Cochrane review: injectable lenacapavir cuts HIV infections versus oral PrEP at 52 weeks

RATIONALE: Globally, there are 1.3 million new HIV infections annually, with a disproportionate burden on young women and girls, especially in sub-Saharan Africa (63% of new infections). Despite the demonstrated effectiveness of pre-exposure prophylaxis (PrEP), global uptake remains low, reaching only 16.5% of the UNAIDS 2025 target. PrEP adherence is suboptimal in vulnerable populations. There is an urgent need to develop and implement alternative, user-friendly PrEP strategies like long-acting formulations that minimise reliance on daily dosing or frequent injections. Lenacapavir is a first-in-class, long-acting capsid inhibitor that disrupts HIV replication at multiple stages. Following an oral loading dose, lenacapavir administered by subcutaneous injection provides six months of protection against HIV. OBJECTIVES: To evaluate the benefits and harms of long-acting injectable lenacapavir for HIV PrEP compared to oral fixed-dose combination PrEP (tenofovir disoproxil fumarate plus emtricitabine (F/TDF) and/or oral tenofovir alafenamide plus emtricitabine (F/TAF)), long-acting injectable cabotegravir (CAB-LA), or placebo or no prophylaxis. SEARCH METHODS: We searched CENTRAL, PubMed, and two trial registers and conducted reference checking to identify eligible studies. The search is current to May 2025. ELIGIBILITY CRITERIA: We included randomised controlled trials (RCTs) with no date or language restrictions in any HIV-negative person at risk of acquiring HIV through sexual contact or exposure to blood, comparing long-acting injectable lenacapavir with oral PrEP, long-acting injectable cabotegravir, placebo or no prophylaxis. OUTCOMES: Our critical outcomes were: new HIV infections or relative risk of HIV infection; serious adverse events (SAEs); adverse events (AEs); adverse drug reactions: injection site reactions; and all-cause mortality. We included data at 26- and 52-week time points. RISK OF BIAS: We used the Cochrane RoB 2 tool to assess risk of bias in the included studies. SYNTHESIS METHODS: We meta-analysed data for each outcome where possible, using the inverse variance statistical method with a random-effects model. We reported risk ratios (RR) with 95% confidence intervals (CIs) for dichotomous data. Where this was not possible, we synthesised results using the direction of effect, guided by the Synthesis Without Meta-analysis (SWiM) reporting guidelines. We used GRADE to assess the certainty of evidence. INCLUDED STUDIES: We included two studies with 8660 participants. The first trial, conducted in South Africa and Uganda, included adolescent girls and young women (16 to 25 years) and compared injectable lenacapavir with daily oral PrEP consisting of F/TAF in one comparator arm and F/TDF in the other. The second trial, conducted in the USA, Brazil, Thailand, South Africa, Peru, Argentina, and Mexico, included cisgender gay, bisexual and other men, transgender women, transgender men, and gender-nonbinary persons of any age who have condomless, receptive anal sex with partners assigned male at birth. It compared injectable lenacapavir with F/TDF. In both trials, participants in the lenacapavir group received placebo tablets that matched the oral PrEP, and participants in the oral PrEP group received placebo injections that matched lenacapavir. SYNTHESIS OF RESULTS: New HIV infections Lenacapavir results in a large reduction in new HIV infections at 52 weeks compared to oral PrEP (RR 0.07, 95% CI 0.02 to 0.22; 2 studies, 8660 participants; high-certainty evidence). There were 14 fewer new HIV infections per 1000 (ranging from 15 fewer to 12 fewer), with a number needed to treat for an additional beneficial outcome (NNTB) of 70. Serious adverse events Lenacapavir results in a slight reduction in SAEs at 52 weeks compared to oral PrEP (RR 0.78, 95% CI 0.61 to 0.99; 2 studies, 8660 participants; high-certainty evidence). There were 8 fewer SAEs per 1000 (ranging from 15 fewer to 0 fewer), NNTB of 128. Adverse events Lenacapavir results in little to no difference in AEs at 52 weeks compared to oral PrEP (RR 0.99, 95% CI 0.96 to 1.01; 2 studies, 8660 participants; high-certainty evidence). There were 8 fewer AEs per 1000 (ranging from 31 fewer to 8 more), NNTB of 55. Adverse drug reactions: injection site reactions Lenacapavir likely increases adverse drug reactions: injection site reactions compared to oral PrEP at 52 weeks (RR 1.68, 95% CI 1.20 to 2.33; 2 studies, 8660 participants; moderate-certainty evidence). There were 295 more adverse drug reactions per 1000 (ranging from 87 more to 577 more), number needed to treat for an additional harmful outcome of 4. All-cause mortality Lenacapavir results in little to no difference in all-cause mortality at 52 weeks compared to oral PrEP (RR 0.57, 95% CI 0.11 to 3.06; 2 studies, 8660 participants; high-certainty evidence). There were 1 fewer deaths per 1000 (ranging from 2 fewer to 4 more), NNTB of 1073. We rated all critical outcomes as low risk of bias in both studies. We found no difference on subgroup analysis between comparators F/TDF and F/TAF. AUTHORS' CONCLUSIONS: When compared to oral PrEP, lenacapavir results in a large reduction in new HIV infections at 52 weeks, with one HIV infection prevented for every 70 people receiving lenacapavir rather than oral PrEP, that is 14 fewer HIV infections per 1000 people treated with lenacapavir. Lenacapavir results in a slight reduction in SAEs and little to no difference in AEs compared to oral PrEP. Lenacapavir likely increases the risk of injection site reactions compared with oral PrEP, but discontinuation of lenacapavir in the included trials due to injection site reactions was rare. There is little to no difference in mortality between lenacapavir and oral PrEP. No studies compared lenacapavir to injectable long-acting cabotegravir, placebo or no prophylaxis. Within the included trials, there was a non-randomised comparison of lenacapavir with background HIV incidence in the screened population as a proxy for a no-PrEP arm. There was a large reduction in HIV incidence in the lenacapavir study arms compared to background HIV incidence in the screened populations. FUNDING: This Cochrane review was part-funded by the South African National Department of Health (NDoH) through the Evidence to Decision (E2D) Collaboration project. The E2D Collaboration is a partnership between the NDoH, the South African Medical Research Council, and Stellenbosch University (2024 to 2028). The views expressed in this review do not necessarily represent the views of the funder. REGISTRATION: PROSPERO (2025) CRD420251080791.