President, Southern California Men's Medical Group
CEO and CMO, Men's Health Foundation
President & Clinical Research Director, Mills Clinical Research
Assistant Professor of Clinical Medicine
University of California, Los Angeles
Los Angeles, California
Anthony M. Mills, MD, has disclosed that he has received consulting fees and funds for research support from Gilead Sciences, Janssen, Merck, and ViiV.
Over the past years, I have often been asked what percentage of my patients living with HIV would be interested in long-acting injectable therapy. I have heard my colleagues toss out numbers like 5% or 10%, but I was frequently the outlier, with my estimates being much higher, in the 50% to 70% range.
I think several factors contributed to my more enthusiastic estimate.
Patient Perspectives on Injection Therapy
First, the vast majorities of patients whom our organization—Men’s Health Foundation—cares for are men. In my experience, many men tend to be unafraid of needles and often have an inherent belief that if a medication is delivered by injection, it is stronger and more powerful.
In an era where testosterone is available in countless forms, my patients still generally prefer injections despite added discomfort or potential side effects.
Clinical Trial Experience
Second, through our organization’s research, I was given the amazing opportunity to work with investigational injectable ART from its inception. For the first year of the trials, I personally administered all the injections because I wanted to get hands-on experience with this new delivery mechanism. Currently, I oversee many patients in clinical trials of long-acting injectable ART and I now have extensive experience with this strategy.
Although some may argue that patients in clinical trials are different from patients in the community, and I agree that channeling bias may affect the overwhelmingly positive patient satisfaction that we have seen, my experience suggests that these successes are real.
Over the years, I have found persons living with HIV to be keenly interested in advancements in the treatment of the disease and open to making changes to their HIV regimen to keep up with advances in science. Patients ask me every day about the availability of long-term injectable therapy. I believe patients are excited about the possibilities and will be excited to try it.
A New Tool to Combat Stigma
Finally, several reasons that fostered the development of long-acting injectable therapy for HIV have less to do with effectiveness and more to do with social determinants of health.
For all the progress that has been made in society, stigma is ever present in the lives of our patients. Across all demographics and all socioeconomic groups, stigma has profound effects on HIV transmission, linkage to care, adherence, and ultimately viral suppression.
I hail from the southern United States, where the percentage of patients living with HIV who are not in care—both in rural and urban areas—is astounding. Yes, this is influenced by the lack of Medicaid expansion and limited resources, but far and away the principal reason that young men and women of color, cis or trans, are not engaged in care is stigma.
We have all the tools today that we need to end the HIV epidemic, but somehow we are unable do it. We need to think outside of the box if we want this to change—and long-acting injectables are an outside-of-the-box approach.
The average length of an injection visit in our clinic is now about 15 minutes. Patients have no aura of illness when they come in. Our patients often greet us with, “Hey doc, I’m here for my shot!” There are no pill bottles to pick up, no need for pharmacy engagement, no need to tell more people about your diagnosis, nothing to hide at home from friends, partners, and family. No daily reminder that, “I have HIV and I have to take these meds every day if I want to survive.” All those things that stand in the way of viral suppression and holistic health are gone.
So perhaps I am being optimistic, and maybe I am overestimating the impact of this advancement, but I have been treating persons living with HIV for a long time and I have a feeling our world is about to change. What do you think?
Can long-acting ART regimens overcome some of the barriers to delivery of care in the setting of HIV? Answer the polling question and add your thoughts in the comments section.