By Shobha Shukla
The fight against HIV has been strengthened in recent years by biomedical innovations that help prevent infection. Among these, Pre-Exposure Prophylaxis (PrEP)—medications taken by HIV-negative individuals to reduce their risk—has been a major advance. Since the US FDA approved daily oral PrEP in 2012, the treatment has become part of global prevention strategies. Now, newer long-acting injectable (LAI) PrEP options are opening new avenues, sparking debates on whether these should eventually replace oral PrEP—especially in regions like the Asia-Pacific, where PrEP uptake remains critically low.
This issue was at the heart of a high-level debate at the recent 10th Asia Pacific AIDS and Co-Infections Conference (APACC 2025) in Tokyo. With the 13th International AIDS Society Conference on HIV Science (IAS 2025) and POC25 also on the horizon, the discussion around PrEP options is gaining momentum.
The Case for Long-Acting Injectables
Despite the availability of oral PrEP, its uptake remains poor across the Asia-Pacific region. As of 2023, only around 204,000 individuals were using PrEP—merely 2% of the target of 8.2 million by 2025. Retention is also a challenge. In Thailand, which hosts more than half of all PrEP users in the region, 47% of users discontinued within a year, according to the Institute of HIV Research and Innovation (IHRI).
Jennifer Ho, a Thai global health advocate, argued passionately in favor of LAIs, especially for key populations who face stigma, discrimination, and legal risks. “Oral PrEP is not reaching those who need it most—transgender women, sex workers, young gay men, people who use drugs. Many are ashamed to take a daily pill, fearing stigma more than side effects,” she said. “Long-acting injectables remove these barriers. There’s no daily reminder, no pill to hide. It’s prevention that respects privacy and autonomy.”
Dr. Nagalingeswaran Kumarasamy, a leading infectious diseases expert from India, echoed this view. “Oral PrEP isn’t suitable for everyone. Expecting daily adherence from healthy individuals is unrealistic,” he said. “Long-acting injectables like cabotegravir and lenacapavir have shown superior efficacy. While initially expensive, they will be cost-effective in the long run. We need to think beyond short-term costs and build financing systems that reflect long-term public health gains.”
“Don’t Replace—Expand Choices”
While acknowledging the promise of LAIs, several experts cautioned against replacing oral PrEP altogether. Danvic Rosadiño, Co-Chair of WHO’s Guidelines Development Group on Long-acting Cabotegravir, said: “This is not a question of either-or. We must expand options, not eliminate them. Oral PrEP is cheaper, community-delivered, and already embedded in systems designed to reach vulnerable populations.”
He warned that LAIs may push prevention efforts back into formal medical systems, potentially excluding people who currently access oral PrEP in safe, peer-led, non-clinical settings. “We’ve built community spaces that offer dignity and safety. Long-acting injectables may undo this if they re-medicalise prevention.”
Dr Rayner Tan from Singapore supported this stance, emphasizing issues of equity and cost. “We don’t yet know what LAIs will cost once generics arrive, and most Asia-Pacific countries cannot afford current prices. Only Australia has approved long-acting injectable PrEP so far. We must protect affordable options for all,” he said.
Cost and Future Access
Cabotegravir, one of the injectable PrEP options approved since 2022, is administered every eight weeks and has shown high efficacy in various groups including cisgender women and transgender individuals. However, its current cost in high-income countries is a major barrier—about US$ 22,000 per user per year. A voluntary license with the Medicines Patent Pool allows for the manufacture of cheaper generic versions by 2027, potentially bringing the cost down to US$ 16–34 per year.
Even more promising is Lenacapavir, injected once every six months. Clinical studies (PURPOSE 1 and 2) showed 100% efficacy in preventing HIV among cisgender women, and 96% among men who have sex with men and transgender individuals. Yet, its current cost is an astronomical US$ 42,250 per year—far beyond the reach of most public health systems. Generic versions, expected by 2027, may reduce this to US$ 200–300 annually.
Real Choices, Real Prevention
Both sides agree on one thing: choice is crucial. Different people have different needs. A flexible approach offering both oral and injectable PrEP—along with emerging options like Doxy-PrEP, which also protects against some STIs—can empower individuals to choose what works best for them.
Speed, scale, access, and equity must guide the deployment of these tools. For now, it’s not about choosing one over the other, but building inclusive systems that trust people to make informed decisions about their own health.
Author’s Note: Oral PrEP remains a highly effective tool, reducing HIV risk by up to 99% when taken daily. Long-acting injectables are promising, but until affordability, access, and infrastructure are addressed, replacing oral PrEP would risk excluding the very people these tools aim to protect. Let’s expand—not limit—our options.
– CNS