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This summer, NICE is expected to make its final decision on whether the first long-acting injectable form of PrEP (cabotegravir – or CAB-LA) will be recommended for NHS use in England and Wales. This follows the recent welcome decisions by the Scottish Medicines Consortium to approve CAB-LA for NHS use in Scotland.
The availability of this new form of PrEP – a drug that prevents HIV acquisition – could be a game-changer by offering something that people have never had before for HIV prevention: the choice of long-acting protection. CAB-LA works through providing people with an injection 6 times a year which prevents them acquiring HIV.
PrEP has been available on the NHS since 2017, and is currently only taken as a pill (either daily, or ‘event-based’ when you need it). While it has undoubtedly been hugely significant in offering protection for thousands of people, we know that not everyone who could benefit from PrEP is able to access it, and some people who can access it find it extremely difficult – often for reasons beyond their control – to keep the medication to hand and take it as required.
The development of injectable PrEP could mean that we are on the cusp of a new era in HIV prevention – with more choice, long-term protection, and an opportunity to tackle growing inequalities and drive efforts to end new HIV cases by 2030.
The data is clear: we are falling behind on the 2030 goal, with new HIV diagnoses in the UK rising by 15% in 2023. The populations that are experiencing disproportionately high rates of new transmissions – Black African people and women – are the same people who are disproportionately low in the uptake of PrEP.
Long-acting PrEP: what it offers and why it can make a difference
Oral PrEP has contributed significantly to a decline in new transmissions of HIV, especially among gay and bisexual men. But a daily pill doesn’t work for everyone. For some, it’s inaccessible, impractical, and carries stigma. This includes people experiencing homelessness or unstable housing who don’t have a settled and safe space to live or are constantly moving from place to place, and others who are concerned about their HIV prevention drugs being found (for example, by parents, by housemates, or in a workplace situation). Women can also face violence or abuse if their partner finds their PrEP pills, and the need to take a daily pill can be a barrier to adherence for people who use drugs.
For these groups, and others, long-acting PrEP could be the only viable option they have to be able to avoid acquiring HIV. An injection which lasts for months offers convenience and discretion while eliminating the daily burden of pill-taking, reducing the risk of missed doses.
At the National AIDS Trust, we’ve worked closely with communities, clinicians, and researchers to present the case to NICE and governments: long-acting PrEP could address inequalities and offer a lifeline to people underserved by current HIV prevention methods.
What NICE, pharmaceutical companies, and the UK governments must do next
First, long-acting PrEP would be a targeted solution, rather than a mass switch from oral pill to injectables. Oral PrEP is working – for those who can access it and take it safely. As NICE makes a determination on cost-effectiveness, they need to consider this as a complementary and additional intervention that reaches the people that oral PrEP can’t, not as a general uptake among the whole population, which would lead to inflated assumptions of use, and not take fully into account that the concentration of uptake of CAB-LA would be among those with a greater risk of acquiring HIV.
Second, pharmaceutical companies should do everything they can to step up and help ensure access to their medicines both in the UK and globally. ViiV and Gilead have rightly highlighted their commitment to ending HIV transmissions by 2030. This commitment must be reflected in fair and affordable pricing for health services across the UK.
We hope that by resolving these issues NICE will approve CAB-LA for the NHS in England and Wales. The UK Government, NHS, and local authorities must then act quickly to prepare for its roll-out, including funding outreach and awareness so that the communities who could benefit the most know that injectable PrEP is an option, and how to access it.
The approval of CAB-LA won’t be a silver bullet that solves all PrEP access problems for everyone. But it could be an essential and necessary part of the solution. As highlighted in our work with Terrence Higgins Trust and Elton John AIDS Foundation to set out priorities for Government to take forward in the new HIV Action Plan for England, Government must double-down on expanding access to oral PrEP by implementing a National PrEP Expansion Plan to ensure PrEP is available beyond sexual health clinics settings and online.
The innovation in treatment in the form of injectable PrEP is an amazing medical advancement that can potentially be a critical step forward. While other injectable HIV prevention treatments are coming down the track (NICE have just announced that later this year they will also be appraising lenacapavir – a form of PrEP that requires a twice-yearly injection) we don’t have any time to lose, and the chance to have a form of injectable PrEP available as soon as possible ifor people across England and Wales, to follow its approval in Scotland, cannot be passed up. NICE must approve CAB-LA and pharmaceutical companies must price it responsibly to enable them to do so. It is only through these kinds of steps forward that we will be able to make HIV prevention a reality for all, and bring the UK closer to the goal of ending new transmissions of HIV by 2030.