This episode, Long-Acting Injectable PrEP and HIV Treatment, is the second in a three-episode series about new evidence-based strategies for addressing HIV and AIDS.


Guests featured in this episode:

Jeremiah JohnsonProgram ManagerPrep4All

Amy Killelea, J.D., Killelea Consulting

Aviva Cantor, PA-C, AAHIVS, PhD, Callen-Lorde Community Health Center

Moderator: Alexandra Walker, Digital Communications Director, NACHC

Alexandra: Hello and welcome to Health Centers on the Frontlines, the podcast of the National Association of Community Health Centers. Today is the second in a three-episode series we're doing about an epidemic that the nation's health centers have been battling for decades: HIV and AIDS. During these episodes, we're sharing promising news about how community health centers, health center controlled networks and primary care associations are employing the latest strategies to link people to ongoing HIV prevention, treatment, and care services.
Today, we're happy to be joined by a panel of experts, Jeremiah Johnson, who is the Program Manager at Prep4All, an organization of professionals and patients based in New York City who advocate for greater access to lifesaving medication for HIV. Also joining us is Amy Killelea, JD, an expert in policy, medication access, and health care financing to develop sustainable HIV and Hepatitis programs. And Dr. Aviva Cantor, HIV specialist and primary care provider at Callen-Lorde Community Health Center, which serves New York City's lesbian, gay, bisexual, and transgender communities.
So in late 2021, the US public was introduced to a bi-monthly injectable form of PrEP, which stands for Pre-Exposure Prophylaxis. Taken in pill form and now also available as an injectable this medication reduces the chance of getting HIV from sex or injection drug use. When taken as prescribed, PrEP is highly effective for preventing HIV, a landmark push to end the HIV epidemic. At the same time, people living with HIV have been introduced to a monthly injectable form of treatment that similarly puts them in charge of their healthcare needs without having to remind themselves to take a daily oral medication. This is revolutionizing the field of treatment and prevention of HIV because we never have had a form of either that was this long lasting. Also, it's exciting news because it expands the number of tools we have in our hands to fight HIV. Health centers have been taking their first steps in implementing these tools. So, starting with our health center guest. Aviva, can you explain to our audience the two types of injectable antiretroviral medication? We've heard that one can be used as PrEP for people who are HIV negative and the other as an HIV treatment for people who are living with HIV. Can you tell us about the similarities and differences?Aviva: Sure. Yeah. So the two medications and we use brand names here. I normally don't like to use brand names, but we’ll use them so that they're more clear for patients in the community. So one is called Cabenuva. That's the medication that's used for HIV treatment. And the other is called Apretude. That is the medication that's used for HIV prevention. What they both have in common are that they are both what I describe to patients and my colleagues as deep intramuscular injections. So they're a little different than your regular intramuscular injections. They have to be done by nurses who have been trained just a little bit differently to make sure they do it the right way. So they're both these deep intramuscular injections. They're actually both now available as bi-monthly or every-two-month injections. They actually sort of follow the same schedule where you're given your initial injection, you're given one one month later as a loading dose, and then you take an injection every two months, every eight weeks, essentially. The big difference between these medications is, first of all, for HIV treatment (Cabenuva), it's two (injections;) it's a combination of two medications. So it's two separate injections, one in each buttock (one medication in each buttock). For HIV treatment, for Apretude, for prevention, it's just the one injection in one buttock.Alexandra: Yeah, that's a good first start. We can get back to some of those issues in more depth. Jeremiah, drawing from your experience as a community member and advocate, what do you think is important for the community health centers that we represent around the country to know and consider as they see these new options for prevention and treatment?Jeremiah: Yeah, happy to talk about that. Thanks for having me on the podcast today. And really, you know, I think, Dr. Cantor, you really set us up really well because I think you clearly have a clear sort of centering of your patients and the way that you're sort of talking about things. Because I think one of the first things that I'll say about long acting injectable is it is exciting. I also, as a community advocate, am very cognizant of the price issue with this, so when you're looking at $22,500 a year for Apretude compared to less than $20 a month for generic TDF FTC (Tenofovir/emtricitabine) or generic Truvada, this is going to be a complicated intervention to get to people. And I do worry as a community advocate, given that there's such important adherence requirements if you're going to be on this, that, you know, community health centers are checking with patients and really making sure that they're not going to run into any sort of unexpected coverage issues or anything that's going to interrupt their ability to continue with their treatment in terms of all of this. And so, you know, one thing that I like to put out there at these sorts of conversations is that, you know, sometimes I think we get really excited about the new modality. We get excited about the new way to sort of put things out there and forget the old classics, you know, and in this case, we have, you know, new sort of access to these generic medications that can be more nimble in a complicated health care system to get to people and we can be more creative in terms of getting that out to people. And so, you know, one thing that we're working a lot here at PrEP4all right now is to try and build a national PrEP program calling for a federal program with centralized reimbursement of laboratory costs and medications, particularly for uninsured and underinsured individualsAlexandra: Thank you. Some really good points there. I want to turn it to Amy. As health centers consider delivering these services, what are the financial or policy hurdles that they need to be aware of?Amy: Yeah. So I think this is a really good question. And, and, you know, the short answer is that there are a lot. So, I think the first one is that, and this has been mentioned several times, the price of the drug and combined with the fact that it is a provider- administered injectable product, so that is just a different administration route than the vast majority of the antiretrovirals that are available right now. And those two things, both apart and combined, do, I think, add some complexity to the finances and the procurement and delivery of both Apretude and Cabenuva. And I'm going to go through some of these challenges and note throughout that the challenges are different depending on what population you're talking about, whether the population is insured or uninsured. So I'm going to try to underscore what some of those differences look like. And, you know, the number one piece and to sort of tie this to specifically for community health centers, so that the price of both drugs was raised, and it is, you know, pretty, it could be higher. Right? But in the grand scheme of things, over $22,000 a year for a list price for an ARV is in the upper threshold of ARVs that are available for HIV treatment and prevention, so it's not an insignificant list price. If we talk about community health centers and their status as 340B entities, there is a discount available to purchase that drug for your uninsured population, and yet even with the discount, the price is still fairly significant. So that's an important factor as community health centers look at budgeting and programmatic decisions on both routes, on both Apretude and Cabenuva. And when we talk about the insured, I think even now when these products have been on the market and available in the case of Apretude for, you know, a little less than a year and for Cabenuva longer than that, we still have sort of complexity challenges and, and murkiness, I would say, with regard to payer behavior for insured clients.

You know, on the PrEP side, we don't have a U.S. Preventive Services Task Force grade for long-acting Cabotegravir. The grade A that we have is based on the oral products for PrEP. We are waiting for a USPSTF grade and that would carry with it a requirement that the vast majority of payers cover long-acting Cabotegravir/Apretude without cost sharing.
Alexandra: Thank you. Would you like to add to that in terms of considerations that other community health centers who are considering offering these should factor in?

Aviva: Yeah, I mean, Amy brought up a lot of things that we are currently dealing with. I present on PrEP and on long-acting medications for PrEP and HIV a lot. And I have this slide (Slide 1) that shows how incredibly excited we are for these medications to be here. And then the next slide (Slide 2) is just total chaos because that's what it feels like. It's sort of like, “Hold up, wait, yes we're excited, but let's be realistic about this.” This is really hard. It's really hard right now. You know, you need the people to do the work, but you also need the fu