When anti-retroviral therapy was introduced to treat HIV-AIDS in 1996, it was revolutionary: Taking a cocktail of pills suppressed the virus to the point where people living with the deadly disease had virtually no symptoms, often described as a “functional cure.”
Since then, there have been slow, but steady improvements in the affordability, availability and practicality of ART.
Worldwide, 28.7 million of the 38.4 million living with HIV are taking ART. The regimes are getting less onerous; some people take a single pill a day, and the treatment makes the virus undetectable, and untransmissible.
Anti-retrovirals have also become a key way of preventing HIV infection, used in the same manner one would take a birth control pill to prevent pregnancy.
More than 1.6 million people worldwide were taking pre-exposure prophylaxis (PrEP for short) in 2021. That is double the number of the previous year, and it could soon jump substantially because researchers have unveiled the latest innovation: long-lasting injectable PrEP.
Studies presented at the 24th International AIDS Conference in Montreal show that a single injection of the drug cobotegravir (CAB-LA for short) every two months is 79 per cent more effective at preventing HIV transmission than taking the oral formulation of the drug daily.
That is being described as a “game-changer” even though the pills are already remarkably effective – providing about a 99-per-cent risk reduction in those who take them properly, meaning without fail daily.
And that’s the rub. Many people, especially those at highest risk of contracting HIV, have trouble adhering to a daily medication regime, for a host of reasons ranging from stigma to the chaos of their lives.
“CAB-LA is a safe and effective HIV prevention tool, and it comes at a crucial time,” said Meg Doherty, director of the Department of Global HIV, Hepatitis and Sexually Transmitted Infection Programmes at the World Health Organization.
She said the challenge will be getting CAB-LA to those who can most benefit, such as adolescent girls and young women, who account for two-thirds of new infections in sub-Saharan Africa.
There were about 1.5 million new HIV infections and 600,000 deaths globally last year, about 70 per cent of them in high-risk groups such as injection drug users, sex workers, men who have sex with men, transgender women, and women in low-income countries.
Oral PrEP costs about US$24,000 annually for uninsured HIV patients in the U.S., but generics can be purchased for as little as $360 a year. In Canada, costs vary by province, but PrEP is mostly provided at little or no cost.
In low-income countries, anti-retroviral therapy, and sometimes PrEP, costs about $60 a year, and is usually provided at no cost by various global health programs.
But it took more than decade after ART was unveiled for the drug cocktails to be made widely available in southern Africa and other regions with high HIV numbers, and activists don’t want those accessibility problems to be repeated.
The new injectable version, CAB-LA (brand name Apretude), is priced at US$22,000 annually.
“I acknowledge that it is not currently affordable in much of the world,” said Deborah Waterhouse, CEO of ViiV, which makes the drug. “But we hope that by sharing our intellectual property it will become widely available.”
The company has already licensed the drug in 90 low-income countries, meaning it can be manufactured by generic companies, mostly without paying royalties.
Ms. Waterhouse said she hopes generic versions of CAB-LA will cost only a few hundred dollars but added that it would be unrealistic to think an injectable drug would be as cheap as an oral medication.
Warren Mitchell, executive director of the AIDS Vaccine Advocacy Coalition, said cost should not be a deterrent because it will come down if the long-acting PrEP is used widely.
He added that the six-times-a-year shots are only the beginning; there are innovative new delivery methods and drugs in the pipeline for treatment and prevention.
In the near future, Mr. Mitchell said, “we will have effective HIV drugs that you take every three months, every six months, maybe once a year.
“Imagine how exciting that will be.”
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