Prioritise HIV prevention injection, activists sayA TAC activist address the attendees at a World AIDS Day event earlier. PHOTO: Denvor De Wee/Spotlight

Prioritise HIV prevention injection, activists say

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Rolling out a new HIV prevention injection should be a priority in South Africa, says Thandi Maluka, Executive Director of HIV activist group Positive Women’s Network (PWN).

She says an HIV prevention injection, administered every two months, is going to make life easier for many people, especially young people. This is because the injection can be taken more discreetly than prevention pills. “This one time per two months injection will give the young people their dignity and privacy because no one will know you are on PrEP unless you tell them,” she says. (PrEP stands for pre-exposure prophylaxis and refers to antiretrovirals taken to prevent HIV infection.)

The only form of PrEP currently available in the public healthcare system in South Africa is a daily pill containing the antiretroviral (ARV) drugs tenofovir and emtricitabine. The pill is, however, not available at all healthcare facilities and so far uptake has been poor.

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What is CAB LA?

The injection, commonly referred to as CAB La, contains a long-acting form of the antiretroviral drug cabotegravir. In 2019, findings from two landmark studies showed CAB LA to be highly effective in preventing HIV infection. Local HIV experts hailed the findings as a “major breakthrough” for women.

CAB LA was registered by the United States Food and Drug Administration (FDA) in December but has not yet been registered by the South African Health Products Regulatory Authority (SAHPRA). (Spotlight previously reported on the regulatory and other steps required before CAB LA can be made available in South Africa.)

“With as few as six shots per year, this highly effective form of injectable PrEP can help bend the curve of the HIV epidemic – but only if its approval is accompanied by strategic, effective, and equitable rollout that transforms the growing list of HIV prevention options into real and accessible choices for the people who need prevention most,” says Mitchell Warren, executive director of New York-based HIV advocacy group AVAC in the statement released by the organisation.

AVAC says it will be working with its partners in the months ahead to support the review of CAB-LA by regulatory authorities in other parts of the world where new HIV prevention options are sorely needed. “Once it is approved by regulators, recommended by WHO, and available throughout East and Southern Africa – hopefully, all within the next six months – it will be an important addition to HIV prevention choices,” Warren tells Spotlight.

Steve Letsike, chair of the South African National AIDS Council’s (SANAC) Civil Society Forum, is similarly excited about the injection. “If we immediately adopt this (CAB LA) I must tell you that these are the news we welcome as civil society with SANAC because this is also a game-changer that we’ve been looking forward to. It’s innovative, it’s proven, and really it gives people prevention options that are needed,” says Letsike.

Sense of urgency

Letsike says that South Africa urgently has to look at a revised approach. “If you look at what is happening now, we’ve got a catch-up plan and we’ve got to be developing the National Strategic Plan in the next year (2023), which then means we [must] utilise this time to develop plans to adopt CAB LA because it fits within the HIV prevention options,” says Letsike.

Several people Spotlight spoke to were of the view that government has to do a better job in rolling out CAB LA than it did with the rollout of prevention pills. We can’t accept that there are prevention options that are proven to be effective and we don’t utilise them, says Letsike.

When it comes to HIV prevention pills, the reality is that there are accessibility gaps with some facilities only targeting certain groups, says Makhosazana Mkhatshwa, a research officer at the Treatment Action Campaign (TAC). “Some people were discouraged because of lack of knowledge about whether they could have access or not. We have seen clients being denied PrEP at some facilities, some facilities demanding proof that the client has an HIV-positive partner [and] even asking them to bring the partners [at times],” she says.

TAC says CAB LA should be made available at all healthcare facilities, from the primary healthcare level and it should be available to everyone who needs it – not just key population groups (such as sex workers and men who have sex with men). They also think there should be a robust communication strategy to raise awareness and to educate people about the new drug to enhance uptake and adherence.

“The most important thing is to go faster with these new options than we did with oral PrEP,” says Warren. “It took three years to go from US FDA approval of oral PrEP to approval in Kenya and South Africa, the first countries in Africa to approve it – and it has taken five more years to even begin to deliver oral PrEP at scale and with impact,” he says.

Options that work in people’s lives

Khanyi Kwatsha, a 28-year-old oral PrEP user, says given the chance to switch to CAB LA, she would go for it. “Taking a pill each and every day is tiring sometimes. So with CAB LA you can just go to the clinic [and] they inject you,” she says. “Everyone prefers a certain method of HIV prevention. So I think if they bring many HIV prevention methods, it will really be a great thing because one will have the chance to choose which method works best for them.”

According to Warren, we know that male and female condoms, VMMC (voluntary medical male circumcision), and oral PrEP are prevention options that work for many people but not for everyone and not at all times in their lives. “CAB LA also won’t be for all people, but when individuals are offered more options, they are more likely to find something that works for them,” he says. “Injectable PrEP may make it easier for some people to use and benefit from an effective HIV prevention option when other options don’t work for them. In that context, CAB LA for PrEP can be lifesaving for some people, while other PrEP options will help other people. CAB LA is not a replacement for other methods. It is a terrific addition.”

For Mkhatshwa, only having to get an injection every two months is the key. “The fact that it’s available in a long-acting injection will be very beneficial. It will enhance adherence as we know that you need to be consistent with PrEP in order for it to be effective in protecting you from contracting HIV,” she says.