Societal Hurdles Threaten Progress in Long-Acting HIV Prevention and Treatment

Recent years have seen rapid advances in the development of long-acting effective methods to prevent and treat HIV, notably long-acting injectable antiretroviral therapy (LAI ART) and long-acting injectable preexposure prophylaxis (LAI PrEP). Yet while these formulations have huge potential, their global availability and access is inhibited by factors including lack of funding from international organizations, unequal insurance coverage, patent protections that keep costs high, and social inequities. The article by researchers at Columbia University and the University of Toronto appears in the journal Current Opinion in HIV and AIDS.

As of February 2022, LA ART administered every two months is approved in the United States, Canada, and Europe. The U.S. also approved LAI PrEP in December 2021. Both are as effective as existing daily oral pills but with a convenience that has the potential to significantly improve uptake. The World Health Organization has recommended the monthly vaginal PrEP ring, which may alleviate adherence barriers that exist for oral PrEP—and the frequency of clinic visits for LAI PrEP—but is much less effective than both. Approximately 30 long-acting ART and PrEP formulations are now in clinical trials, including monthly oral pills; vaginal and rectal gels; vaginal rings, films, and inserts; intramuscular and subcutaneous injections; implants; enemas; and micro-array patches.

“The development of long-acting ART and PrEP have provided renewed hope that ending the HIV epidemic is within reach. However, pervasive socio-structural inequities highlight the need for cautious optimism,” says study co-author Morgan Philbin, PhD, assistant professor of sociomedical sciences at Columbia University Mailman School of Public Health.

However, LA ART could exacerbate existing social inequities in care access because it is only available to virologically suppressed individuals; viral suppression is lower among minoritized populations, including by race and ethnicity, sexuality, gender, and socioeconomic status. Additionally, insurance coverage for long-acting ART and long-acting PrEP is lacking in the U.S., with many states’ AIDS Drug Assistance Programs (ADAP) not covering LAI ART; insurance coverage for LAI PrEP remains unknown. In addition, people in the Global South who participated in the research trials that demonstrated their efficacy may not have equitable access once they are approved—LAI ART is only currently approved in the U.S., Canada, and Europe.

“Tackling the social and political dimensions that limit equitable access requires political struggle, social movements, and global accountability. In order for long-acting HIV formulations to truly fulfill their promise of ‘ending the HIV epidemic’, equity in availability, access and uptake must be addressed on a global scale,” says Philbin.

Earlier research by Philbin and colleagues examined attitudes toward long-acting injectable HIV therapy among women with a history in injection, and among women more broadly. She has also uncovered geographic disparities in HIV care.   

The study’s co-author is Amaya Perez-Brumer, PhD ‘19, assistant professor at the Dalla Lana School of Public Health, University of Toronto.

The journal article was supported in part by grants from the U.S. National Institute on Drug Abuse (DA039804A) and National Institute of Mental Health (MH124552); and the Canadian Institute of Health.