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The long-acting, injectable drug is seen as a major advance in HIV prevention (PrEP) and treatment — it’s an effective alternative to taking pills daily.
There is no vaccine for HIV, the virus that can cause AIDS. And stories of people being cured of HIV are still read as miracles. However, HIV can be prevented, controlled and treated with pills – sold as Truvada.
But from 2020, Europeans suffering from sexually transmitted infections have an option other than a daily intake of pills: an injectable drug.
The European Medicines Agency (EMA) has approved rilpivirine and cabotegravir (sold as Rekambis and Vocabria, respectively, and together as Cabenuva) to treat patients with HIV-1, the most widespread type of the virus worldwide.
In 2021, the U.S. Food and Drug Administration (FDA) approved cabotegravir (sold as Apretide) as a prophylactic. After the initial two doses, spaced one month apart, people take it every two months.
And in July 2022, the World Health Organization endorsed the use of a long-acting injectable – cabotegravir (CAB-LA) – as a prophylactic.
HIV medications 101: The difference between PrEP, PEP, and ART
First, there are pre-exposure prophylaxis medications, also known as PrEP.
PrEP is recommended for people who are considered to be at risk of infection. This includes, for example, people who inject drugs, the chemsex scene (where drugs are used in group sex), certain ethnic groups (such as black and Hispanic in the US), sex workers, and transgender women who have sex with men.
Also read: World AIDS Day: 10 frequently asked questions on HIV and AIDS
Meanwhile, PEP is also for people who do not have HIV but have had sexual contact with someone who has HIV. PEP stands for post-exposure prophylaxis and is usually only recommended in emergency situations.
And then there are treatments known as antiretroviral therapy, or ART.
ART helps people with HIV reduce their so-called “viral load” — the amount of HIV in their body — and supports their immune response.
The term “antiretroviral” is also abbreviated as ARV.
Why develop injections when we have tablets?
Until recently, PrEP, PEP, and ART were only available in pill form. And that has been effective, but sometimes people forget to take pills, some have difficulty swallowing them, and others may feel stigmatized by carrying pills with them or keeping them at home. Still, some people may refuse to take them all together.
So the hope is that long-acting, injectable drugs “will increase adherence to treatment, reduce stigma, and improve overall quality of life among people living with HIV,” said Meg Doherty, director of global HIV, hepatitis and STI programs at the World Health Organization.
Also Read: World AIDS Day: Does HIV affect menstruation?
“The most important advantage of HIV injectable medication is that it reduces the pill burden. Instead of taking oral medication every day, a person can take injections at longer intervals,” Doherty said.
In 2022, the WHO stated that CAB-LA had been shown to be safe in two trials and resulted in a “79% relative reduction in HIV risk compared with oral PrEP.”
Two years later, Doherty told DW, “If taken correctly, the efficacy of long-acting injectable and daily oral ARV drugs in suppressing the virus is similar.”
Injectable drugs also have fewer gastrointestinal side effects than oral medications, Doherty said.
What are the disadvantages of taking HIV drugs by injection?
Long-acting HIV drugs have both advantages and disadvantages.
“The frequency of dosing is still not ideal,” Doherty said.[They also have] complex injection requirements – different injections, intramuscular or intravenous routes – and cold chain requirements.”
We mentioned the frequency of two months for cabotegravir and rilpivirine. Another treatment drug, ibazulimab (sold as Trogarzo), is given every two weeks, either by injection or infusion. It must be taken in combination with other drugs.
Long-acting rilpivirine also requires refrigeration, which presents a potential limitation—potentially inconvenient for hot climates and remote areas.
“Addressing these limitations is essential to ensure that injectable HIV medications can be used effectively across a variety of settings,” Doherty said.
lenacapavir: injection only given every six months
These drugs also differ in what they target. For example, ibazulimab is a monoclonal antibody – it’s designed to behave like a natural, human antibody.
On the other hand, lenacapavir is a capsid inhibitor – the first of its kind in HIV treatment. It is designed to interfere with the HIV capsid, the protein shell that protects HIV’s own genetic material.
[It’s] “This one is the most promising,” Doherty said. Lenacapavir needs to be administered every six months — subcutaneously, just under the skin, and it doesn’t require refrigeration.
But while data on cabotegravir and rilpivirine have been collected for four years, there is still little data on the long-term efficacy and safety of lenacapavir – at least so far.
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