Violette Lauren R, Zewdie Kidist, Gitahi Nyawira, Beima-Sofie Kristin, Heffron Renee
Department of Epidemiology, University of Washington, Seattle, USA.
Department of Medicine, University of Washington, Seattle, USA.
Implement Sci Commun. 2024 Sep 18;5(1):101. doi: 10.1186/s43058-024-00637-1.
Longer-acting cabotegravir (CAB) is a novel, safe, and efficacious pre-exposure prophylaxis (PrEP) for HIV prevention. As we near a time for CAB scale-up, the experience of global leaders in PrEP research and implementation can be leveraged to identify optimal strategies for scaling and integrating CAB into existing PrEP infrastructure worldwide.
We recruited leaders of HIV prevention clinical trials and large PrEP programs through a combination of purposive and snowball sampling for participation in individual interviews. We conducted interviews using a semi-structured guide that compared CAB to oral PrEP and sought perspectives on barriers and strategies for CAB scale-up. Interviews were conducted virtually, audio recorded, and transcribed. We used thematic analysis, grounded in an adapted version of the Intervention Scalability Assessment Tool (ISAT), to identify critical elements for optimizing delivery of CAB.
From October 2021 to April 2022, we interviewed 30 participants with extensive experience in PrEP research, care, and programming. Participants worked in all seven WHO regions and reported a median of 20 years working in HIV and 10 years in PrEP. Participants agreed that CAB was efficacious and discrete, therefore having the potential to address current concerns about oral PrEP adherence and stigma. Participants indicated direct and indirect costs for provider training, expansion of existing medical infrastructure, and the current medication cost of CAB as major concerns for roll out. The true cost to the end-user and health system were unknown. There were some conflicting strategies on how to best address product targeting, presentation of efficacy, and timing of product availability with scale-up. Some thought that targeting CAB for the general population could normalize PrEP and decrease stigma, while others thought that prioritizing key populations could optimize impact by targeting those with highest risk. Overall, participants emphasized that to ensure successful CAB scale-up, communities and stakeholders must be involved at every stage of planning and implementation.
Our evaluation found that although there is a clear and urgent need for additional HIV PrEP options beyond daily oral PrEP, CAB scale-up must be thoughtful, flexible, and based in lessons learned from oral PrEP rollout.
长效卡博特韦（CAB）是一种用于预防HIV的新型、安全且有效的暴露前预防（PrEP）药物。随着我们接近扩大CAB使用规模的阶段，可以借鉴全球PrEP研究与实施领域领导者的经验，以确定在全球范围内将CAB扩大规模并整合到现有PrEP基础设施中的最佳策略。
我们通过目的抽样和滚雪球抽样相结合的方式，招募了HIV预防临床试验和大型PrEP项目的领导者，参与个人访谈。我们使用半结构化指南进行访谈，将CAB与口服PrEP进行比较，并征求关于扩大CAB规模的障碍和策略的意见。访谈通过线上方式进行，进行了录音和转录。我们采用基于干预可扩展性评估工具（ISAT）改编版的主题分析，以确定优化CAB给药的关键要素。
2021年10月至2022年4月，我们采访了30名在PrEP研究、护理和项目实施方面有丰富经验的参与者。参与者分布在世界卫生组织的所有七个区域，报告在HIV领域工作的中位数为20年，在PrEP领域工作的中位数为10年。参与者一致认为CAB有效且隐秘，因此有可能解决当前对口服PrEP依从性和耻辱感的担忧。参与者指出，提供者培训的直接和间接成本、现有医疗基础设施的扩展以及CAB目前的药物成本是推广的主要担忧。终端用户和卫生系统的实际成本尚不清楚。在如何最好地解决产品目标定位、疗效展示以及随着规模扩大产品可获得的时间安排等方面，存在一些相互冲突的策略。一些人认为将CAB针对普通人群可以使PrEP常态化并减少耻辱感，而另一些人则认为优先考虑重点人群可以通过针对风险最高的人群来优化影响。总体而言，参与者强调，为确保CAB成功扩大规模，社区和利益相关者必须参与到规划和实施的每个阶段。
我们的评估发现，尽管除了每日口服PrEP之外，显然迫切需要更多的HIV PrEP选择，但扩大CAB规模必须深思熟虑、灵活，并基于从口服PrEP推广中吸取的经验教训。
