Population‐level impact of expanding PrEP coverage by offering long‐acting injectable PrEP to MSM in three high‐resource settings: a model comparison analysis

Abstract

Introduction: Long-acting injectable cabotegravir (CAB-LA) demonstrated superiority to daily tenofovir disoproxil fumarate/emtricitabine (TDF/FTC) for HIV pre-exposure prophylaxis (PrEP) in the HPTN 083/084 trials. We compared the potential impact of expanding PrEP coverage by offering CAB-LA to men who have sex with men (MSM) in Atlanta (US), Montreal (Canada) and the Netherlands, settings with different HIV epidemics. Methods: Three risk-stratified HIV transmission models were independently parameterized and calibrated to local data. In Atlanta, Montreal and the Netherlands, the models, respectively, estimated mean TDF/FTC coverage starting at 29%, 7% and 4% in 2022, and projected HIV incidence per 100 person-years (PY), respectively, decreasing from 2.06 to 1.62, 0.08 to 0.03 and 0.07 to 0.001 by 2042. Expansion of PrEP coverage was simulated by recruiting new CAB-LA users and by switching different proportions of TDF/FTC users to CAB-LA. Population effectiveness and efficiency of PrEP expansions were evaluated over 20 years in comparison to baseline scenarios with TDF/FTC only. Results: Increasing PrEP coverage by 11 percentage points (pp) from 29% to 40% by 2032 was expected to avert a median 36% of new HIV acquisitions in Atlanta. Substantially larger increases (by 33 or 26 pp) in PrEP coverage (to 40% or 30%) were needed to achieve comparable reductions in Montreal and the Netherlands, respectively. A median 17 additional PYs on PrEP were needed to prevent one acquisition in Atlanta with 40% PrEP coverage, compared to 1000+ in Montreal and 4000+ in the Netherlands. Reaching 50% PrEP coverage by 2032 by recruiting CAB-LA users among PrEP-eligible MSM could avert >45% of new HIV acquisitions in all settings. Achieving targeted coverage 5 years earlier increased the impact by 5-10 pp. In the Atlanta model, PrEP expansions achieving 40% and 50% coverage reduced differences in PrEP access between PrEP-indicated White and Black MSM from 23 to 9 pp and 4 pp, respectively. Conclusions: Achieving high PrEP coverage by offering CAB-LA can impact the HIV epidemic substantially if rolled out without delays. These PrEP expansions may be efficient in settings with high HIV incidence (like Atlanta) but not in settings with low HIV incidence (like Montreal and the Netherlands).

Interest in long-acting injectable PrEP among transgender women in eastern and southern United States

“…1,2 Modeling studies have suggested that among communities with elevated HIV burden, uptake of and adherence to LAI PrEP could expand PrEP utilization, reduce HIV incidence at the community level, and contribute to Ending the HIV Epidemic efforts in the United States (US). [3][4][5] Transgender women-particularly Black and Latina/x transgender women-experience among the highest HIV incidence rates across priority populations within the US HIV epidemic. [6][7][8] Engagement with daily, oral PrEP among transgender women in the United States has been suboptimal, with sociostructural barriers, stigma, and difficulty taking pills associated with lower adherence to a daily, oral regimen.…”

Advancing use of long‐acting and extended delivery HIV prevention and treatment regimens

“…These considerations must also align with a country's HIV epidemiologic profile. Stansfield et al.’s [17] research article highlights how high PrEP coverage with CAB‐LA might substantially reduce HIV in settings that experience high HIV incidence. However, the paper also serves as a reminder that LAED regimens may not be a silver bullet and that careful consideration of the epidemiological context is essential as part of the introduction and scaling of LAED regimens.…”