To be or not to be? Daily oral versus long-acting injectable medicines for HIV prevention
SHOBHA SHUKLA - CNS
Scientific research has gifted us with a range of evidence-based options to protect ourselves from getting infected with HIV. In 2012, US FDA had first approved Pre-Exposure Prophylaxis (PrEP) daily oral medicines for HIV prevention. More recently, long-acting injectable options of PrEP are also approved. We at CNS listened to the experts on both of these PrEP options so that we can make an informed choice.
A lively debate was organised at the recently concluded 10th Asia Pacific AIDS and Co-Infections Conference (APACC 2025) in Tokyo, Japan, on "Should Long-Acting Injectables (LAIs) Replace Oral Antiretrovirals for Biomedical HIV Prevention in the Asia-Pacific Region?" Also, 13th International AIDS Society Conference on HIV Science (IAS 2025) and 2nd Asia Pacific Conference on Point-of-Care Diagnostics for Infectious Diseases (POC25) will open soon.
Arguments in favour of long-acting injectable PrEP dwelt upon the current dismally low use of oral PrEP in the Asia Pacific Region - as of end 2023, around 204,000 individuals were actively using PrEP - just 2% of the 8.2 million target set for 2025. Also a significant number of individuals discontinue PrEP within a relatively short period of time after initiation. For example, in Thailand, a programme serving over half of all PrEP users, saw 47% of clients discontinuing within 12 months, according to the Institute of HIV Research and Innovation (IHRI).
"I don't fear the side effects. I fear the side eyes"
Varied reasons were put forward by debater Jennifer Ho, a global health advocate from Thailand, included "Oral PrEP is not reaching those most at risk. Transgender women navigating stigma in clinics, sex workers who cannot safely carry pills; men who have sex with men and young men hiding their PrEP from family; persons who use drugs facing criminalisation - all of these find it difficult to take daily oral PrEP. Pill shaming keeps people from starting or leads them to quietly stop, because of 'I don't fear the side effects. I fear the side eyes.' On the other hand, long-acting injectables remove structural and behavioural barriers and can reach people outside formal systems. We need prevention tools that meet people's needs. Prevention works when it does not depend upon disclosure, disability or perfect routine. Oral PrEP stigmatises life because you have to take a pill daily. Long-acting injectables are discreet, there is no daily pill to remember, there is no need to hide. Long-acting injectables are a prevention strategy that is realistic, respectful and responsive."
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