Sunil Solomon, CROI 2023: Current knowledge surrounding long-acting injectable PrEP for the prevention of HIV

It was a pleasure to talk with Dr Sunil Solomon (The Johns Hopkins University School of Medicine, Baltimore, MD, USA) about the evidence from clinical trials for the use of long-acting injectables in the prevention of HIV and how long-acting injectable cabotegravir compares to oral pre-exposure prophylaxis (PrEP). Dr Solomon also discussed who is most likely to benefit from long-acting PrEP, and outlined its current guidelines for use.

The presentation, ‘LA PrEP: What We Know and What We Still Need To Know.’ was presented at the Conference on Retroviruses and Opportunistic Infections (CROI) 2023, 19–22 February 2023.

Access an interview with Dr Sunil Solomon on the unknowns and hurdles surrounding long-acting injectable PrEP for the prevention of HIV

Questions:

1. What evidence have we gathered from clinical trials for the use of long-acting injectables in the prevention of HIV? (0:14)
2. Among the interventions for the prevention of HIV, where does long-acting pre-exposure prophylaxis (PrEP) fit in? (1:08)
3. How does the efficacy of long-acting injectable cabotegravir compare with oral PrEP? (2:01)
4. Who is likely to benefit most from long-acting PrEP, what are the current guidelines for use and in whom is it contraindicated? (2:57)

Disclosures: Sunil Solomon has received grants and honoraria from Gilead Sciences and Abbott Laboratories.

Support: Interview and filming supported by Touch Medical Media Ltd. Interview conducted by Atiya Henry.

Filmed as a highlight of CROI 2023.

Transcript:

Hi I’m Sunil Solomon. I’m a professor of medicine and epidemiology in the Division of Infectious Diseases at the Johns Hopkins University school of medicine.

What evidence have we gathered from clinical trials for the use of long-acting injectables in the prevention of HIV? (0:14)

So most of the evidence we have to date on the use of long acting injectables for the prevention of HIV comes from two trials, the HIV prevention Trials Network protocol 083 and protocol 084. Protocol 083 was with among cisgender men and trans women in multiple countries in North America, Africa and South America and two sites in Asia. HPTN 084 was among cisgender women, primarily in sub-Saharan Africa. And what both these trials showed us is compared to oral FTDF after acetonal tenofovir and emtricitabine, long acting cabotegravir reduced the incidence of HIV infections by about 66 to 88%, depending on the population you are looking at.

Among the interventions for the prevention of HIV, where does long-acting pre-exposure prophylaxis (PrEP) fit in? (1:08)

So I think over the past decade, we’ve actually had a lot of new interventions come in to help with HIV prevention. For example, we have two different regimens that can be used for oral prep. We have the dapivirine ring, which is like a women’s centered approach, and now we have long acting injectables. So the question of what works in who is really like a very challenging question and everybody has a choice. And I think the best regimen for a person is something the provider discusses with the person. Just to say that I don’t think one regimen is superior to another, but because one of the predictors of how good an intervention is, is adherence to the intervention. So I think incorporating personal choice, any of these interventions could be extremely efficacious in preventing HIV infection in the right population.

How does the efficacy of long-acting injectable cabotegravir compare with oral PrEP? (2:01)

So in the trials the comparison arm was oral after FTDF, compared to long acting cabotegravir, which was recently approved by the FDA, EMA and multiple other regulatory authorities globally. So what they showed in the trial was that there was a reduction in the number of new HIV infections in the cabotegravir arm compared to the oral prep arm. But actually, if you look at the data very closely, it does come down to adherence to the oral drug or compliance to injection schedule, because if you compare the individuals who are adherent to that oral FTDF and compliant for their injection, there really was not much of a difference in terms of efficacy. So yes, overall in the trial, there was a reduction in incidence, but that was primarily driven by adherence to the oral product or compliance to the long acting injectable.

Who is likely to benefit most from long-acting PrEP, what are the current guidelines for use and in whom is it contraindicated? (2:57)

So in terms of population that might benefit the most from long acting prep is essentially going to be high risk populations who are vulnerable to HIV infection, where adherence to oral medications is probably going to be challenging. For example, perhaps substance using populations, substance using MSM who engage in a lot of chemsex as a group where we’ve seen even among HIV positive persons. So populations such as that are probably the ones who are going to benefit the most from a long acting that essentially ones who are not able to adhere to an oral regimen. As of now, it’s indicated for cisgender men, cisgender women and trans women who are at risk of HIV from sexual acquisition. I think the biggest contraindication is really making sure that the person is not HIV positive at baseline. When you start taking this medication, I think that does get challenging around the period because these are long acting injectables, so you can’t stop. So there is a recommendation suggesting we probably even do an HIV RNA test between injections and before injections. So that really would be the one population in terms of drug-drug interaction that really is pretty minimal. And the one thing that we should be aware of, especially in low and middle income country setting, is the concomitant use of rifampin, which is a common drug in the management of tuberculosis.

Subtitles and transcript are autogenerated