On July 16, 2012, the U.S. Food and Drug Administration (FDA) approved Truvada, a pre-exposure prophylaxis (PrEP) medication that effectively prevents the transmission of the human immunodeficiency virus (HIV) when taken consistently. PrEP has been one of the greatest advancements since the HIV/AIDS pandemic began in 1981 and is free under most health insurance plans in the United States. Preventative medication, along with advances in treatment for people living with HIV, increases the potential to eliminate HIV/AIDS by 2030. However, taking a daily pill was a barrier to consistent use. In 2021 the FDA approved a bi-monthly injectable form of PrEP (also known as long-acting injectable PrEP, or LAI-PrEP) to overcome this barrier. However, one challenge remains: creating systems to get PrEP to people who need it.
The California HIV/AIDS Research Program (CHRP), based in the University of California Office of the President, is working to change that by prioritizing ways to get LAI-PrEP out to the community efficiently and effectively. As such, the work CHRP is doing to mandate and fund LAI-PrEP research exemplifies this year’s World AIDS Day theme: “Collective Action: Sustain and Accelerate HIV Progress.”
CHRP functions similarly to a state-funded National Institutes of Health (NIH), and since its inception in 1983, it has invested over $383 million in research and capacity-building grants. In early 2024, their Community-Centered Demonstration Projects to Support Implementation of Long-Acting Injectable PrEP Adoption Across California awarded five grants totaling nine million dollars around California specifically to expand access to LAI-PrEP. “The purpose of the request for proposals was to integrate this new medication into a suite of existing prevention services that exists in county health clinics, health departments, and hospitals,” says Rhodri Dierst-Davies, PhD, MPH, director of CHRP. This approach of supporting non-traditional service delivery models within the community is an important step, but also something that big institutions like the NIH might shy away from funding. “Our mandate is to fund novel, high-risk, high reward research that the NIH is too afraid to fund,” says Dr. Dierst-Davies. These are directly linked to priorities aligned with the State of California’s Ending the Epidemic(s) strategies.
An example of this novel approach is funding capacity-building to integrate LAI-PrEP into mobile van programs like the San Diego Department of Public Health, which already had a similar program designed for hard-to-reach populations, including people who use drugs. Additionally, the grant wants to reach communities that don’t have access to as many HIV/AIDS treatment and prevention resources. Sacramento and Fresno Counties, for example, have been under-resourced in these areas and that is why CHRP was excited to fund a project led by Kim Koester, PhD, MA, associate professor in the School of Medicine at the University of California San Francisco (UCSF) to partner with community-based public health centers to develop systems to deliver LAI-PrEP immediately and effectively to the community members.
Sacramento was named a priority county under the Center for Disease Control’s Ending the HIV Epidemic (EHE) program with HIV transmission rates going in the wrong direction. Partnering with Sacramento County, Dr. Koester’s background in anthropology and qualitative methods has been essential to discovering what community members want and need from services, specifically heterosexual women, gay, bisexual, and transgender persons. “We wanted to create systems where people felt safe, could easily access what they wanted and with the frequency with which they wanted it,” she says. “So, kind of coming up with a dream sexual health clinic.” This four-year project is called Breaking Barriers. “It’s all about building the capacity…We know that people want it. We know that providers would like to make it available to them, but it’s harder than we might like to think to set up the systems to offer it.”
Clinicians are trained to assess candidate eligibility for LAI-PrEP, and staff members are trained to deliver, administer, and track the injections in the system. “PrEP navigation is a big component of the system of having PrEP be easily accessible to make sure that people can, if they choose, to stay on PrEP over the long term,” says Dr. Koester. The research is a cross-section of community-based participatory research (CBPR)–involving and giving ownership to community members over the research–and implementation science–which seeks to reduce the time between science discovery and implementation in the community. As such, community engagement has been an essential component of the roll-out of Breaking Barriers, and they recently held their first peer learning session with a pharmacy and a sexual health clinic that both offer injectable PrEP. “We brought them in to share about their programming and how they do it and then everyone in the audience can learn about what kind of mistakes they've made and how they've learned,” says Dr. Koester.
Dr. Koester wants Sacramento to be a PrEP-friendly city. “We have all these measurements across the U.S. to understand the degree to which PrEP has penetrated the communities in need,” she says. “And we see that in places like in San Francisco and in New York, there's high penetration of PrEP to people who need it. My interpretation is that they are a PrEP-friendly city–there are a lot of providers who know how to go about prescribing it, they don't make people feel ashamed, they don't stigmatize people. People feel like they can go and get what they need and continue to get what they need.”
Dr. Dierst-Davies feels optimistic about the example the collective impact of Dr. Koester and the four other grantees on widely-held best practices for PrEP delivery across the country. “We would like to look at those in totality at the completion of the projects and look at best practices across them,” he says. “I'm hoping we have a paper about trying different implementation strategies for long-acting, injectable PrEP, what works and what doesn't.” Dr. Dierst-Davies has optimistic that these grants could lead to very high rewards. What helps communities in California could lead to helping communities all over the world and even being a part of ending the HIV pandemic altogether.