potential condition, as opposed to a condition that already exists among young people who by nature tend to feel invincible and tend not to associate anything as pleasurable as sexual activity with risk to life, these constitute a set of challenges to daily oral pill-taking that make it difficult for many people to consistently adhere and be more selective about when and how they use daily oral PrEP. There’s been a lot written and studied, but it’s hard to take pills every day, and I think it’s even harder if you have maybe other social challenges like stigma, need for privacy, lifestyle non-disclosure, insecurity of housing, other insecurities, psychiatric or drug use problems. All of these make reliance on the patient taking daily oral pills more precarious than being able to directly observe and administer within a healthcare setting at every 2-month intermuscular injection.

Charles Schmid: It is important to have different types of PrEP. Until now, it’s been a daily pill, which may be enough for some people, but people may not want to take a pill for a disease they don’t have. People may forget to take a pill every day. They may not adhere to the prescribed course. It’s important to have long-acting medications, and people don’t have to think about taking a medication every day. It might help with adherence, and studies show it’s superior. What is all this? What is the purpose of PrEP to prevent HIV? These FDA studies show that the long-acting [PrEP] is higher There are fewer infections. It’s important to have it, to have the one that’s been approved right now, but I’m also looking forward to future long-acting drugs.

People I think could really take advantage of the long-acting [PrEP] they are people who are healthy, they have access to health care, they have health insurance, they have access to good health care, they can go to a clinic. It may be better for them. That is a group of people. It is a preferred option for them. Instead of taking a medicine every day, it fits better into your lifestyle. There are other people who long-acting [PrEP] could be beneficial for that which we are not hitting at the moment. People may not want to alert their partners that they are taking PrEP. When you have pills at home every day, I could see this, particularly for women.

they may not want their partner to know that they are working to protect themselves from HIV. It’s a privacy issue that they may want to go and take prolonged action. You might also see it for people who have a lot of other things going on in their lives: kids running around, commuting to and from work, dealing with substance use issues, homeless people. There are too many things that happen in our lives like interruptions, and they may not remember to take their medicine every day. If they have access to a clinic to go to and make sure they get regular and lab tests as well, I think it’s a good option for them. It’s new. There is an appetite with all different types of people, based on their lifestyle, the coverage they have and access to health care and the things that are going on in their lives. I think long-acting could be an important new tool for many people.

Lynne Milgram, MD, MBA, CPE: I think of this as, who wants to take a pill every day? Women who take birth control pills may want to take a pill every day, but not most people. Our most vulnerable and most at risk population is probably not going to take a pill every day. We need another type of therapy, a long-acting therapy. There is also a stigma associated with this prophylaxis. There shouldn’t be, but there is, and even people don’t want to have their pills lying around or others seeing that they have pills lying around. There is a large group of the population that needs prophylaxis, that is not going to take it because there is a real burden of pills and a stigma associated with it. Many of these patients are young, invincible patients, and they honestly don’t think they need prophylaxis. If they do, they certainly don’t want to take a pill every day. The more I think about it, there is a large population for whom daily pills do not work.

Transcript edited for clarity.

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