Adolescents prefer long-acting injectables to daily oral HIV treatment, study finds

How young people feel about long-acting injectable treatment remains largely unexplored. The More Options for Children and Adolescents (MOCHA) study provides some insight into the experiences of young people aged 12-18 who have switched to long-acting cabotegravir / rilpivirine based treatment. It is the first to examine use of long-acting injectable antiretrovirals in virally suppressed adolescents.

Understanding what makes them a good option for young people is vital to the success of their rollout. Whilst data shows they are safe, we have little knowledge of their acceptance in adolescent populations.

At the recent Conference on Retroviruses and Opportunistic Infections (CROI 2024), Dr Aditya Gaur presented results on the safety, tolerability and pharmacokinetics of this long-acting combination in adolescents. Week 24 results showed that in almost 150 adolescents in five countries who switched from oral treatment to long-acting injectable treatment, there was no virological failure, no deaths or adverse effects. Drug levels were similar to that seen in adults.

Turning to young people’s experiences taking the long-acting combination, further results were presented by Dr Elizabeth Lowenthal from University of Pennsylvania. She found that the injectable medication reduced the burden of receiving HIV treatment by:

• having the medical team's support and monitoring for adherence to each injection.
• being free from a daily reminder of a HIV diagnosis.

The study included 144 participants between 12 and 17 and their average age was 15. They were based in Botswana, South Africa, Thailand, Uganda and the US. There was a roughly even split of sexes: 74 females and 70 males. Most of the cohort acquired HIV perinatally, at around 92%. Most participants were Black or African (74%), with other participants being either Asian (25%) or White (1%). Two participants withdrew from the study, one left due to pregnancy and another was lost to follow-up.

The researchers asked participants at 8, 24 and 48 weeks about whether they preferred long-acting injectables or oral treatment, and the reasons behind their preference. By week 8, around 97% of participants preferred long-acting treatment, which increased to 99% by week 24 and 100% by week 48.

The few participants who preferred oral treatment at weeks 8 and 24 all said injection pain was the reason. Those who preferred injections did so due to convenience, which meant an uninterrupted lifestyle and no daily treatment, and reduced burden.

The team also conducted in-depth telephone interviews with eight adolescents. All interviewees were based in the US, had perinatal HIV infection and were Black. There were three females and five males in this group, with an average age of 16. They spoke to four parents about their children’s experiences too, and this largely confirmed the feelings expressed by the young people.

Young people shared:

“Because I don’t have to remember to take my tablets anymore at soccer.”

“I don’t have to wake up early to take my medicine.”

Young people also reported a reduced burden of treatment, which meant less anxiety, less treatment fatigue, better adherence and more privacy. For example:

“The injection treatment is not so stressful”

“I hate pills and I would forget to take them.”

“People won’t ask me about the medicine if I get the injection.”

However, analysis also revealed gaps in understanding of long-acting injectables. Young people shared sentiments which showed they did not understand the process. For example, there was confusion about where the injections would be given, even though the participants had completed informed consent and counselling.

“I’m like, where?!..I thought I was getting it in my arm.”

A 17-year-old male shared:

“I was really excited about taking the shots, and then like I did zone out a little bit for the debriefing and all of that.”

One parent of a 15-year-old female said:

“They did explain it to her, but she was not hearing it.”

The study results show that long-acting injectables are a favourable form of treatment, with preference remaining high throughout the study. However, it is worth noting that this cohort was a group of adolescents who chose to be amongst the first to receive the treatment. There remains a need for tailored counselling and support, delivered by trained clinic staff, for successful implementation of long-acting treatment.