Combating HIV with New PrEP Options: What Healthcare Professionals Need to Know

The recent rise in HIV rates across various regions, including Boston, has raised alarms among healthcare professionals and public health authorities. Despite decades of progress in HIV prevention and treatment, outbreaks continue to emerge, underscoring the need for more effective prevention strategies. Pre-exposure prophylaxis (PrEP) has been a game-changer in the fight against HIV, but newer forms of PrEP are being developed and introduced, offering hope for even more effective prevention. This article explores the current landscape of HIV prevention, the reasons behind rising HIV rates, and the potential impact of new forms of PrEP on curbing the epidemic.

Current HIV Prevention Strategies: A Brief Overview
PrEP, which involves the use of antiretroviral drugs by HIV-negative individuals to prevent infection, has been one of the most effective tools in reducing HIV transmission rates. The most widely used PrEP regimen involves a daily oral pill containing tenofovir disoproxil fumarate and emtricitabine (TDF/FTC), marketed as Truvada. Another formulation, Descovy (tenofovir alafenamide/emtricitabine), has also been approved for use among certain populations.

While oral PrEP has proven to be highly effective when taken consistently, adherence remains a significant challenge. Some individuals may find it difficult to take a daily pill due to factors such as stigma, inconvenience, side effects, or personal preferences. This has prompted researchers and healthcare providers to explore alternative PrEP options that could offer greater flexibility and cater to diverse needs.

Rising HIV Rates: A Concerning Trend
Despite the availability of effective PrEP regimens, HIV rates have been rising in certain areas, such as Boston. According to a report from The Boston Globe (https://www.bostonglobe.com/2021/04/20/metro/health-officials-struggle-contain-boston-hiv-outbreak/), health officials have been struggling to contain a recent HIV outbreak. The outbreak has been particularly concentrated among people who inject drugs (PWID), homeless populations, and other vulnerable groups.

Several factors contribute to these rising rates:

1. Inconsistent Use of PrEP: Many individuals at risk of HIV do not use PrEP consistently or discontinue its use due to various barriers, including access issues, cost, stigma, or side effects.
   
   
2. Lack of Awareness and Access: Despite efforts to promote PrEP, there is still a lack of awareness about its benefits, especially among marginalized communities. Additionally, access to PrEP may be limited in some areas due to healthcare infrastructure or cost barriers.
   
   
3. Stigma and Discrimination: Stigmatization associated with HIV and high-risk behaviors can deter individuals from seeking prevention services or adhering to PrEP.
   
   
4. Sociocultural Factors: Complex social determinants, such as homelessness, drug use, mental health issues, and socioeconomic disparities, play a significant role in driving HIV transmission in vulnerable populations.
   

New Forms of PrEP: Innovations on the Horizon
Recognizing the need for diverse and more user-friendly PrEP options, researchers have been developing new formulations that could potentially enhance adherence and effectiveness. Two notable innovations in PrEP include the Dapivirine Vaginal Ring and Long-Acting Injectable Cabotegravir.

1. Dapivirine Vaginal Ring
The World Health Organization (WHO) has recently recommended the Dapivirine vaginal ring as a new HIV prevention choice for women at substantial risk of HIV infection (https://www.who.int/news/item/26-01...or-women-at-substantial-risk-of-hiv-infection). This flexible, silicone ring releases the antiretroviral drug dapivirine slowly over a period of one month. The ring is designed to be inserted into the vagina and provides a discreet, self-administered form of protection against HIV.

Key Benefits:

• Increased Discretion: The ring is a female-controlled method that can be used discreetly, without the need for daily dosing.
• User Preference: Many women have reported preferring the ring over daily oral pills due to its ease of use and reduced burden of daily adherence.
• Potential to Reach New Populations: The vaginal ring could be particularly useful in settings where women face gender-based violence or power imbalances that limit their ability to negotiate condom use or adherence to daily PrEP.

Challenges:

• Efficacy Variation: While the dapivirine ring reduces the risk of HIV infection by about 30-40%, this efficacy is lower than that of daily oral PrEP, which can reach up to 99% with consistent use.
• Accessibility and Cost: Ensuring widespread access and affordability of the dapivirine ring remains a challenge, particularly in low-resource settings.

2. Long-Acting Injectable Cabotegravir
Another promising development in the field of PrEP is the long-acting injectable form of cabotegravir (CAB-LA). Unlike oral PrEP, which requires daily dosing, CAB-LA involves an intramuscular injection every two months, providing an extended duration of protection. Studies have demonstrated that injectable cabotegravir is highly effective in preventing HIV, with some trials showing it to be more effective than oral PrEP.

Key Benefits:

• High Efficacy: The HPTN 083 and HPTN 084 trials have shown that CAB-LA is more effective than daily oral PrEP in preventing HIV acquisition among men who have sex with men (MSM), transgender women, and cisgender women.
• Reduced Adherence Burden: The bi-monthly injection eliminates the need for daily adherence, which can be a significant barrier for some individuals.
• Greater Acceptability: Many participants in clinical trials reported a preference for long-acting injectable PrEP over daily oral pills due to convenience and privacy.

Challenges:

• Implementation and Access: Scaling up access to CAB-LA involves logistical challenges, such as ensuring adequate supply, training healthcare providers, and developing delivery systems for injectable PrEP.
• Potential for Resistance: As with any antiretroviral-based intervention, there is a risk of developing resistance if the drug levels drop below the protective threshold or if individuals acquire HIV while using injectable PrEP.

The Future of HIV Prevention: Combining Strategies
While new forms of PrEP, such as the dapivirine vaginal ring and long-acting injectable cabotegravir, offer promising alternatives to traditional oral PrEP, it is essential to recognize that no single prevention strategy will be universally effective. Combining different prevention methods tailored to individual needs, preferences, and risk factors is likely to yield the best results in curbing HIV transmission.

Key Considerations for Healthcare Providers:

1. Individualized Risk Assessment: Healthcare providers should conduct thorough risk assessments and consider factors such as gender, sexual behavior, drug use, and adherence capabilities when recommending specific forms of PrEP.
   
   
2. Education and Counseling: Comprehensive education and counseling about the different PrEP options, their benefits, and potential side effects are crucial to ensuring informed decision-making and adherence.
   
   
3. Addressing Structural Barriers: Efforts to make PrEP accessible should also focus on addressing structural barriers, such as healthcare disparities, stigma, discrimination, and socioeconomic inequalities.
   
   
4. Monitoring and Follow-Up: Continuous monitoring of individuals on PrEP is essential to ensure adherence, manage side effects, and prevent potential resistance.
   
   
5. Community Engagement and Advocacy: Engaging communities, especially those most affected by HIV, in the development and implementation of PrEP programs is vital for ensuring acceptance, trust, and effectiveness.
   

Conclusion
As HIV rates continue to rise in certain regions, exploring new forms of PrEP and combining them with existing prevention strategies is critical to controlling the epidemic. Innovations such as the dapivirine vaginal ring and long-acting injectable cabotegravir provide new options for people who may not adhere to daily oral PrEP. However, the success of these new interventions will depend on comprehensive approaches that address individual needs, reduce barriers to access, and promote education and awareness among at-risk populations.