Zandraetta Tims-Cook, MD, MPH, AAHIVS, discusses access challenges, missed-dose management, and scalable care models for cabotegravir PrEP in women.
Long-acting injectable cabotegravir (Apretude) has expanded HIV prevention options for women, offering an alternative to daily oral preexposure prophylaxis (PrEP). However, real-world implementation continues to be shaped by challenges related to risk perception, provider education, and clinic workflows, factors that directly influence uptake and persistence.
To explore how these issues play out in clinical practice, Contagion spoke with Zandraetta Tims-Cook, MD, MPH, AAHIVS, an infectious disease specialist and internist based in Atlanta, Georgia, whose work focuses on HIV health disparities and women’s access to prevention and care. Her work spans both clinical care and community engagement. “I do a lot of clinical work in a private practice, as well as community-based outreach and support for that population.”
When asked about the most significant barriers limiting women’s access to long-acting cabotegravir for PrEP, Tims-Cook emphasized that perceived risk is often underestimated. “I think one of the biggest barriers, believe it or not, is perceived risk—people having a low perceived risk of their possibility for HIV transmission,” she said.
She noted that relationship dynamics can complicate risk assessment. “I think sometimes it’s difficult for people to conceptually accept that they can be in a wonderful, loving relationship with a person who loves them back, and that person can also have experiences sexually outside of that relationship.”
According to Tims-Cook, acknowledging this complexity is essential for prevention. “Two things can be true at the same time. So getting people to open their eyes to that possibility, and then adopt behaviors and tools that can help mitigate the risk of HIV transmission, is really important.”
Beyond patient perception, Tims-Cook identified provider-level barriers that limit access to PrEP education. “The second barrier, I believe, is limitations in people being educated about their PrEP options, especially from their primary care providers,” she said. “There’s a lot of disconnect in terms of acceptance as to whose turf it is to educate patients about PrEP.”
She explained that prevention opportunities are often missed before patients reach specialty care. “By the time someone sees a specialist like me, usually they’re already educated or they’ve already had an opportunity for an HIV transmission, and that’s why they’ve been referred.”
For that reason, she emphasized the importance of primary care engagement. “But primary care providers, I think, are the biggest gatekeepers and the most effective avenue for people getting educated.”
Low perceived HIV risk and gaps in primary care–based PrEP education remain major barriers to long-acting injectable PrEP uptake among women.
Counseling on injection timing, the pharmacologic “long tail,” and pregnancy-related considerations is essential before initiating cabotegravir PrEP.
Flexible clinic workflows, including reminder systems and extended hours, can improve persistence and access for women using long-acting PrEP.
Despite these challenges, Tims-Cook pointed to several factors that have supported increased awareness and interest in long-acting PrEP. “As far as what has helped move the needle, I think it’s twofold: peer support and people who are educated and out influencing what people know—whether that’s through social media, sometimes through commercials people see on TV that trigger questions they want to pursue,” she said.
She also highlighted the value of open clinician-led conversations. “And I think content like this, where people can just hear a conversation about tools like Apretude, is really helpful.”
Effective use of long-acting cabotegravir requires careful patient counseling, particularly around missed injections and the pharmacologic “long tail” of declining drug levels. “I think it’s important to have those conversations up front so patients know what the expectations are in terms of being on time with those injections,” Tims-Cook said.
She framed adherence as central to patient autonomy. “People are seeking out tools like Apretude PrEP so they can have better control over HIV prevention.” Maintaining therapeutic drug levels is a shared responsibility, she explained. “In order to do that, I stress that their responsibility is getting in on time so those levels stay therapeutic and they’re adequately covered while living their lives, living their best lives, and enjoying their sexual experiences.”
Pregnancy and postpartum care require additional discussion. “For pregnant patients, sometimes there are required dosing changes,” she said. “Sometimes with the addition of new medications, therapeutic levels can be decreased. Sometimes there are dosing adjustments needed.”
Setting expectations early supports informed decision-making. “We talk about all of those things up front and level-set those expectations before people make that initial commitment to this type of PrEP.”
For clinics aiming to scale long-acting injectable PrEP programs for women, Tims-Cook emphasized operational flexibility as a key driver of success. “To scale up, I think flexibility is one of the most pivotal parts,” she said. “There’s inherent dosing flexibility with Apretude because you have a two-week window where injections are still considered on time.”
She noted that real-life barriers often interfere with rigid scheduling. “Outside of that, people just have life—things happen that are unexpected. There are traffic delays, emergencies, family issues that come up. People may just need to get into the office when they can.”
Clinic-level adaptations can make a meaningful difference. “So building flexibility within the clinic to accommodate patients is really important,” she said. “Reminders can help. Sometimes even having access outside of traditional business hours—like evenings or Saturdays—has proven helpful in ensuring that patients have consistent access to PrEP.”
In closing, Tims-Cook emphasized the role of clinicians across specialties in expanding HIV prevention. “I always like to encourage primary care providers to stay educated and stay proactive in introducing PrEP or reminding patients about PrEP and all the various options that are available,” she said.
She stressed that individualized care remains essential. “There’s no one-size-fits-all, and there are many different options today.” Ultimately, she encouraged broader engagement beyond HIV specialty care. “I encourage those of us who provide care outside of a given specialty to consider PrEP education with their patients.”
Stay ahead of emerging infectious disease threats with expert insights and breaking research. Subscribe now to get updates delivered straight to your inbox.
