Injectable Pre-Exposure Prophylaxis for HIV Prevention: Perspectives on the Benefits and Barriers from Gay,Bisexual,and Queer Men and Health System Stakeholders in Ontario,Canada

Abstract

One hope surrounding long-acting HIV pre-exposure prophylaxis (PrEP) is reaching new users who could most benefit, as well as improving the experiences of oral PrEP users who may desire to switch modalities. Gay, bisexual, queer, and other men who have sex with men (GBQM) continue to make up over half of new HIV diagnoses in Canada, and oral PrEP uptake has plateaued among this population. Approval of injectable PrEP is anticipated, but there is a paucity of research to inform health promotion and implementation. Between June and October 2021, we conducted 22 in-depth interviews with GBQM oral PrEP users and non-PrEP users living in Ontario, Canada. We also conducted small focus groups or individual interviews with 20 key stakeholders (health care providers, public health officials, community-based organization staff). Interviews were audio recorded, transcribed verbatim, and analyzed in NVivo using thematic analysis. Only about one-third of GBQM had heard of injectable PrEP. Many PrEP users perceived greater convenience, adherence, and confidentiality with injectable PrEP. Some PrEP users did not anticipate switching because of needle discomfort or feeling more “in control” with oral PrEP. None of the non-PrEP users said that injectable PrEP would make them start PrEP. Injectable PrEP may offer additional convenience for GBQM; however, it did not appear to affect participants' PrEP decision-making significantly. Stakeholders noted that injectable PrEP may improve access, support adherence, and benefit marginalized groups. Some clinicians expressed concerns about the time/personnel required to make injectable PrEP available. System-level challenges in implementing injectable PrEP, including cost, must also be addressed.

Introduction

In Canada, gay, bisexual, queer, and other men who have sex with men (GBQM) are disproportionately affected by HIV, making up over half (52.2%) of new HIV diagnoses in 2018.¹ As such, many GBQM may benefit from biomedical HIV prevention strategies such as pre-exposure prophylaxis (PrEP). Oral PrEP, tenofovir disoproxil fumarate with emtricitabine (TDF/FTC) or tenofovir alafenamide with emtricitabine (TAF/FTC), is usually taken as a pill daily, although TDF/FTC can also be used off label in Canada as “on demand” PrEP.² Oral PrEP was first approved for HIV prevention by Health Canada in 2016. Nonetheless, the uptake of oral PrEP in Canada has been described as “sub-optimal,” with many GBQM meeting clinical guidelines, but not taking this form of HIV prevention.³

In December 2021, the US FDA approved long-acting cabotegravir (CAB-LA) for use as injectable PrEP. However, injectable PrEP has not yet been approved for use in Canada. Clinical trials for GBQM and transgender women,⁴ as well as cisgender women,⁵ have shown that an injection of CAB-LA administered every 8 weeks is highly effective in preventing HIV infection. A primary benefit of long-acting PrEP over current oral options is easier adherence. Studies have noted that convenience, duration, ease of access, and privacy are important considerations for patients' PrEP decision-making.^6
–8 Thus, it is possible that the added convenience of injectable PrEP versus oral PrEP might encourage some eligible PrEP candidates to become PrEP users.

Research from the United States and Australia on willingness to use long-acting PrEP has demonstrated that many GBQM are interested in using or switching to injectable PrEP, with some preferring it instead of oral PrEP, because of potentially reduced side-effects and helping to overcome challenges with daily adherence.^9
–11 PrEP-using GBQM have reported that a sense of responsibility, the emotional burden of taking medication daily, and identifying as an “early adopter” were reasons for wanting to switch from oral to long-acting PrEP.¹² One study of 314 GBQM in Washington, DC showed that 67% preferred injectable PrEP compared to 24% preferring oral PrEP, with the remainder choosing not to take PrEP at all.¹³ Sixty-two percent of the GBQM surveyed also said that they would try long-acting PrEP if it were available for free.¹³

A US study noted that despite an interest in long-acting PrEP among GBQM, some reported that they were concerned about the half-life of the injection.¹⁴ From a clinical perspective, the reason for specific concerns is the risk of inducing resistance if someone with low residual levels of cabotegravir were to acquire HIV. Similarly, another study found that young cisgender men and transgender women who have sex with men (16–29 years old) in the US reported concerns about pain, side effects duration/severity, level of protection between each injection, and distrust of injections/medical systems.¹⁵ The same study noted HIV stigma, sexual stigma, and cost as barriers to the uptake of injectable PrEP.

New modalities for PrEP delivery have the potential to change the experience of PrEP use among GBQM, including improving uptake and adherence. However, limited qualitative research exists to inform health promotion and implementation of injectable PrEP. As Philbin and Perez-Brumer have argued, the promise of long-acting PrEP modalities, including injectable PrEP, “must be approached with cautious optimism in light of the embedded inequities across all stages of research, development, and, most critically, population-level scaleup” (2022:73).¹⁶

We explored GBQM's interest in using injectable PrEP for HIV prevention, their willingness to use it, their preferences between different PrEP options, and their acceptability more broadly. We also interviewed health system stakeholders (e.g., health care providers, public health officials, community-based organization staff) to understand the broader structural context to explicate possible intersecting implementation barriers at the patient, provider, and systems levels.¹⁷

Methods

We conducted qualitative interviews with PrEP using and sexually active non-PrEP using GBQM to learn about their PrEP decision-making and experiences. Participants lived in one of three cities in Ontario, Canada: Toronto, Ottawa, or Hamilton. The interviews are part of a 3-year, annual longitudinal series called PRIMP, a multi-component implementation science project that started in 2020. The data below come from the second round of interviews conducted in the spring and summer of 2021 and include 22 participants in Ontario (16 current and former PrEP users and 6 non-PrEP users). Two PrEP users and two non-PrEP users who participated in first-round interviews in 2020 did not complete their second-round interviews in 2021.

During the second interview, participants were asked if they had heard of injectable PrEP (“Have you heard about injectable PrEP?”). We explained what injectable PrEP was to those who had not heard about it, and asked all participants if this would be a method they would be interested in pursuing when it became available (“Would this be something that would interest you (more or less) than taking PrEP as a pill?”). We then elicited further explanations from participants for their affirmative or negative responses, probing to explore what they thought about this new modality. Participants received $50 CAD after completing the second interview.

In addition, 20 key stakeholders from Ontario participated in the study through small focus groups (n = 17; 6 focus groups with between 2 and 4 participants each) or individual interviews (n = 3), which took place between July and October 2021. Participants included four public health officials (directors and clinical personnel), nine health care providers (infectious disease specialists, general practitioners, nurses/nurse practitioners, pharmacists, and sexual health counselors), and seven representatives from HIV/AIDS service and community-based organizations. No honorarium was provided to key stakeholders. These participants were asked how they thought the implementation of PrEP would be affected by the availability of an injectable option (“How will injectable PrEP affect implementation?”). They were also probed about the potential impacts of injectable PrEP on their clients (“Do you see injectable PrEP as valuable for the people you work with? How so?”).

The focus groups were interdisciplinary to allow for cross-professional discussion, and the sessions lasted between 45 and 90 min. We stopped recruiting key stakeholder participants once thematic saturation was achieved. An important benefit of focus groups was that they provided key stakeholders an opportunity to reflect upon and engage with the experiences and perspectives of their peers (e.g., building upon examples provided, agreeing, or disagreeing with assessments). We had three key stakeholders who elected to take part in individual interviews due to availability/scheduling conflicts.

We have reported the in-depth details of our methods elsewhere.¹⁸ In summary, both interviews and focus groups were audio recorded, transcribed verbatim, and analyzed in NVivo using thematic analysis.¹⁹ When coding focus group interviews, we also analyzed the exchanges between participants to help analytically account for the convergence and divergence of stakeholder perspectives. The initial coding phase was deductive, with all mentions of injectable PrEP coded together, followed by an inductive analysis of key trends regarding interest in and willingness to use injectable PrEP, as well as stakeholders' reactions to injectable PrEP and the perspectives of their colleagues on this topic. This study was approved by the Research Ethics Board of the University of Toronto and Unity Health Toronto.

Results

At baseline, 10 participants were in their 20s, 6 were in their 30s, 5 were in their 40s, and 1 was in their 60s. Seven self-identified as White, four as Asian, three as Middle Eastern, two as South Asian, one as Latino, and one as mixed race. Nineteen participants identified as gay, and two as both queer and bisexual. One participant identified as pansexual. Twenty participants self-identified as cisgender and two as transgender. Fifteen people lived in Toronto, six lived in Ottawa, and one lived in Hamilton (all cities in Ontario, Canada).

Some context regarding participants' PrEP use trajectories from baseline (over 12 months) is important to note. Nine participants who reported daily PrEP use in 2020 did not report altering their regimens in 2021. Two participants who had stopped PrEP in 2020 due to the COVID-19 pandemic resumed using PrEP daily in 2021. One participant using PrEP on demand in 2020 continued to do so in 2021. One non-PrEP user in 2020 initiated PrEP use in 2021. Three participants had experience using PrEP before their interviews at baseline, but stopped during the 2020 and 2021 interviews. Six participants did not have any experience of using PrEP in 2020 or 2021 (Table 1).

Table 1.

Sociodemographic Characteristics and Pre-Exposure Prophylaxis History of Gay, Bisexual, Queer, and Other Men Who Have Sex with Men Study Participants

Total (n = 22)	n (%)
Age range
19–29	10 (45.5)
30–39	6 (27.3)
40–49	5 (22.7)
50+	1 (4.5)
Ethnoracial background
Black	4 (18.2)
East/Southeast Asian	4 (18.2)
Latin American	1 (4.5)
Middle Eastern	3 (13.6)
Mixed race/ethnicity	1 (4.5)
South Asian	2 (9.0)
White	7 (32.0)
Gender identity
Cisgender	20 (91.0)
Transgender	2 (9.0)
Sexual identity
Gay	19 (86.5)
Bisexual and queer	2 (9.0)
Pansexual	1 (4.5)
PrEP use status^a
Current PrEP user	13 (59.1)
Non-PrEP user	6 (27.3)
Former PrEP user	3 (13.6)

As of 2021 interview.

PrEP, pre-exposure prophylaxis.

Of the 22 GBQM we interviewed, only eight had previously heard about injectable PrEP, six of whom had experience using PrEP (current or former users), while two did not. A few participants knew that this form of long-acting PrEP was still being trialed and that it was not yet available in Canada. As one participant said, “I've been hearing that it's a new thing that could be like a twice a year kind of a thing, but I don't know if that's something that's even available” (30s, PrEP User). It is possible that this participant was referencing another injectable agent that is also being studied as PrEP (lenacapavir), for which the regimen is administered every 6 months. It could also be that he had inaccurate information about CAB-LA or even confused it with other investigational PrEP formulations.

This is significant because while our discussion with participants about injectable PrEP largely focused on CAB-LA, injectable PrEP could take a number of forms that may have varied levels of acceptability, and it is important not to conflate different PrEP products. In one instance, a participant thought that they were aware of injectable PrEP, but it was HIV vaccine trials that they had read about.

Overall, the GBQM participants were interested in long-acting PrEP. Below, we outline participants' different reactions to injectable PrEP based on their PrEP usage. PrEP users considered the advantages of switching between PrEP options; non-PrEP users discussed whether this new option may change their interest in taking PrEP. Key stakeholders were excited about the promise of long-acting PrEP to increase uptake but were concerned about its limited accessibility and provided insight into both the clinical context and broader access challenges. Most stakeholders were aware of injectable PrEP, and only one person said that they were not sufficiently knowledgeable to comment on this new modality.

Our thematic results from both sets of interviews are summarized in Table 2.

Table 2.

Summary of Key Perceived Benefits and Barriers for the Use of Injectable Pre-Exposure Prophylaxis

	Gay, bisexual, and queer perspectives (n = 22)		Health system stakeholders (n = 20)
	Current and former PrEP users (n = 16)	Non-PrEP users (n = 6)	Health system stakeholders (n = 20)
Perceived benefits	Convenience	Convenience	Convenience
	e.g., “would be nice to just have it in, to set it and forget it”	e.g., “definitely [be] more convenient”	e.g., “really exciting” since it will be “a lot easier” and “convenient” for users
	Adherence	Adherence	Adherence
	e.g., “so much easier… every time I want to sleep over at somebody else's place, [. .] camp, or I want to travel, I always have to think about like, ‘don't forget PrEP, don't forget PrEP, don't forget PrEP’”	e.g., “less likely to be neglected”; “[if I decided] to take PrEP I would seriously consider that option [injections] because like I said, I'm terrible at taking meds every day”	e.g., likely to help those who “struggle with adhering”; benefit “people with marginalized identities” that are “unstably housed, or have mental health or substance use issues”
	Confidentiality		Confidentiality
	e.g., “… my alarm rings, ‘what's if for?’ [someone asks], ‘oh I have to take my meds’. ‘What meds?’ ‘Oh PrEP’. ‘Oh my God, what does that do?’ blah, blah, blah. I don't need that”		e.g., “people who are, maybe living with roommates or family members who don't know that they're taking PrEP, will stand to benefit greatly”
	Limits pill taking		Efficacy
	e.g., already on other medications so want to “limit the number of pills”; daily pill as “a chore”		e.g., “better intervention” that is “more effective” than oral PrEP
			Increased health care engagement
			e.g., “more points of contact with the healthcare system” could lead to “a sense of closeness and of trust” with providers
Perceived barriers/reasons for not using	Cost	Cost	Cost
	Cost/insurance coverage described as a barrier both to oral PrEP and potentially to injectable PrEP when it becomes available if not fully covered
	e.g., cost/loss of coverage for oral PrEP part of reason some people stopped using: “Should I cut this [PrEP] from my budget because of the cost adding up?”	e.g., found oral PrEP “unaffordable” so thought injectable PrEP would be as well: “Universal pharmacare would make it easier for me and lots of other people too”	e.g., injectable PrEP “not going to be helpful at all” if it is not covered by public insurance
	Time/Adherence	Time/Adherence	Time/Adherence
	Time/adherence described as a potential barrier to injectable PrEP (e.g., spending time at a clinic/pharmacy to receive injections every two months)
	e.g., “I wouldn't like it because I would have to go to the doctor, or the nurse, and that would take more time”	e.g., not sure if injectable PrEP would “take more time”	e.g., some patients “not returning” for injection
	“Aversion to needles”
	e.g., trans participant tired of taking needles for testosterone and would “not be so inclined” to switch	e.g., “don't like the idea of using a needle”
	Efficacy concerns		Implementation challenges
	e.g., “oh my God, is the shot still working or something? I feel like the pill gives you that sense of… you know, you're actually doing it”		e.g., increased in-person visits required: “we don't have enough resources to provide [oral] PrEP when people need it [now], without more support from government with injectable PrEP I think it's going to be you know… it's going to be tough to implement”
	Not required for them personally
	e.g., PrEP adherence not a significant challenge and oral PrEP currently working for them or no longer needed: “I'd probably keep the pill because that way, I'm consistent”	e.g., not interested in any form of PrEP; using other HIV prevention strategies or did not consider themselves at risk: “If I can successfully navigate sexual life without needing to use technologies that have potential harm to the body, why would I do that sort of thing?”

PrEP, pre-exposure prophylaxis.

Current and former PrEP user perspectives

Among PrEP users—both current and former—the general reaction toward injectable PrEP was favorable, with many interested in trying it once it became available if it “was just as effective” as taking PrEP as a pill (40s, current PrEP user). Some described taking a daily pill as “a chore, and a needle every 2 months doesn't sound that bad” (20s, former PrEP user). One PrEP user commented that “it would be nice to just have it in, to set it and forget it” (30s, current PrEP user).

A few people who were currently using PrEP discussed how it was sometimes difficult to find a regular time every day to take PrEP and how it can be a hassle to get prescription refills: “the problem with the pills is that you have to take it regularly, I think, to try to get it at the same time in the day, it has to be consistent for it to work, and also you run out” (40s, current PrEP user). This participant described how some pharmacies restricted refills to a 30-day supply during the COVID-19 lockdowns, which caused an extra barrier. As such, he articulated how “the idea of a dose that lasts a couple of months at a time does sound really good.”

Others mentioned how an injection would help “limit the number of pills” they had to take daily as they were already on other medications (20s, current PrEP user). In discussing the possibilities of injectable PrEP, a number of participants noted that it was not clear if this new form of PrEP would alter the number of times they needed to see their doctor compared to oral PrEP, noting that an increased number of doctor visits would be a deterrent to switching.

Many PrEP users describe how an injectable format might help them adhere. Some found it “confusing” to remember whether they took their PrEP. In addition, some participants discussed how an injection would make it easier if their schedules were irregular, including when they were traveling, by removing the privacy concerns associated with taking HIV medication across borders, or when they were hooking up at other people's homes:

I take one injection [for allergies] a month. It's just so much easier and you wouldn't have to think about it that much. With PrEP, every time I want to sleep over at somebody else's place, or every time I want to go to a camp, or I want to travel, I always have to think about like, ‘don't forget PrEP, don't forget PrEP, don't forget PrEP’, and just kind of having one less thing to think about is a good thing. (20s, current PrEP user)

Linking to the travel-related benefits of injectable PrEP, an injection was thought to help some GBQM keep their PrEP use more “confidential” and avoid unwanted conversations about it. A current PrEP user put it as follows:

I move around a lot and you know. I would hate to forget [my PrEP]. It's never happened because I have an alarm, but it's just the constant, oh my alarm rings, what's it for, oh I have to take my meds. What meds? Oh PrEP. Oh my God, what does that do, blah, blah, blah. I don't need that. I would rather just have it and then I don't have to see a professional until x, y, and z. (20s, current PrEP user)

Some PrEP users were curious about injectable PrEP but did not think they would switch from taking it in a pill form, mostly because they “don't like the idea of using a needle” (20s, current PrEP user). For example, a trans participant discussed being tired of taking needles for testosterone; thus, he would “not be so inclined” to switch to injections (30s, current PrEP user).

Two GBQM with experience taking PrEP discussed preferring to still take PrEP as a pill so that they could feel more in control of the process: “I'd probably keep the pill because that way I'm consistent, the drug is consistent in my body… so unless there's a pressing need for it, I probably wouldn't [switch to injections]” (40s, current PrEP user). Another participant thought injectable PrEP was “amazing,” but he did not want to switch methods because, even though taking a pill everyday can be “annoying” with the injection, “I would be very anxious about that, like oh my God, is the shot still working or something? I feel like the pill gives you that sense of … you know, you're actually doing it” (30s, former PrEP user).

Having to spend time at a clinic to receive injections every 2 months was another barrier to uptake according to some participants: “I wouldn't like it because I would have to go to the doctor or the nurse and that would take more time” (20s, current PrEP user).

While some PrEP users described forgetting a pill occasionally, in general, no PrEP users discussed significantly struggling to adhere to PrEP. Furthermore, across these accounts, stopping PrEP for periods of time or altogether was not attributed to adherence challenges or the PrEP modality (e.g., an oral pill) but rather to changes in relationship status, sexual behaviors (including changing sex lives in the context of COVID-19), and cost or loss of insurance coverage, given that PrEP medication is not universally free of charge in Ontario.

Non-PrEP user perspectives

Similar to current and former PrEP users, non-PrEP users were interested in injectable PrEP and expressed favorable views. They understood that it could “definitely [be] more convenient and less likely…to be neglected” (40s, non-PrEP user). Others commented that the injectable format could help those who struggle to take medication routinely. One participant discussed how, if he decided “to take PrEP, I would seriously consider that option [injections] because, like I said, I'm terrible at taking meds every day” (20s, non-PrEP user).

Another man thought that injectable PrEP “definitely sounds pretty good. I'd still probably lean more towards taking the pill just because I personally don't love needles” (20s, non-PrEP user). One non-PrEP user (60s) clarified that he was glad that the option for injections would make PrEP access more accessible, but it would not change his decision not to try PrEP. He was confident of his safer sex strategies, which involved knowing the HIV status or viral load status of his partners and strategic positioning.

Non-PrEP users decided against trying PrEP because they did not consider themselves at risk, were confident with their current safer sex strategies, and/or found PrEP unaffordable. For example, a participant noted: “If I can successfully navigate sexual life without needing to use technologies that have potential harm to the body, why would I do that sort of thing?” (60s, non-PrEP user). However, no participant chose not to take PrEP because they thought the pill format was too much of a hassle or feared they could not remember to take it as prescribed. For both PrEP and non-PrEP users, injectable PrEP offered additional convenience to those not afraid or already encumbered by needles. Despite the noted benefits for many, the injectable modality did not appear to significantly affect PrEP decision-making (e.g., starting PrEP or switching PrEP modalities) for the GBQM we interviewed.

Perspectives of health system stakeholders

Overall, the stakeholders we interviewed were interested in the prospects of injectable PrEP and optimistic about its benefits. For example, one provider described injectable PrEP as “really exciting” (general practitioner, interview) since it will be “a lot easier” and is a “better intervention”—that is, more effective—than oral PrEP. Another provider said that this increased benefit may be especially the case for those who “don't have a steady routine” and that injectable PrEP can also create “more points of contact with the healthcare system” that could lead to “a sense of closeness and of trust” with providers (general practitioner, interview).

A few providers mentioned that their clients were already asking about injectable PrEP. While some considered how it would be a “really great fit” (nurse practitioner, focus group) for certain PrEP users, they also thought that its implementation is “so far off that it's not even on my radar,” given that no submissions to Health Canada to consider approval for long-acting PrEP modalities had been made at the time of interview. However, another participant explained that “we've had conversations on my team [about injectable PrEP] but I don't know that it's formally really come up,” (government staff, focus group) suggesting that while this new modality is on the radar of some within the Canadian HIV sector, specific implementation logistics may have had limited consideration and planning to date.

Some providers have argued that injectable PrEP might be better (or more suitable) for some patients. Various stakeholders noted that injectable PrEP would likely help individuals who struggle to adhere to their daily PrEP regimen. A general practitioner articulated that it would be more “convenient” than oral PrEP and, as such, “people with marginalized identities” who are “unstably housed, or have mental health or substance use issues, or people who maybe living with roommates or family members who don't know that they're taking PrEP” will stand to benefit greatly.

Another provider also discussed how it would be ideal for the “most high-risk population” (nurse practitioner, interview), such as those who inject drugs. Yet, they argued that it is “not going to be helpful at all” if it is not covered by public insurance. They said that those with private insurance “are fairly good about taking their medications and adherence,” and thus, they are not the ones who need injectable PrEP the most.

The stakeholders cautioned that for injectable PrEP to be effective, patients will still need to adhere to health care visits by returning to the clinic every 2 months (as opposed to every 3 months with oral PrEP). Concerns about patient compliance for injectable PrEP were noted by several providers; therefore, “whether or not [patients] want a daily medication or … an injectable every couple of months, it's gonna be a personal preference for people” (nurse practitioner, focus group) and their capacity to return to the clinic at regular intervals.

Some clinicians also expressed concern about the greater human resources needed to administer injectable PrEP. As one provider declared,

So, if we're sort of complaining that we don't have enough resources to provide [oral] PrEP when people need it [now], without more support from [the] government with injectable PrEP, I think it's going to be, you know… it's going to be tough to implement. (infectious disease specialist, focus group)

This health care provider estimated that for every 100 patients currently on oral PrEP, injectable PrEP would add “an extra 200 visits” over the year, creating serious logistical concerns for doctors. Moreover, a number of providers noted that because injectable PrEP will require that patients be present at a clinic in person, reconciling it with new models of virtual or tele-health PrEP popularized during COVID-19 may be challenging from an implementation perspective.

Nevertheless, while stakeholders described various issues and considerations for the implementation of injectable PrEP in Canada, they agreed that this new modality is an innovative and welcomed addition to their HIV prevention toolbox. As the following stakeholder reflected:

Yes, there will always be implementation concerns for any new product or use of these technologies, but I think if we don't have them then we're stuck. So, the more choice you have in terms of how we're offering the things, the better. Yes, it's going to be work to figure out how best to use them […] but you're kind of limited to what you have, so I think we should always be scanning for … thinking about mitigation to potential downsides but also allowing for innovation. (government staff, focus group)

Discussion

As the HIV prevention landscape continues to evolve, long-acting PrEP delivery options, including injectable PrEP, may increase the appeal, uptake, scalability, and overall impact of PrEP nationally and globally.²⁰ A core hope for novel PrEP modalities is to appeal to new users and ultimately lead to reduced HIV infections. However, it is necessary to address access barriers and implementation issues proactively to ensure the successful and equitable rollout of injectable PrEP. This requires addressing potential barriers at the intersecting levels of patient, provider, and systems. ¹⁷ Our research provides a preliminary assessment of the acceptability of injectable PrEP in Ontario as a way to ground future research and program planning.

GBQM accounts revealed limited knowledge of injectable PrEP among current PrEP users and nonusers in Canada. This lack of knowledge in the sample is perhaps not surprising, given that injectable PrEP has not yet been approved by Health Canada at the time of the interviews and the dearth of public health messages about this long-acting modality in Canada. Despite this, many PrEP users expressed enthusiasm about injectable PrEP and interest in switching to injectable PrEP due to its perceived convenience. Some non-PrEP users also described injectable PrEP as convenient, which may help those who have difficulty adhering to the dosing regimen. However, some PrEP users said they still preferred taking PrEP as a pill because they feared injections and doubted the effectiveness of injectable PrEP. Non-PrEP users cited low perceived HIV risk, confidence in current safer sex strategies, and cost as reasons for not adopting injectable PrEP.

Given these perspectives, it is necessary to further understand how PrEP users and potential users may select among PrEP options, switch between options, or discontinue PrEP altogether.¹² Knowing GBQM's preferences could help providers support GBQM during their decision-making and further aid in planning for the implementation of long-acting PrEP modalities. Furthermore, from a public health perspective, these data could indicate whether introducing more PrEP options would increase PrEP uptake and help prevent more HIV infections.

Some studies suggest that the acceptability of injectable PrEP may differ across sociodemographic groups, with some younger GBQM being more inclined to switch to or start long-acting/injectable PrEP modalities.^21,22 Sex workers and people who use injectable drugs have also demonstrated varying degrees of acceptability for injectable PrEP, but have generally reported greater acceptability and perceived usefulness of being able to adhere to the medicine inconspicuously.^7,23,24 This suggests that acceptability/uptake of injectable and long-acting PrEP may be greater for populations that seek to conceal their PrEP use, including some closeted queer people and those who may feel stigmatized for using PrEP. Another study reported privacy as a key consideration by US GBQM when choosing a PrEP modality.⁸ However, some participants in that study noted preferring oral PrEP over other long-acting modalities for being able to take a pill unnoticed.⁸ Although, in some respects, injectables allow for more privacy, this may not be the case depending on people's circumstances and specific privacy concerns (e.g., if someone is worried about being seen attending health care facilities where they would receive injections from a health care provider).

Studies have also suggested that PrEP acceptability and uptake varies across ethnoracial groups, including lower uptake in Black communities, and have mainly attributed this reduced uptake to medical mistrust.^25,26 Notably, one study with a sample of 303 GBQM in the US reported that while Black men were least likely to have tried oral PrEP, they reported equally high levels of interest in injectable PrEP compared to White and Hispanic respondents.²⁷ Further efforts are required to provide culturally competent and relevant information about PrEP to communities who could stand to most benefit so that people can make informed decisions about their own health needs.

In our sample, it is notable that while the GBQM we interviewed were supportive of this new modality in general, none of the non-PrEP using participants expressed interest in starting to use injectable PrEP. Non-PrEP users either did not think they needed PrEP, or thought it would remain unaffordable, as they noted that oral PrEP was. However, recent research using a discrete choice experiment has argued that having a wide range of PrEP options can motivate some people who do not take oral PrEP to consider a different long-acting PrEP modality.²⁸

As public health researchers, we hope that having more PrEP options will attract new users, and if it does not, we should seek to better understand how to address community needs. However, even with more options, PrEP—in any form—may not be suitable for some GBQM for various reasons. While removing structural barriers to access is imperative, it is also important to avoid pathologizing non-PrEP use. Rather, it is crucial that GBQM and all communities who stand to benefit from this form of HIV prevention have the knowledge and resources they need to have a safer, pleasurable sex, which may (or may not) involve a variety of biomedical HIV prevention strategies depending on their context and needs.

Notably, most of the non-PrEP users in our sample said they did not need to use PrEP because they did not consider themselves at risk of acquiring HIV, either because they were in a monogamous relationship or were using condoms consistently with nonregular partners. One strength of our ongoing longitudinal analysis is the tracing of these trajectories and (re)assessments over time. For example, as noted in this analysis, some GBQM reassessed their PrEP use needs from baseline to the second interview 12 months later (e.g., restarting PrEP after a period of nonuse because of having less sex during the first waves of COVID-19). Future research is needed to realize the potential of these longitudinal data. It is also important to consider how some HIV-negative GBM may consider the message of undetectable equals untransmittable, or U = U, as part of their PrEP decision-making and how these assessments may change over time.^29
–31

From the providers' perspective, it is necessary to build capacity among different health care professionals—not just HIV specialists—so that they can offer proper assessment and counseling for PrEP users to help sort through options.¹⁷ A latent class analysis exploring sexual health care decision-making among young GBQM in the US found that participants in the shared decision-making class (high communication with providers and high autonomy) had higher PrEP awareness as well as past and current PrEP use compared to provider-led decision-making and patient-driven decision-making.¹¹ US research has also noted the lack of comfort some providers have with recommending PrEP in any form to young people, citing concerns about medication adherence, consent, and the appropriateness of prescribing/managing PrEP use among adolescents.³²

The providers we interviewed noted significant advantages to this long-acting PrEP modality (e.g., convenience, adherence, confidentiality, efficacy, and health care engagement). However, the capacity challenge noted by Meyers and Golub was a significant implementation issue, most notably, the time resources required to make injectable PrEP available.¹⁷ Recent literature has similarly identified a lack of provider knowledge about PrEP modalities and clinician capacity/resources as important considerations for the implementation of injectable PrEP.^33,34 To address these concerns, providers must be better informed about different PrEP modalities and be supported to learn about and communicate these options to their clients. Moreover, as some providers have identified frequency of visits as potential barriers to implementation of injectable PrEP, offering accessible options, such as pharmacies for testing and delivery, should be considered. It is also important to promote long-acting PrEP options when they become available to increase community knowledge of PrEP in its multiple forms.³⁵

At the system level, resources need to be devoted to ensuring that potential users who could stand to most benefit have access as well as current PrEP users who may wish to switch.^17,36 Even oral PrEP is not currently free across Canada to those who meet clinical guidelines,^18,36 and cost barriers remain a significant cross-cutting concern for all stakeholders interviewed when considering this new iteration of biomedical HIV prevention. We echo recent calls for an equity-promoting framework in the implementation of new PrEP modalities to avoid widening disparities in access and health outcomes.³⁷ Although PrEP is frequently marketed as free for “most” people (https://www.gofreddie.com; online PrEP clinic) in Canada, cost remains a structural access barrier in Ontario.

It is notable that online options for prescribing PrEP, such as the example of Freddie, have also capitalized on the idea that: “Awkward doctor's visits are a thing of the past…our inclusive clinicians “get” LGBTQ2S+ healthcare.”³⁸ It is unclear if and how online oral PrEP options that prescribe and deliver PrEP will adapt to new long-acting modalities given the need for in-person engagement with health care practitioners.

Despite the promise of injectable PrEP, its approval and availability alone are not sufficient to increase its use. A significant public health hope is that new PrEP options would attract new users and overcome the shortcomings of oral PrEP that threaten its effectiveness (e.g., adherence). While our sample in this analysis was modest, our findings raise the question of whether and for whom injectable PrEP is most attractive. To move the needle to prevent new HIV infections, it is necessary to continue to better understand the potential limitations of this new modality and determine what else can be done to address these gaps. As has been raised by others,³⁴ implementation considerations for long-acting PrEP should target specific patient populations who may benefit the most from this new modality as well as address barriers at the provider and systems levels.

Our study has several limitations. More research with participants from diverse sociodemographic profiles in and beyond GBQM, including younger people, women, and racialized communities (and their intersections), is needed to understand if injectable PrEP might lead to expansion of PrEP uptake within the larger community, particularly within groups that may have higher rates of new HIV diagnoses. We also believe that more research is required to further understand who among non-PrEP users may benefit most from this form of HIV prevention. It is noteworthy that our questions regarding injectable PrEP were hypothetical during the interviews.

While a 2020 systematic review found heterogeneity in the preferences of patients for different PrEP modalities, the authors argue that patients may need to try or gain familiarity with new modalities—rather than rate them hypothetically, as was done in this study—to increase acceptability and uptake of newly available options.³⁹ As Bernays et al. argue, responding to “contested questions such as for whom PrEP is for and how to ensure greater equity in its availability and accessibility, as well as exploring its varied appeal and ability to meet the needs (and risks) of potential users,” are complicated and require sustained attention (2021:5).²⁰

Injectable PrEP will hopefully soon be added to the menu of biomedical HIV prevention options that are available to GBQM and other populations who may benefit from it in Canada. While increasing approved PrEP modalities offers an exciting opportunity for expanding HIV prevention at the individual and population levels, it is also necessary to emphasize that injectable PrEP (or any form of PrEP) may not be of interest to GBQM for a variety of reasons. Furthermore, this new modality alone—or any long-acting form of PrEP (e.g., long-acting oral, infusion, and implantable options)—will not resolve structural barriers to PrEP access, including cost and access to knowledgeable and supportive health care providers.⁴⁰ Possible implementation challenges, including the time and personnel needed for injectable PrEP to be made available, also require sustained attention to ensure equitable access.

Footnotes

Acknowledgments

The authors thank the research participants, the PRIMP Community Advisory Board, Karla Fisher, and Saira Mohammed.

Authors' Contributions

D.G. conceived this article and led the development of this article. M.G. and J.S. conducted the qualitative interviews and contributed to the analysis and article development. D.G. and N.J.L. oversaw the qualitative arm of the study in collaboration with D.H.S.T. and M.H. E.D. and M.M. contributed to the literature review and analysis. All authors reviewed and approved the final article.

Data Availability

The full qualitative transcripts that support this study cannot be publicly shared for ethical or privacy reasons. These questions may be directed to the corresponding author.

Author Disclosure Statement

D.H.S.T.'s institution has received support from Abbott and Gilead for investigator-initiated research grants and from Glaxo Smith Kline for industry-sponsored clinical trials. M.H.'s institution received support from Gilead for investigator-initiated research grants. The other authors have no conflicts of interest to declare.

Funding Information

This work was supported by the Canadian Institute of Health Research (no. CTW 155346). D.G. was supported by a Tier 2 Canada Research Chair in Sexual and Gender Minority Health. N.J.L. was supported by the Michael Smith Foundation for Health Research Scholar Award (no. 16863). D.H.S.T. was supported by a Tier 2 Canada Research Chair in HIV Prevention and STI Research.

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