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Long-Acting HIV Medicines and the Pandemic Inequality Cycle - Rethinking Access
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NEJM December 9, 2024
Winnie Byanyima, M.Sc., Linda Gail Bekker, M.B., Ch.B., Ph.D., and Matthew M. Kavanagh, Ph.D.
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The world may look back on 2024 as a pivotal time in the fight against AIDS - the start of a revolution in the global biomedical response to HIV using long-acting antiretroviral medicines. Young women in southern Africa have described new prevention options as empowering, allowing them to “own their own sexual destiny” for the first time. Young people with HIV, many of whom have lived their lives dependent on daily pills, long to be free of the daily reminder of their stigmatizing infection. Members of criminalized groups, such as gay men in Uganda and Malaysia, are seeking HIV options they can leave at the clinic. New long-acting prevention and treatment innovations have the potential to change the HIV narrative - from dependency and stigma to empowerment and healthy lives. Whether they will do so depends on whether policymakers and pharmaceutical companies avoid repeating past mistakes in the few years that remain before 2030, the target date set by United Nations member states for ending the AIDS pandemic.
A similar opportunity presented itself in 1996, when it was announced at the International AIDS Conference in Vancouver, Canada, that triple-combination antiretroviral (ARV) treatment had proved effective in preventing deaths from AIDS.1,2 The HIV-treatment era had begun.
The science of long-acting ARVs for prevention and treatment is advancing quickly.9 In the PURPOSE 1 study of lenacapavir (in which one of us was a national principal investigator), this HIV-prevention technology afforded 100% protection.10 That study included thousands of young women in South Africa and Uganda, who received the medication as a subcutaneous injection just two times a year - which many experts see as potentially transformative. A follow-up study, PURPOSE 2 - conducted in Argentina, Brazil, Mexico, Peru, South Africa, Thailand, and the United States and involving cisgender men, transgender men, transgender women, and people of nonbinary gender who have sex with men - found an HIV-acquisition rate 96% lower than the expected background incidence rate.11
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