France’s healthcare system has long been recognised for its broad access, strong public coverage and ability to make innovative treatments available through the Social Security system. That combination is particularly important in HIV prevention, where access to effective, discreet and convenient protection can make a significant difference. Now, people in France have another option: injectable PrEP.
Since February, Apretude, the first long-acting injectable PrEP available in France, has been reimbursed by Social Security. Containing the antiretroviral drug cabotegravir, Apretude is administered by injection every two months after an initial phase, offering an alternative to taking PrEP tablets regularly.
PrEP, or pre-exposure prophylaxis, is a preventive treatment for people who are HIV-negative but may be exposed to HIV. The French National Authority for Health (HAS) recommends injectable PrEP as an alternative for people for whom oral PrEP is not suitable or practical.
Who can benefit from injectable PrEP?
Unlike some prevention programmes that focus on specific groups, injectable PrEP is not restricted by the HAS to particular populations. Instead, it can be considered for anyone who is HIV-negative and may benefit from PrEP, particularly when taking tablets is difficult or inappropriate.
This can include people who struggle to maintain a daily medication routine, including some people who use drugs or engage in chemsex, sex workers, migrants or people who need to keep their PrEP use discreet because of stigma or their personal circumstances.
It may also be appropriate for people for whom oral PrEP is not recommended because of kidney or bone problems, those with difficulties absorbing medication through the digestive system, including following certain types of surgery, and people who have difficulty swallowing tablets.
The principle is relatively simple: prevention works best when people have access to an option they can realistically use. As Valérie Grange, public affairs director at ViiV Healthcare, which developed Apretude, explains, the aim is to find the most appropriate option for each individual and expand access to PrEP as widely as possible.
Are there contraindications?
There are relatively few medical contraindications, but injectable PrEP is not appropriate for everyone.
Apretude should not be given to people who are HIV-positive or whose HIV status has not been established. It is also contraindicated in people with a known hypersensitivity to the treatment.
Certain medications can also interact with cabotegravir, including some treatments for tuberculosis, such as rifampicin and rifapentine, as well as several anti-epileptic medicines including carbamazepine, oxcarbazepine, phenytoin and phenobarbital.
Because Apretude is injected into the muscle, it is also generally not recommended for people taking therapeutic doses of anticoagulants because of the potential risk of bleeding or a haematoma. People with buttock implants may likewise not be suitable candidates.
Is injectable PrEP as effective as PrEP tablets?
Yes. When taken correctly, both oral and injectable PrEP provide a very high level of protection against HIV.
Injectable PrEP does, however, offer one major practical advantage: there is no daily tablet to remember. For people who find adherence difficult, removing the possibility of missed daily doses can make injectable PrEP an especially attractive option.
There is an important caveat. Protection is not immediate after the first injection and reaches full effectiveness after seven days.
And while PrEP is highly effective against HIV, it does not protect against other sexually transmitted infections. It also does not protect against hepatitis B, for which vaccination remains an important form of prevention.
How do you get injectable PrEP in France?
Apretude can be prescribed by a doctor experienced in HIV care, whether a general practitioner or specialist.
Before treatment begins, a comprehensive blood test is required to make sure the person does not have an existing HIV infection, including a recent infection that might not yet be obvious. This is particularly important because giving cabotegravir to someone who already has HIV could contribute to the development of resistance to certain HIV medicines.
Screening for other sexually transmitted infections is also carried out, while kidney and liver function are checked.
For most people, treatment can then begin. In some cases, particularly where there are concerns about allergies or tolerance, doctors may recommend an initial course of oral medication before moving to injections.
The standard injectable schedule begins with two injections one month apart. After that, injections are administered every eight weeks.
Regular medical monitoring remains part of the process, with blood tests generally performed every two months initially and then every four months.
Stopping treatment also needs to be discussed with a doctor. Cabotegravir can remain in the body at very low levels for many months — potentially close to a year — after the last injection, meaning appropriate follow-up and alternative HIV prevention should be considered when treatment is discontinued.
Does the injection hurt?
Apretude is injected into the gluteal muscle, so there is inevitably a little more involved than simply swallowing a tablet.
The injection can cause some discomfort, and soreness around the injection site can last for a day or two. However, clinical experience indicates that injection-site discomfort generally becomes less troublesome with repeated injections.
Apretude is otherwise generally well tolerated. Some people may experience mild and temporary side effects such as headaches or a slight fever.
For many users, the trade-off may be worthwhile: a brief period of discomfort every two months rather than remembering to take a tablet every day.
How much does Apretude cost?
One of the major advantages of the French healthcare system is that access to important preventive treatments does not depend entirely on a person’s ability to pay out of pocket.
Apretude is fully reimbursed for people covered by French Social Security, Complementary Solidarity Health Insurance (CSS) and State Medical Aid (AME).
There is, however, one additional cost that can complicate access. The HIV viral-load test required before prescribing PrEP is reimbursed at 65 percent, except for people covered by AME. Supplementary health insurance will generally cover the remainder.
The test can also be obtained free of charge through CeGIDD — free information, screening and diagnostic centres — as well as through some community health organisations and centres specialising in sexual health.
Organisations such as AIDES have nevertheless argued that requiring this test creates an unnecessary barrier for people who are already more likely to be disconnected from mainstream healthcare.
The hope among advocates and healthcare professionals is that future evidence could eventually lead to changes in the reimbursement requirements. For now, however, the testing requirement remains part of the French prescribing pathway.
Another tool in France’s HIV-Prevention arsenal
The arrival of injectable PrEP represents an important expansion of HIV prevention in France. Rather than replacing oral PrEP, condoms or regular STI testing, Apretude adds another option for people who need or prefer a different approach.
That flexibility matters. HIV prevention is most effective when people can choose a method that fits their health, relationships, lifestyle and circumstances.
With France’s public healthcare system providing broad reimbursement for the treatment, injectable PrEP is now considerably more accessible than it would be if patients had to shoulder the full cost themselves. The challenge ahead is ensuring that people who could benefit from it actually know it exists, can access appropriate testing and feel comfortable discussing their sexual health with healthcare professionals.
In other words, science has moved forward. The next step is making sure access keeps pace.
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