Ideal Patient Selection for Long-Acting Injectable PrEP

EP: 1.Overview of HIV Prevention with PrEP

EP: 2.CDC PrEP Care System Process and Assessing Risk of HIV

EP: 3.Initiating PrEP: Patient Clinical Evaluation

EP: 4.Payer Barriers to PrEP

EP: 5.Addressing Patient Persistence and Adherence to PrEP in the Clinical Setting

EP: 6.Challenges to Monitoring PrEP Adherence and Persistence

EP: 7.Barriers to PrEP Uptake

EP: 8.Improving PrEP Use Among Clinicians

EP: 9.Abandoned PrEP: Targeting Nonadherent Patients

EP: 10.Grade A Recommendation: Impact of USPSTF Grading on PrEP

EP: 11.PrEP Pipeline: Effects of USPSTF Grading

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EP: 12.Ideal Patient Selection for Long-Acting Injectable PrEP

EP: 13.Future of PrEP

Neil Minkoff, MD: What I would do in a situation like this, running a formulary in New England, would be to say to somebody like you, who are the patients who should be on an injectable, longer-acting drug versus who should be on something else? Where are we trying to slot different patients to different levels of therapy? You could help me understand, what is the level of coverage I need to provide? What would you say if I were to ask you that question? If you are in my network, as I’m starting to build my formulary, how many long-acting choices do I need and for whom am I using them?

Ian Frank, MD: Well, it’s harder to say that without seeing the characteristics of the product.

Neil Minkoff, MD: Understood. I mean conceptually help us to understand.

Ian Frank, MD: What I would say is, we choose the thing that is most likely to be beneficial for the majority of the patients we’re prescribing for. The most effective and the safest. Those are the products we prefer, and there should be a few options. There are going to be people who don’t want an injection, so we need to have oral options available. There will be many people who will do better not having to take a daily pill, so we do need to have injectables available. How many? Well, let’s see what the products offer. Let’s see what the logistical challenges are. It’s not just the drug cost. If somebody’s got to come to my office to get an injection rather than them being able to do it at home, there’s an added cost associated with that. There are different types of costs, and it’s not just the pharmaceutical product we need to be thinking about.

Neil Minkoff, MD: Any response to that? How would you think about trying to provide different drugs for different populations or patients in your practice?

Ryan Bitton, PharmD, MBA: That seems fair. I think that tends to be what we try to do. If we see an opportunity for management, we want to manage in a way that provides the easiest access, lowest co-pays, whatever you want to call it, to the agents that are going to provide the value that the providers are thinking of, and also the…recommendations. Dr. Frank’s description of what he would use and his desires I think would be the approach we would take.

Carl Schmid, MBA: I’m not a provider, but as a patient advocate, I would make sure to encourage that we get as much PrEP [pre-exposure prophylaxis] out there as possible to the people who need it. If long acting is the way to do it for certain people to help with the pill burden, to help with adherence, then I would support it. However, we also have to recognize that it’s not right for everyone. They do have to go into some sort of medical clinic, right now I guess it would be every 2 months. Maybe in the future it would be longer. There is some discomfort as well to the injections. It depends on the patient, but I think we, as a society, need to make PrEP a lot easier for people. Again, they’re taking something to prevent a serious illness, and they may question, “Why do I need to take a drug when I’m not sick?”Having a long-acting injectable may help increase PrEP uptake, and I hope it will.

Neil Minkoff, MD: Mr. Crowley, do you want to add to that?

Jeffrey Crowley, MPH: No, I would largely concur with what was said. I think that what we know from experience is that the more options, the better. That 1 thing won’t work for everybody. Daily pill taking works really well for some people, but as we see with our challenges with both uptake and persistence, it doesn’t work for everybody. Thus, the more options we can give, the better.

Transcript edited for clarity.