The word of the week at the 2024 HIV Research for Prevention Conference, held last week in Lima, Peru, was “choice.”

As in PrEP choice, a driving concern for the more than 1,300 scientists, advocates, community representatives, and policymakers who gathered at the fifth annual HIVR4P conference, organized by the International AIDS Society.

“This is the only global scientific conference focused exclusively on the rapidly evolving field of HIV prevention research,” said Dr. Beatriz Grinsztejn, the infectious diseases researcher serving as IAS president, addressing the event’s opening press conference.

Attendees at HIVR4P 2024 — which included NIH’s National Institute of Allergy and Infectious Diseases director Jeanne Marrazzo, who succeeded Anthony Fauci in the role — spent the week at sessions poring over the latest advances in science and research that could expand the growing list of available HIV prevention options.

Currently, those who want or need to take some form of pre-exposure prophylaxis to prevent HIV might opt for daily oral PrEP, long-acting injectable PrEP medicines, or, in a handful of African nations, a topical vaginal ring. The underlying point there being that choice depends on access.

Not everyone at risk of HIV, everywhere in the world, has the same access to all the same prevention tools science has produced. But access, though a key topic of research and discussion, was not the buzzword at the HIVR4P 2024 press conference.

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“It’s becoming increasingly clear that the HIV prevention field is focusing on expanding choice for women among long-acting prevention technologies,” said the morning’s first presenter, Jeremy Nuttall, of the Population Council’s Center for Biomedical Research (CBR), a scientific investigation hub based at Rockefeller University in New York City.

Nuttall presented the results of a clinical trial in the development of a dapivirine vaginal ring for HIV prevention that provides protection for three months rather than just one month. The one-month version is effective, Nuttall pointed out, and fully under the woman’s control. “However, we’re interested in having a longer-acting version for a number of reasons.”

A three-month ring would reduce burden on the user, he explained. “In terms of fewer insertions and visits to the clinic, which, in turn, could lead to increased adherence and effectiveness of the product. Reduced annual cost, requiring only four rings annually, rather than twelve. And reduced waste and environmental impact.”

The estimated cost for the three-month ring would be less than $16, excluding distribution costs, and CBR is “currently preparing to seek regulatory approval,” targeting entrance into the market as early as 2026. Touting the three-month ring as another prevention technology with life-changing potential, Nuttall ended by emphasizing “the importance of choice in combating the epidemic.”

The next speaker, Elizabeth Irungu, of Jhpiego, the international health organization in Kenya affiliated with The Johns Hopkins University, also made that emphasis. A consistent theme of HIVR4P was how choice has a measurable effect on uptake and adherence to PrEP usage.

Irungu presented results from a study of uptake of the vaginal ring, compared to oral PrEP, among nearly 4,000 women at 28 sites in Kenya, Lesotho, South Africa, Uganda, and Zimbabwe. “When we asked women who chose the ring, why they chose the ring, they said it’s because it was easy to use,” Irungu informed us.

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“Fifty-nine percent said it was easy to use. About thirty-two percent said it was because they felt it was effective.” Some reported that they just didn’t like to take pills. “So we conclude,” she said, “that women are taking advantage of choice, and they’re choosing a method that works for them.”

Advancing another method that soon could join this array of options, Alessandro Grattoni, a researcher from Houston Methodist Hospital, shared promising pre-clinical data on a subdermal implant designed for ultra-long-acting delivery of antiretrovirals for HIV prevention.

Conceived as an alternative to oral and injectable applications, the implantable device was developed “to achieve this constantly sustained administration of drugs for years,” as Grattoni put it. “Distinct from other platform technologies, and other implants, the device is subcutaneously refillable, so it needs to be inserted surgically once and can be refilled every couple of years.”

In non-human primate studies, Grattoni’s lab demonstrated that, used in combination with investigational drug islatravir, their subdermal device “could sustain islatravir delivery for 29 months uninterrupted, without any refilling required,” he said. And the device achieved 100% PrEP efficacy.

While also studying use of the device as a platform for simultaneous delivery of HIV prevention and contraception meds, Grattoni and his team have formed a company called Continuity Biosciences, to take the technology towards commercial use. Commerce and science sometimes make uneasy partners in the ongoing race to bring more choice to the marketplace.

Also playing a major part at HIVR4P are scientists, administrators, donors, and other stakeholders determined to add a vaccine or cure as another tool in the comprehensive approach to HIV prevention around the globe.

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“We are still not where we need to be, in terms of the global HIV pandemic,” NIAID director Marrazzo noted in her speech at the conference’s opening ceremony, referring to sobering statistics released in the 2024 global AIDS update.

“We’re still seeing over one million new infections a year, and, by 2025, our goal, at one point, had been to see less than 370,000,” said Marrazzo. “We have almost forty million people living with HIV, and about 77% of them are on antiretroviral coverage, but that’s really not enough.”

Antiretroviral treatments for people living with HIV work to contain the virus to undetectable levels, thus effectively preventing transmission, i.e., U=U, Undetectable equals Untransmittable.

Getting more people who are living with HIV on treatment, and more people at risk on PrEP, remains vital to reversing trends of rising HIV rates in regions like Latin America and the Middle East. And, barring a viable cure, the solution ultimately may lie in providing as much choice as possible for prevention.

That includes Gilead Science’s shiny (and expensive) new option in the toolbox, the twice-yearly injectable PrEP, lenacapavir, which is steadily, though too slowly for some, proceeding to market. It might be years before it’s readily available, or affordable, for everyone who might choose it.

Until then, assuredly, the HIV prevention community must continue working to maximize the reach of those choices currently on the table.