Sunil Solomon, CROI 2023: Unknowns and hurdles surrounding long-acting injectable PrEP for the prevention of HIV

touchINFECTIOUSDISEASES were delighted to speak with Dr Sunil Solomon (The Johns Hopkins University School of Medicine, Baltimore, MD, USA) about the hurdles surrounding the use of long-acting injectable pre-exposure prophylaxis (PrEP) for the prevention of HIV in at-risk populations. Dr Solomon discussed the main barriers to conducting HIV research in at-risk populations, such as people who use drugs, and highlighted the key gaps in our knowledge surrounding the use of long-acting injectables in at-risk populations. 

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 current knowledge surrounding long-acting injectable PrEP for the prevention of HIV

Questions:

1. What potential hurdles and limitations surround the use of long-acting injectable PrEP in at-risk populations? (0:14)
2. What are the main barriers to conducting HIV research in at-risk populations, such as people who use drugs? (1:32)
3. What are the key gaps in knowledge surrounding the use of long-acting injectables in at-risk populations? (2:28)

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 potential hurdles and limitations surround the use of long-acting injectable PrEP in at-risk populations? (0:14)

I want to address this question from two different angles. One, I think, is the actual understanding of the optimal delivery mechanisms, because in HIV, they’re moving more and more towards person-centered care and differential service delivery models and multimodal dispensation, kind of minimize the interaction between the person and the provider. Well, this is in all of these trials that had participants come in to a clinic or research site for an injection. So it really is going to come around. What is the optimal delivery mechanism? Could we do this remotely through telehealth? Could we do this through field-based, home-based injections? Could we use mobile units to deliver? So I think that really is a big challenge from like how do we actually get this to the population that are needed? And I think the bigger question is, at what cost? Look, I think there are some steps and some things in place to try and reduce the cost. But again, as I mentioned, that if people are adhering to that oral medication, that really isn’t that much of a difference in terms of really figuring out what is that price point where there would be a significant return on investment from a government standpoint or from a stakeholder standpoint. That is going to be something else that’s going to be very critical to tease out as we go forward.

What are the main barriers to conducting HIV research in at-risk populations, such as people who use drugs? (1:32)

I believe the strongest and the biggest barrier to conducting research among people who use drugs or people who inject drugs, is this preformed notion that this group is going to be lost to follow up, they’re not going to be adherent, and so we really can’t do efficacy or phase III trials in them, which is sort of counterintuitive to a population that would benefit most from such long acting injectables – populations such as MSM who use drugs or people who inject drugs, especially now with polydrug use, that’s very common. Because these populations really have a challenge adhering to oral regimens. So it really does come down to the scientific community and the political commitment and the funders to recognize that if you really want to achieve HIV, AIDS epidemic control, it’s essential that we include all populations in these trials going forward, including people who inject or use drugs.

What are the key gaps in knowledge surrounding the use of long-acting injectables in at-risk populations? (2:28)

So in addition to what I already mentioned in terms of the optimal delivery strategy, I think another key question is outside of a trial setting, how acceptable is this going to be to any population? For example, like we know that there are injection site reactions, we know there is a potential that you could still have breakthrough infections when you might be infected with an integrase strand transfer inhibitor resistant form of the virus, which does affect some of your treatment options. And so how acceptable are these different risks to the community, especially the pain of having to come in every two months for an injection and the fact that it isn’t 100% efficacious. So how does that really add up and work out to the community? I think that’s something we really need to understand is like the acceptability in these different communities.

Subtitles and transcript are autogenerated