HIV treatment is always evolving. At the moment, many guys in NSW are accessing free and effective oral treatments that can be as simple as one pill a day. Treatment is effective, it provides great health benefits, and helps many people achieve an undetectable viral load, preventing onward transmission.
There are some exciting new developments happening around treatment, especially what’s called ‘long-acting injectable’ treatment.
What is long-acting injectable HIV treatment?
A long-acting injectable HIV treatment is a medication for HIV that is injected, rather than a pill, and taken less frequently than daily. The frequency depends on the type of drug, and the treatment regime recommended by your doctor.
At the moment, there is one option of injectable treatment approved for use by the TGA in Australia. Known as Cabenuva, it is a drug combination consisting of long-acting Cabotegravir, a new form of integrase inhibitor, and Rilpivirine, a non-nucleoside reverse transcriptase inhibitor (NNRTI).
Other options are also being studied. Lenacapavir is a new class of drug known as a capsid inhibitor, and has been effective in clinical trials. It is being investigated as a combination treatment alongside Islatravir, an NNRTI.
How do injections for HIV treatment work?
Cabenuva consists of two intramuscular gluteal injections (two injections into your butt muscles) given at the same time (one for each cheek). These are injected by your doctor or a nurse, either as a monthly shot, or once every two months, depending on what the doctor recommends for you.
Before you can start Cabenuva, you need to take two pills daily for a month: Vocabria (cabotegravir) and Edurant (rilpivirine) tablets, to check that you can tolerate these kinds of meds before you go all-in on the long-acting injectable treatments.
Cabenuva is just as safe and effective as oral treatments. However, it has only been approved for use in adults who already have an undetectable viral load (less than 50 copies/mL), so it might not be for you if you haven’t started treatment yet.
It’s currently not subsidised by the PBS, which means that if you can actually get your hands on some, it’ll be very expensive– in the US, it’s about $48,000USD a year.
The lenacapavir/islatravir combination is still under investigation. There’s potential for it to be a once every six months subcutaneous (under the skin) injection. Subcutaneous injections are much easier to self-inject or have a friend do the injection. But these drugs have not yet been approved, and their safety and efficacy have not yet been fully studied, so we don’t really know how they will work just yet.
What are the advantages?
The advantages or disadvantages of long-acting treatments really depends on your style, and what you value. There are some great benefits to a long-acting form of treatment, especially around frequency of medication, convenience, and privacy.
Not having to take medication daily could come as a huge relief to some. And, because Cabenuva needs to be administered by a doctor or nurse, there’s no need to store your own medication – so no carrying it around, and no risk of it being found by people who don’t know your status.
This is great news for your privacy, and also for things like travelling: with new long-acting injectable HIV medication, you can go away for a long holiday without having to carry heaps of medication with you!
If you’re the type of person that occasionally forgets to take your pills, injectable treatment might be the way to go – a doctor’s appointment every month might be easier to remember (especially if they’re the kind of doctor that texts you a reminder!).
Injections are also a great alternative way to get the medication you need if you struggle to stomach pills, or if they’re a bit rough on your intestines sometimes.
Cabenuva was well-liked in the clinical trials. Around 9 in 10 of the participants said they preferred the injectable treatment to pills.
What are the disadvantages?
The biggest disadvantages at the moment relate to cost and accessibility. Cabenuva is currently prohibitively expensive and functionally unavailable.
Should Cabenuva become more affordable, via listing on the PBS or by other means, it still requires a visit to the doctor for the medication to be administered. This means 6-12 appointments per year, which is likely a few more than you’re currently used to. That’s not great if you’re someone that has trouble finding a good doctor, or negative encounters with healthcare professionals.
Because it’s a long-acting form of treatment, there are also greater consequences if you miss a dose, especially around losing viral suppression or developing resistance to the strain of drug. So it’s super important that you’re able to schedule those appointments for the injections at consistent intervals – which could impact things like holidays or travel.
There are a few reported side effects to Cabenuva, most of which are extremely mild. The most common side effect is pain at the site of injection – so, some sore butt cheeks for a few days post injection. In the clinical trials, more than three quarters of the participants experienced this, but less than 1% of people in the trials stopped the injections because of it.
Other less common side effects include things like fever, tiredness, diarrhoea and nausea – the type of side effects that come with many medications.
There will be other advantages and disadvantages as more drugs become available. For example, because lenacapavir/islatravir could be self-administered, that could mean more convenience, and less doctors’ visits. Less-frequent injections are also potentially more convenient. But we can’t really speculate until they’re approved for use.
When can we expect to be using these in Australia?
Cabenuva has been approved by the TGA, but the PBS has decided not to subsidise it at the moment. This is generally because the PBAC, the committee that decides what goes on the PBS, has decided that the benefit of this treatment doesn’t outweigh the cost. In a nutshell, it doesn’t offer substantial benefits compared to the pills the government already pays for, so it’s not worth the hefty price tag that a new medication comes with.
As more long-acting treatments become available, this could make prices more competitive, and the benefit of government subsidy more obvious – and that’s good news for the community. Gilead, the company that makes lenacapavir, submitted an application to the FDA for approval of the drug in June. So, watch this space.
It won’t happen overnight, but we’re in the middle of another treatment evolution.