Expanded Choices with Greater HIV Prevention Benefits: A Mathematical Model of Long-Acting Injectable and Daily-Oral Pre-Exposure Prophylaxis
ObjectiveTo assess the population impact of long-acting injectable pre-exposure prophylaxis (LAI-PrEP) when available concurrently with daily oral (DO) PrEP among men who have sex with men (MSM). DesignDynamic network model of HIV transmission among MSM. MethodsWe calibrated our model to the current uptake of DO-PrEP (15% among indicated) and HIV prevalence (25.3%) among MSM in the southeastern US. Parameters for LAI-PrEP pharmacokinetics and efficacy were estimated from Phase IIa safety trials in human and macaque models. Primary analyses explored varied conditions of PrEP uptake and proportion choosing LAI-PrEP given initiation. Secondary analyses evaluated uncertainty in pharmacokinetic efficacy and in persistence to LAI-PrEP relative to DO-PrEP. ResultsIf 50% of MSM currently accessing DO-PrEP choose LAI-PrEP when it becomes available, an additional 14.3% of infections could be averted over 10 years. If the availability of LAI-PrEP increased overall uptake of PrEP to 50%, the expected infections averted would increase to 23.9%. The benefit of LAI-PrEP was weakly sensitive to pharmacokinetics with 9.9% of infections averted even if LAI-PrEP efficacy were half of current empirical estimates. The superiority of LAI-PrEP was strongly attributable to better adherence and persistence with only 4.3% of infections averted if persistence were the same as DO-PrEP. ConclusionsLAI-PrEP availability is projected to decrease HIV incidence. However, increased benefits depend upon improvements to adherence and persistence above current DO-PrEP levels. As LAI-PrEP becomes available, uptake and persistence should be monitored to ensure optimal implementation.
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