What patient factors influence your decision between prescribing oral pre-exposure prophylaxis and long-acting injectable PrEP for HIV prevention?

First of all, is the patient generally compliant? Most of the time we use oral, once-daily agents for PrEP, but we do have some individuals on every-2-month injectable Cabenuva now. We do not have anyone on every-6-month lenacapavir, since the VA does not offer it. Have a discussion with the patient and see whether they are ready and willing to come to the clinic for injections every 2 months.

Parenthetically, we had one patient on injectable Cabenuva who developed hepatitis. We stopped it, the liver function tests came down, and we started oral cabotegravir/rilpivirine, and he has done very well. I am very suspicious that most patients do not take PrEP every day, but instead take it when they think they had (or will have) an exposure.

In our system, we have IM cabotegravir. Lenacapavir is covered by Medi-Cal, but is not on our formulary yet.

In our publicly funded, managed care system, we are more cost-conscious than most, and we tend to prefer oral, generic FTC/TDF.

However, when patients ask for IM HIV PrEP, we do our best to accommodate--this is usually a signal that they face barriers to adherence to PrEP--adherence to daily or on-demand PrEP, stigma, access to medications/refills, etc. To get IM PrEP, we only need to document that they have "failed" oral PrEP (which we interpret as being at-risk for failure).

For IM PrEP or long-acting ART, we assess:

• access to transportation,
• ability to attend clinic appointments within the acceptable window (Work/school, travel s...