Background
Long-acting injectable cabotegravir (CAB-LA) is superior to oral pre-exposure prophylaxis (PrEP) regimens. The slow scale-up of oral PrEP has left significant gaps in HIV prevention among men who have sex with men (MSM), and global HIV prevention targets have been missed. The introduction of CAB-LA could facilitate broader prevention choices and help reach these targets. We modeled the potential impact of expanding PrEP coverage to reduce unmet PrEP needs by offering CAB-LA among MSM and studied the impact of rapid and delayed CAB-LA scale-up in the Netherlands.
Methods
The National PrEP Program (NPP) in the Netherlands has reached its maximum capacity of 8500 slots. However, data from the PROTECT survey suggested around 75% of HIV-negative Dutch MSM intend to use PrEP, indicating substantial unmet PrEP needs that CAB-LA can mitigate. We calibrated our model to Dutch HIV epidemic data among MSM. We modelled alternative scenarios of introducing CAB-LA in 2025 to alleviate the estimated unmet PrEP needs. We considered covering 75% of HIV-negative MSM by offering CAB-LA within two years by 2027 as a rapid scale-up, by 2030 as a medium and by 2032 as a delayed scale-up. We assumed that current oral PrEP users with a CAB-LA preference would switch to CAB-LA, informed by data from a Dutch PrEP cohort that suggested around 50% of the current oral PrEP users preferred CAB-LA. We additionally assessed the impact of terminating NPP by 2025. Oral PrEP effectiveness was set at 86%, and CAB-LA efficacy was assumed to be 91% following results from the HPTN083 trial.
Results
Closing unmet PrEP needs by offering CAB-LA was shown to further reduce the HIV epidemic in the Netherlands, with the potential to avert 14% (delayed scale-up) up to 21% (rapid scale-up) new infections within ten years of its introduction, and can reach zero new infections within 10 years. However, a delayed CAB-LA scale-up would delay reaching zero by three years compared with a rapid scale-up. While terminating the current NPP would result in more HIV infections (Figure a). The additional number needed to treat (NNT) on CAB-LA to prevent one HIV infection was estimated over 1000+ in all CAB-LA scale-up scenarios between 2025-2035. A rapid CAB-LA scale-up would be 12% more efficient than a delayed scale-up (Figure b).
Conclusions
Continuing the NPP is crucial. A swift introduction of CAB-LA could significantly reduce the PrEP unmet needs, paving the way toward ending the HIV epidemic in the Netherlands.