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Projected Impact of Expanded Long-Acting Injectable PrEP Use Among Men Who Have Sex With Men on Local HIV Epidemics
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"LAI PrEP has the potential to substantially reduce HIV incidence among MSM"
JAIDS Oct 2022 Balasubramanian, Ruchita MPhila; Kasaie, Parastu PhDa; Schnure, Melissa ScMa; Dowdy, David W. MD, PhDa; Shah, Maunank MD, PhDb; Fojo, Anthony Todd MD, MHSc
Abstract
Background:
Pre-exposure prophylaxis (PrEP) is a key component in helping to reduce HIV incidence in the United States. Long-acting injectable (LAI) PrEP is a new alternative to oral PrEP; its potential to affect local HIV epidemics remains unclear.
Methods:
The Johns Hopkins HIV Economic Epidemiological model (JHEEM) is a dynamic model of HIV transmission in 32 US urban areas. We used JHEEM to project the HIV incidence among men who have sex with men (MSM) from 2020 to 2030 under a range of interventions aimed at increasing PrEP use.
Results:
In the absence of any intervention (ie, current levels of oral PrEP and HIV care engagement), we projected a 19% reduction (95% credible interval, CrI 1% to 36%) in HIV incidence among MSM from 2020 to 2030 across all 32 cities. Adding 10% LAI PrEP uptake (above a base case of all oral PrEP) reduced the incidence by 36% (95% CrI 23% to 50%) by year 2030. This effect varied between cities, ranging from 22% in Atlanta to 51% in San Francisco. At 25% additional LAI PrEP uptake, this incidence reduction increased to 54% (95% CrI 45% to 64%). Reductions in incidence after introducing LAI PrEP were driven primarily by increased uptake and sustained usage rather than increased efficacy.
Conclusions:
LAI PrEP has the potential to substantially reduce HIV incidence among MSM, particularly if it increases PrEP uptake and continued use beyond existing levels. Because potential effects vary by city, the effectiveness of expanding PrEP use is dependent on local dynamics.
BACKGROUND
In the United States, HIV imposes a substantial health burden, with an estimated 36,000 new infections and 1.2 million prevalent cases in 2019; two-thirds of new infections were among men who have sex with men (MSM).1 Pre-exposure prophylaxis (PrEP) is a key tool in ongoing efforts to reduce HIV incidence in the United States2 and has been shown to be effective among MSM.1,3,4
In 2017, the CDC estimated that 1.1 million adults have indications for PrEP use but only 100,000 accessed PrEP.5,6 To date, only oral formulations of PrEP are approved for use, and at-risk groups have demonstrated mixed adherence to a daily oral regimen.7 Furthermore, approximately 44% of MSM discontinue PrEP use during their first year.8 Long-acting injectable (LAI) formulations of PrEP may help to address these challenges of uptake and continuation8–10 and be preferable for some individuals who are less likely to take a pill on a daily basis.11–15 Injectable cabotegravir, given every 8 weeks, was recently shown to have superior efficacy compared with oral PrEP in cisgender and transgender men who have sex with men.10
The potential population-level benefit of implementing LAI PrEP in the context of local HIV epidemics remains unclear. The Johns Hopkins HIV Economic Epidemiological model (JHEEM) is a dynamic, compartmental model of HIV transmission in 32 high-burden US cities.16 We applied JHEEM to project the effects of PrEP expansion and LAI PrEP availability on future HIV transmissions among MSM in these 32 cities.
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