Acceptability and Preferences of Long-Acting Injectable Pre-Exposure Prophylaxis and Antiretroviral Therapy Among Men Who Have Sex With Men and People Who Inject Drugs in India: Insights for Future Implementation.

Abstract

Introduction: Long-acting injectable (LAI) antiretroviral therapy (ART) and pre-exposure prophylaxis (PrEP) have significant potential to impact the HIV epidemic, but there is little data on the acceptability of these newer technologies among people who inject drugs (PWID) and men who have sex with men (MSM) in low-resource settings. We examined acceptability and preferences of LAI ART and PrEP among community-based samples of PWID and MSM in India.

Methods: We conducted a cross-sectional survey of PWID and MSM in eight Indian cities (November 2022-May 2024) using respondent-driven sampling. Participants completed a survey including socio-demographics, substance use, risk behaviours, HIV testing/care history, acceptability of LAI ART and knowledge, acceptability, and preferences of different PrEP modalities (i.e. daily oral, monthly oral, LAI and implant). We assessed correlates of acceptability using Poisson regression models. To understand PrEP preferences, we used a modified Borda count method-a rank voting procedure.

Results: Overall, 2249 MSM and 4499 PWID (98% male) were recruited. Among those previously diagnosed with HIV, 89% (MSM) and 75% (PWID) reported a very good chance they would use LAI ART. MSM experiencing unstable housing and PWID virally suppressed were more willing to use LAI ART. Twenty percent and five percent of MSM and PWID, respectively, had ever heard of PrEP. Among those without an HIV diagnosis, 77% (MSM) and 62% (PWID) reported a very good chance they would use LAI PrEP. MSM with more sexual partners and sexually transmitted infection symptoms and PWID who had heard of PrEP were more willing to use LAI PrEP. Among MSM interested in PrEP, monthly oral pills were most preferred, followed by LAI, daily oral pills and then implant. Among PWID, monthly oral pills were most preferred, followed by daily oral pills, LAI and then implant.

Conclusions: MSM and PWID in India were open and interested in LAI ART and PrEP. Once these become available, programmes with thoughtful community outreach and education, alongside flexible delivery models, will be critical to success. For PrEP, continued investment in the development of extended-duration oral formulations is warranted and valuable in order to provide a variety of HIV prevention choices.