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By *SAOFMan
2 weeks ago
Work/Play in London, live in Kent |
"In previous contributions to chemo-prevention threads I have been accused of liking the sight of my own typing … if you choose to read on, you have been warned."
Lenacapavir is a new, long-acting form of prep that is injected. You get one injection every six months.
The treatment is just as effective as Descovy and Truvada (when used as prescribed) in preventing HIV seroconversion.
Unlike both the tablet forms, a twice-a-year injection has no risk that you forget to take a pill one day. Failures in oral PrEP are not failures in those who took the drug, they are failures in those who have not remembered to take their pills. Therefore for six months until due a new shot, you are protected.
Side effects exist but are less than some people get with Truvada or with Descovy.
Because you go to a clinic to get your injection, you have no PrEP pills to carry around with you. That means you are not going to interact with some who stigmatises you for having PrEP pills - no more visits to family where you have a nosy relative look in your medicines bag and ask awkward questions. More importantly if you have to travel in certain countries you may need not to flag that you are sexually active particularly for gay sex but also non-married straight sex. There are examples of deportations from Arab countries for the crime of having Truvada in one’s luggage. All of that is not an issue with an injectable.
Lenacapavir's injectable format provides a new option for other people who struggle with daily medication, be it a learning disability or a swallowing issue. It does bring its own challenges.
It needs clinic vists for the injection which is probably a good thing as it enables testing of other STIs. In fact, increased screening of gay men for STIs has been a major positive side impact of three-monthly PrEP and reducing to 6 monthly comes with a potential to limit uptake of STI screening.
It also costs more. The inventors of Truvada no longer hold a patent. It is cheap as chips. Descovy is patented but the NHS has a good deal though sensibly the NHS only gives out Descovy to patients not clinically suitable for Truvada. Lencapavir is expensive. It is a new drug so needs an enhanced level of specialist supervision driving up costs.
There are some people where access to PrEP is very poor. Some of these include women, particularly straight women. Sex workers may be independently managing their health but many are controlled by others and this may limit access. The at-home sexual partners of those who engage in risky behaviours have long been at increased risk. All of these link into a scenario of cohesive control. While some are seen in men who have sex with men, cohesive control victims are disproportionately female.
This brings us to its status in the UK. The drug is licensed here so it can be prescribed. However it is licensed as treatment not prevention. So while legal to prescribe, a doctor would be acting outside of “clinical norms”. Prescribing off-label as it’s known is common - almost every drug given to someone under 18 or who is pregnant is off-label. However, no one down the pharmacy is going to bat an eye giving antibiotic treatment to little Timmy’s ear infection cause each augmemtin tablet costs 5p. Similarly no one is going to worry if your sex health clinic prescribes long term doxycycline for STI prevention even though long term use is only licenced for malaria and psoriasis.
But if something costs the NHS thousands of pounds and could require thousands of patients to have two doses a year for ever, the people on the NHS and the departments of Health and HM Treasury get very interested very quickly. The list price for Lencapavir is set at £18,000 currently. The NHS will get very substantial discounts. But it will probably be at least £10k plus, so with twice yearly dosing you only need to treat 50 patients and it will cost £1m. And there are a lot more than 50 people who can benefit.
The National Institute for Health and Care Excellence (NICE) is currently evaluating its cost-effectiveness for the NHS. Approval is expected later in 2025, followed by a potential Medicines and Healthcare Products Regulation Authority (MHRA) decision within a month, making it a viable PrEP option for the UK for those who want to pay privately.
The best way to get unlicensed drugs in the UK is to be in a trial as that is how new uses eventually get licenced. I signed up for one not because I am controlled or worried about people seeing my Truvada but I sometimes forget. My 28 tablets usually see me through for 32 days. Nothing to worry about but the injectable would fix the problem.
I spoke to the researcher leading a London based study, having seen reference in a trials update where I work. He said he was surprised to be approached as their target demographic was not likely to come forward. I said that sounds like I am not part of their target.
His answer was informative even if he were couching his terms. They want the significant money they will spend to get as much bang for their buck. Whilst it is expensive, they want to pick up as many people who should be on PrEP but aren’t and in particular those that don’t feel comfortable taking pills or are in life situations where they can’t. It is the cohesively controlled, the sex workers whose pimps move them around, the wives who know their husband play away but are afraid to challenge them.
I can see their point. A white middle aged gay cis married man whose family all know he is gay, and know he is on PrEP and who will come in regularly and who will be 90% good at remembering to take his drugs is not likely to get significantly more benefits from the injectable over the oral PrEP. And definitely not £36k worth more benefit on the NHS’s dime.
So while the treatment is available in the UK it is unlikely to be available in the NHS for sometime outside of trial contexts.
In the meantime if you are not in the target demographics of the studies being set up, you are unlikely to benefit from the injectable above the swallowable. So stick to Truvada (or Descovy if you have serious kidney or bone issues).
"I did warn you about my War and Peace tendencies."
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