Having access to long-acting option increased PrEP coverage in Ugandan study
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Key takeaways:
- PrEP coverage increased by around five times when the option of long-acting medication was offered in a Ugandan study.
- At any point during the study, 56% of patients opted for the long-acting version.
DENVER — Giving patients the option of choosing long-acting PrEP resulted in a fivefold increase in coverage and a reduction in HIV incidence during the SEARCH trial in Uganda, researchers reported.
“Last year we presented results from three randomized trials in Kenya and Uganda of this SEARCH dynamic choice HIV prevention package, and we showed that ... it increased biomedical prevention coverage, but this was still not high enough,” Moses R. Kamya, MBChB, MMed, PhD, MPH, professor of medicine at Makerere University, said during a press conference at the Conference on Retroviruses and Opportunistic Infections.
“So, we hypothesized that if we added cabotegravir to our prevention options, we might increase coverage,” Kamya said.
Kamya and colleagues recruited patients from three randomized studies of the SEARCH dynamic choice HIV prevention (DCP) intervention vs. standard of care in antenatal clinics, outpatient departments and the community. Eligible participants had to be older than age 15 years with a reported risk for HIV.
Participants in the standard-of-care arm had access to oral PrEP and post-exposure prophylaxis (PEP) at local Ministry of Health clinics, whereas the SEARCH DCP model included a choice between oral PrEP, PEP or injectable long-acting cabotegravir (CAB-LA), with the ability to switch between or stop products over time based on preference and risk. The primary outcome was coverage time over 48 weeks, and secondary outcomes included coverage during periods of retrospectively self-assessed HIV risk and incident HIV infection.
Overall, they enrolled 984 patients — 487 to receive DCP and 497 to receive standard of care. The study showed that PrEP adherence was higher in the DCP group vs. standard of care (69.7% vs. 13.3%), a difference of 56.4 percentage points (95% CI, 50.8-62.1). The intervention’s effect on coverage during periods of HIV risk was even larger — 76.5% in the DCP group vs. 16.2% in standard of care.
After assessing patient preferences in the DCP group, the researchers found that 56% used CAB-LA at one point, 53% used PrEP and 2% PEP. They noted that 43% of people who opted for the CAB-LA option were not previously using oral PrEP or PEP, “showing benefit of adding the CAB- LA option.”
Additionally, seven patients acquired HIV infection and there was one perinatal transmission in the standard-of-care treatment group during the study (incidence rate = 1.8%), whereas no HIV infections were reported in the DCP group.
“People want product options,” Kamya said. “It is my appeal to all key stakeholders and policymakers that we make person-centered care models and access to cover a priority.”
Perspective
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This study is a randomized trial of SEARCH dynamic choice HIV prevention, including CAB-LA. This is a person-centered dynamic choice HIV Prevention package offering product choice and ability to switch over time. When this study design was done previously by the same group for oral HIV PrEP formulations, it increased HIV prevention coverage by 30% to 40% in Uganda and Kenya. Now this study is including CAB-LA as an option in addition to oral HIV PrEP and HIV PEP.
Person-centered care, structured choice and ability to switch or stop products over time is a really refreshing study design to mirror our goals in real-world care. The intervention was compared with the control, which included standard of care and being referred to Ministry of Health clinics.
The primary outcome was biomedical HIV prevention coverage with oral PrEP, PEP or CAB-LA over 48 weeks. In total, 984 individuals enrolled in the extension study, with 74% being women, thanks to recruitment form antenatal clinics. With respect to the primary outcome of HIV prevention coverage, there was a 56.4 percentage point difference in coverage between the intervention and control arms.
For the secondary outcome, they looked at HIV prevention coverage for individuals with an increased self-reported HIV acquisition likelihood, with the intervention covering 76.4% of individuals compared with 16.2% coverage in the standard-of-care arm.
Overall, 56% of participants used CAB-LA, with 42% of individuals on CAB-LA not using any other prevention products in the prior month.
This emphasizes general interest in CAB-LA as a prevention method compared with oral formulations of PrEP. A total of 28% of participants used at least two different products during this study, with CAB-LA being the most selected choice and used biomedical prevention method.
There were seven seroconversions in the standard-of-care arm compared with zero in the intervention arm. This just goes to show that if CAB-LA is accessible, people want to use it.
Patient-centered care should be the standard of care, as should allowing patient choice to meet people where they are. In the U.S., our choices are are often limited by insurance companies, but if we have options and cost was not an issue, we can certainly increase PrEP coverage and decrease HIV acquisition in the populations that need it the most.
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Kamya MR, et al. Abstract 172. Presented at: Conference on Retroviruses and Opportunistic Infections; March 3-6, 2024; Denver.
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