Preventing HIV through the power of choice

The value of reducing HIV transmission is almost incalculable when one considers the personal, societal, and healthcare burdens that come with each new HIV infection. In yesterday’s amazing plenary session, “Empowering Choice by Providing More Options in HIV Prevention,” Sharon L. Hillier, PhD, shared some exciting new advances in this area.

Hillier is the Richard Sweet Professor of Reproductive Infectious Disease, vice chair for faculty affairs at the University of Pittsburgh School of Medicine, and the director of reproductive infectious-disease research at the Magee-Womens Research Institute. She started the session by challenging attendees to follow their passions and shared some of her own experiences as a woman starting out in academia at a time when gender inequality was arguably much more apparent than it is today. 

Hillier then introduced a theme that she came back to throughout her presentation — the idea that people have both options (things) and choices (decisions) in life and in healthcare. While it’s always good to have options, what matters most is the choices we make regarding those options.

She then presented a comprehensive and eye-opening overview of various pre-exposure prophylaxis (PrEP) therapies available for HIV today, including a description of the clinical research used to prove their efficacy.

Hillier noted that PrEP can be highly effective, but only if it is used properly and consistently. She provided data showing a surprising lack of compliance with oral and other PrEP options. Moreover, in many clinical trials, participants’ therapeutic adherence rates, which were grounded in measurements of plasma drug concentrations, hovered around 25% after three months on PrEP and declined further over time.

To help attendees better understand the causes behind this noncompliance, Hillier invoked the metaphor of a bridge. Just as a bridge is built to span a physical obstacle without blocking the path underneath, HIV-prevention options should help patients to avoid infection without blocking their normal routines, experiences, and desires.

Thus, the best options for HIV prevention should act as bridges. While current alternatives, such as abstinence, condom usage, knowing a partner’s HIV status, and PrEP, may all be documented to be effective to varying degrees, in practice they could be completely ineffective for individuals for whom those choices are unavailable or unrealistic.

Injectable PrEP is a recent option that holds promise to become more popular for some patients, Hillier noted, as are drug-containing vaginal rings, which are currently available in Africa but not the United States.

Different people have different preferences. Thus, the key to ensuring people at risk of HIV infection are most protected is to create more options. Hillier shared exciting results published just last week from the PURPOSE 1 trial of lenacapavir, an antiretroviral used for PrEP. This study demonstrated a complete absence of HIV infections among 2,134 women treated with the new long-acting lenacapavir (LEN-LA) PrEP option.

But she cautioned the audience to remember that compliance is critical to prevention, and LEN-LA requires precise timing of both oral loading doses and sub-cutaneous injections, which might limit access or acceptance for many.