Preparing for Long-acting PrEP Delivery: Building on Lessons from Oral PrEP

Introduction: With recent approvals of long-acting (LA) HIV pre-exposure prophylaxis (PrEP) in the form of injectable cabotegravir and the dapivirine ring, programmes need to consider how to optimize the delivery of PrEP methods, including by leveraging lessons from the past decade of oral PrEP delivery.

Discussion: Framed around differentiated service delivery building blocks, the major considerations for the delivery of LA PrEP are how to reach the populations who would most benefit from PrEP, where to locate PrEP services, how to reduce the user burden of accessing and continuing with PrEP, and how to integrate PrEP with other services. Demand creation for LA PrEP and education about new LA PrEP options should be co-developed with communities and be positively framed. Client-facing clinical decision support tools provide information about HIV prevention and PrEP options in non-technical ways and can support their informed decision-making about PrEP. Training for providers is needed to increase their ability to ask about sexual and drug use behaviours in a non-judgmental and comfortable manner as part of risk assessment, discuss harm reduction strategies and counsel about available PrEP options that fit clients' circumstances and needs. PrEP adherence support should include supportive counselling and be tailored to address an individual's particular barriers and needs. Reminders through text messaging or calls can foster PrEP persistence, given the narrow the window around dosing for injectable cabotegravir. Strategies are needed to expand PrEP delivery options, including telePrEP, pharmacy-based PrEP, key population-led services and mobile venues. Integrated delivery models are needed which include sexually transmitted infection testing and treatment, contraception for cis-women not desiring to become pregnant, PrEP for pregnant women in high HIV prevalence settings, and gender-affirming hormones and support for transgender persons.

Conclusions: The outcome of expanding PrEP options through LA PrEP formulations is to increase PrEP coverage, adherence, persistence and effectiveness by offering a choice of PrEP that meets the needs of persons who would benefit from PrEP. The lessons learned from the delivery of oral PrEP about demand creation, informed client decision-making, provider training, adherence support and service delivery model are relevant to the delivery of LA PrEP and integration with other services.