Florent Jouinot, Swiss AIDS Federation

The ‘options’ are the totality of existing and available methods, in particular biomedical methods, but also the various ways of accessing them, as well as the conditions under which this is possible. The various methods must, of course, be as safe and effective as possible, but also as numerous and diverse as possible. Combinations with other tools should be encouraged (e.g. HIV PrEP and contraception or prevention of bacterial STIs). Barriers to access should be minimised (distance, duration, deadlines, costs, etc.).

The term ‘choice’ refers to an individual's ability to select the option or options that best suit them from among the possible options. This means that governments, legislators and implementing providers must ensure that as many options as possible are available and that they are accessible to as many people as possible who could benefit from them.

Multiplying the drug options

Today, there are several ways for people not living with HIV to use antiretroviral drugs to protect themselves from the virus. These include tablets taken orally (e.g. TDF/FTC or TAF/FTC), either continuously (year-round or at certain periods) or intermittently (2+1+1). Several of these options are already available in an increasing number of countries, others will be available soon, and still others are in the development or evaluation phase.

While it took many years from the first HIV-PrEP trials to making it available to the population worldwide, the processes have been greatly accelerated so that new tools can be added more quickly once their safety and efficacy have been scientifically confirmed.

For example, the results of the Purpose programme on the efficacy of lenacapavir (LEN) in HIV PrEP (1 SC injection every 6 months) are expected to lead to the first marketing approvals and inclusion in international and national guidelines from 2025. After the results for cisgender women (purpose 1 - 100% efficacy), which were presented at the IAS scientific conference in Munich in July, the results for cisgender men who have sex with men and for trans and non-binary people (purpose 2) were presented at the HIV 4P conference in Lima, and they are impressive: 96% reduction in the number of people who found out that they were living with HIV compared to the expected incidence without intervention, and 89% reduction compared to the group taking oral HIV PrEP. As a reminder, the effectiveness of oral HIV PrEP was around 85-90% in the various studies.

The higher efficacy seems to be due to the fact that it is easier for those affected to inject themselves every 2-6 months than to take tablets daily in the days before and after sexual intercourse. Apart from the fact that it can be forgotten to take it, it is also no longer necessary to have the drug at home or even on one's person, especially for people who cannot openly express their sexuality.

In the studies on the introduction of cabotegravir (CAB-LAI), HIV PrEP, which is injected intramuscularly every two months, was widely preferred, especially among groups that are particularly exposed to HIV (intersectionality), such as financially disadvantaged, young, transsexual, racialised, sex-working individuals and/or individuals who use psychoactive substances, including in a sexual context. Long-acting HIV PrEP has not only significantly increased the rate of HIV PrEP initiations, but has also helped to ensure that more people remain in HIV PrEP for longer, particularly in these groups. For cisgender women, combination in a single delivery device (e.g. vaginal ring, implant) appears to be another important lever for increasing the rate of HIV PrEP initiation and, above all, continuation of HIV PrEP.

Diversify services and make them accessible

In addition to product options, other parameters also play a role in the uptake and continuation of HIV PrEP.

These include, for example, the type and location of PrEP centres. In several countries, HIV PrEP has been incorporated into the services offered by public HIV hospitals, often for practical reasons. However, members of the most at-risk populations do not want to go to a state department and/or HIV centre for (often justified) fear of stigmatisation and discrimination by the staff of these institutions, but also by their environment. As a result, they want to be able to start and monitor their HIV PrEP in centres close to home, preferably in sexual health clinics where they are already receiving treatment or would go for contraceptive and family planning advice or check-ups. Trans people prefer facilities where they are treated for their gender, and people who use drugs prefer to go to facilities that deal with reducing the risks associated with substances. Others often do not want to or cannot go to a health centre and prefer HIV-PrEP to be offered as part of mobile (e.g. health bus) and/or community-based (e.g. mobile teams working in social spaces) services.

Ideally, all types of centre would offer all available options. This then raises the question of the conditions for access. In the studies, a series of visits and laboratory tests were necessary to assess the safety and efficacy of a new option. Once these have been established, is it still necessary to maintain the same frequency of visits and the same list of tests? One of the biggest concerns is that a person living with HIV initiates or continues PrEP and the virus develops resistance to the molecule(s) used. To enable the introduction of HIV PrEP, various strategies have been explored, in particular de-medicalisation. In some settings, HIV PrEP has already been dispensed (oral) or administered (injected) on the first visit after a rapid test, including a peer or self-test, has been carried out. The number of missed infections before PrEP is started is extremely low. Furthermore, individuals who found out that they were already living with HIV before starting PrEP were able to take a therapeutic treatment that quickly rendered the virus undetectable in the blood. This means that the protocols must be scrutinised to strike a balance between benefits (access to HIV PrEP for people who would not otherwise take it) and actual risks (delay in discovering that a person is living with HIV).

Reducing the medical requirements for access to HIV PrEP also makes it possible to diversify the modalities of delivery, in particular by working with pharmacies, community organisations or other partners that are geographically and culturally close to the target groups, as well as through vending machines placed in public areas (e.g. train or bus stations) or in the community.

More broadly, implementation studies have addressed the preferences of the individuals to be reached in terms of options and conditions, which vary greatly from region to region and from population group to population group. Such studies are therefore still needed to ensure that the options and offers are (always) appropriate. However, they are now also called upon to research the factors that influence actual accessibility and to ask about more structural challenges.