A clinician, advocate, and payer provide their expert knowledge on the multiple modalities of PrEP therapy and how some can be more beneficial than others.
Frank J. Palella Jr, MD: In thinking about the multiple modalities that are available for PrEP, this gives us opportunities to customize therapy even more. There are persons for whom intermittent PrEP might be appropriate, and certainly, for some people, daily oral pill-taking might be the right thing. However, the bar has been clearly raised by the availability of injectable PrEP, as evidenced from the data of HPTN 083 and 084, and I think it's set a new standard for diverse types of patients, for MGM [transgender men] and cisgender men, for cisgender women, for people of color, for transgender women in 083. It is wonderful that we have different types of PrEP to offer patients, but in terms of effectiveness, tolerability, and adherence, the new option demonstrated by injectable PrEP with cabotegravir, with Apretude, has set a new standard.
Challenges associated with needing to take daily oral pills, tablets, capsules for PrEP is about adherence. Oftentimes, the people that we target most for use or initiation and use of PrEP and retention and care with PrEP are people who don't have a need to take other pills for other conditions, meaning that they have no other comorbidities. The presence of their risk for HIV 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 life risk, these constitute a set of challenges for daily oral pill-taking that make it challenging for many people to consistently adhere and to be more selective about when and how they use daily oral PrEP. A lot has been written and studied, but it's hard to take pills every day, and I think it's harder yet if you have maybe other social challenges like stigma, the need for privacy, non-disclosure of lifestyle, housing insecurity, other insecurities, psychiatric or drug use issues. All of those make reliance upon the patient to take oral daily pills more precarious as opposed to being able to directly observe and administer within a health care delivery setting in every 2-month intermuscular injection.
Carl Schmid: It's important to have different types of PrEP. Up until now, it's been a daily pill, which may be sufficient for some people, but people may not want to take a pill for a disease that they don't have. People may forget taking a pill every day. They may not adhere to the prescribed course. It is important to have long-acting medications, and people don't have to think about taking a drug every day. It could help with adherence, and the studies show that it's superior. What is it all about? What is the purpose of PrEP to prevent HIV? These FDA studies show that the long-acting [PrEP] is superior. There are fewer infections. It’s important to have it, to have the one that's been approved right now, but I'm looking forward to future long-acting drugs as well.
The people who I think could really take advantage of long-acting [PrEP] are people that are healthy, have access to health care, have health insurance, have access to good medical care, can go to a clinic. It may be better for them. That's one set of people. It's a preferred option for them. Instead of taking a drug every day, it fits into their lifestyle better. There are other people that long-acting [PrEP] could be beneficial for that we're not hitting right now. People may not want to alert their partners that they're taking PrEP. When you have pills at home every single day—I could see this, particularly for women—
they may not want to make their partner aware that they're taking efforts to protect themselves from HIV. It's a privacy issue that they may want to go and take a long-acting. I could also see it for people who have a lot of other things going on in their lives—kids running around, getting to the job(s) and back, dealing with substance use issues, homelessness. There's just too many things going on in our lives as disruptions, and they may not be remembering to take their drug every single day. If they have access to a clinic to go to, and make sure they do the periodic testing and lab test as well, I think it's a good option for them. It's new. There's an appetite with all different types of people, depending on their lifestyle, the coverage that they have, and access to medical care and things that are happening in their lives. I think long-acting could be an important new tool for many people.
Lynne Milgram, MD, MBA, CPE: I think about this as, who wants to take a pill every day? Maybe women who are taking birth control pills want to take a pill every day, but not the majority of people. Our most vulnerable, 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's 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 have other see that they have pills lying around. There's a large group of the population who needs prophylaxis, who's not going to take it because there's a real pill burden and a stigma associated with it. Many of these patients are young, invincible patients, and they honestly don't believe they need prophylaxis. If they do, they certainly don't want to take a pill every day. The more I think about it, there's a large population out there that everyday pills do not work for.
Transcript edited for clarity.