- U.S. researchers surveyed a national sample of gbMSM about their PrEP preferences
- The researchers reached more than 2,500 sexually active men via the Internet
- 75% preferred to use long-acting PrEP vs. daily oral PrEP or no PrEP
Oral HIV pre-exposure prophylaxis (PrEP) consists of two drugs (tenofovir + FTC) sold as Descovy and Truvada. The latter is also available in generic formulations. In clinical trials, daily oral PrEP has proven to be highly effective when used as directed, reducing the risk of HIV by more than 99%. Oral PrEP needs to be initiated in advance of sexual activity. Some people may not be able to accurately predict their sexual activity and may also have difficulty taking pills.
A new long-acting injectable HIV prevention option will shortly become available in Canada. This formulation uses the drug cabotegravir, which is injected deep into the buttocks, ultimately every two months. In clinical trials, long-acting injectable PrEP has been found to be highly effective and even statistically superior to daily oral PrEP. This statistical superiority likely arises because most people who took injectable PrEP had fewer adherence problems than people who relied on daily oral PrEP.
In addition to long-acting cabotegravir (LA cab), other long-acting formulations of drugs are being developed for use as PrEP. One such drug is lenacapavir (Sunlenca). This drug is injected every six months. Thus, it is likely that in the future long-acting PrEP will become an important option for many people wanting to reduce their risk for HIV infection.
Researchers at several universities in the U.S. cooperated and developed a questionnaire for men who were taking part in the 2020 American Men’s Internet Survey (AMIS). The men were all gay, bisexual and other men who have sex with men (gbMSM). A subgroup of these men—2,506 who disclosed that they did not have HIV and who had oral or anal sex with a man in the past 12 months—was chosen to participate in questions about PrEP. The researchers stated that their survey took less than 12 minutes to complete.
At the time the survey was initiated, long-acting injectable PrEP was not yet available in the U.S.
A brief average profile of participants who completed the survey was as follows:
- age distribution: 15 to 39 years – 78%; 40 and older – 22%
- main ethno-racial groups: White – 78%; Black – 10%; Asian – 3%
- access to private insurance coverage – 69%
- 72% of men reported having condomless intercourse with men in the past 12 months
- 83% reported never having used oral PrEP
Key findings
Most of the men (2,074, or 83%) disclosed that they had never used oral PrEP. However, 53% of these men (1,332) said that they would be willing to use it.
As mentioned, at the time the survey was initiated, long-acting injectable PrEP was not yet approved in the U.S. However, 60% of the men (1,500) said that they would be willing to use it.
When participants were asked what they would choose if they were offered long-acting injectable PrEP or daily oral PrEP or no PrEP, their responses were as follows:
- long-acting PrEP – 74%
- daily oral PrEP – 15%
- no PrEP – most of the remaining men
Those less likely to choose long-acting injectable PrEP included men with the following characteristics:
- Black, Indigenous or people of colour
- without private insurance
- never used daily oral PrEP
- had only one male sexual partner
Those who preferred long-acting PrEP included men with the following characteristics:
- aged 40 or younger
- college educated
- had used oral PrEP in the past
- had two or more sexual partners
Time
Taking PrEP involves regular checkups, including screening for HIV and other sexually transmitted infections (STIs). These necessitate visits to clinics and, in some cases, laboratories, which takes time. When the researchers asked people how much time they felt comfortable spending on PrEP-related medical visits (including HIV testing, travelling to appointments and waiting), participants were willing to spend up to two hours. They felt that three hours was too long.
Disinterest in long-acting PrEP
The researchers speculated that some of the reasons that men were not interested in PrEP included the following:
- they perceived themselves at no or low risk for HIV
- they consistently used condoms
- they lacked private insurance
Note that in the U.S. the list price of long-acting injectable PrEP is at least $22,000 per year.
Areas for future study
In the U.S., racialized gbMSM bear a disproportionate burden of HIV. The researchers stated that PrEP programs “should seek to identify and overcome barriers racialized minority gbMSM face […].” They encouraged other research teams to develop and initiate studies to explore issues and potential barriers to accessing long-acting PrEP by minority groups, including transgender people. Such studies will become important as long-acting PrEP is rolled out in the years ahead.
Another area that the researchers recommended for study is the implementation of long-acting PrEP by clinics and health systems. Long-acting PrEP requires injections administered by healthcare providers. Some clinics may not have the staff to do this, which would be a barrier to its use. The researchers also encouraged health systems to find subsidies for long-acting PrEP, as otherwise the cost will be formidable for most potential users.
Although long-acting PrEP does away with the need for daily oral doses, it still requires adherence to regular lab, clinic and injection visits. Studies need to be done to assess adherence with these issues.
The present study was done in the U.S., yet it is likely that the rollout of long-acting PrEP in Canada will need to be monitored and fine-tuned. Some clinics may need assistance with staffing if they have many users of long-acting injectable PrEP.
—Sean R. Hosein
REFERENCE:
Cole SW, Glick JL, Campoamor NB, et al. Willingness and preferences for long-acting injectable PrEP among US men who have sex with men: a discrete choice experiment. BMJ Open. 2024 Apr 22;14(4):e083837.