In this study, we investigated patient satisfaction with current anti-HIV drugs, and surveyed patient needs for long-acting injectable medications prior to approval of these drugs in Japan to determine for which patients long-acting injectable medications would be appropriate. The results showed that although patients were generally satisfied with most items used to determined satisfaction with anti-HIV drugs, satisfaction with “daily oral therapy” was lowest. In addition, we also found that there is a need for long-acting injectable drugs in Japan, which may be suitable for patients who are dissatisfied with the tablet size and daily oral therapy of current anti-HIV drugs.

Current guidelines for HIV infection recommend ART in the form of one tablet once daily as primary treatment [8, 9]. Currently recommended anti-HIV drugs have stronger antiviral activity and higher genetic barriers than previous anti-HIV drugs. It has been reported that once-daily, single-tablet regimen (STR) initiators were significantly less likely to discontinue therapy and had greater adherence and persistence compared to multi-tablet regimen (MTR) initiators among patients newly prescribed ART [15]. Accordingly, reducing the frequency of dosing and the number of pills taken per day is thought to have alleviated the burden on patients. Nevertheless, it is reported that 38.7% of patients would like to see the advent of long-acting drugs that do not require daily dosing as a priority improvement in the treatment of HIV infection [16]. QD (once daily) is the most convenient way to take ART, as recommended by current practice guidelines, but even with QD, it is reported that once-daily administration can be emotionally taxing for patients because it triggers patients to remind themselves that ‘I have HIV infection’ [17]. As reported elsewhere by Koga et al [16], the results of this study were inferred to mean that satisfaction with anti-HIV drugs is affected by the burden of daily oral therapy. Regarding patient needs for anti-HIV drugs, the results showed that most patients preferred the following formulation types among the many options available: “daily or weekly tablets,“ “once every three months subcutaneous formulation,“ and “once every eight weeks intramuscular formulation”. We infer from the relatively high preference for weekly tablets and two- or three-monthly injectable formulations that many patients feel burdened by daily oral medication, whereas other patients are satisfied with their current once-daily medication.

Recently, long-acting injectable drugs have been approved in Japan, and many hospitals have begun to use them. We conducted the present survey before the approval of these drugs and simultaneously investigated patient need for long-acting injectable drugs (Q8W). The findings indicate that patients who preferred the once-every-eight-week intramuscular formulation (Q8W) were dissatisfied with “tablet size” or “daily oral therapy” of their current anti-HIV drugs.

Pharmaceutical tablets typically range in size from 5 to 10 mm, but anti-HIV drugs tend to be larger. The smallest tablet size for anti-HIV medication is 6.4 mm (EDURANT® Tablets), while the largest is 23 mm (PREZCOBIX® Combination Tablets). We therefore assumed that patients were dissatisfied with tablet sizes and wished for an injectable form.

In many PLWH treated with anti-HIV medications, their HIV infection is controlled by ART and they are able to lead a daily life similar to that of non-HIV-infected people. In addition, many PLWH have improved symptoms and return to society following treatment and are in general employment and have a variety of social backgrounds. It is therefore considered important to choose a drug that fits the patient’s lifestyle to ensure adherence in perpetuity. It has also been reported that Shared Decision Making with the patient is an important communication strategy when initiating or changing ART to select a more appropriate drug for the patient [18, 19].

In the present investigation, it is possible that as PLWH underwent prolonged ART, they may have opted for a once per eight weeks injectable drug due to the inadequacy of their current anti-HIV drugs in accommodating their lifestyle, and that dissatisfaction with “daily oral therapy” was one contributing factor of the reasons why they chose long-acting injectable drugs in this preference.

In general, comorbidities and the number of medications increase in older age. It is similarly reported that HIV-infected patients have more comorbidities and medications than non-infected patients [20]. Polypharmacy in those aged over 50 years old has also been reported [21, 22]. Nevertheless, Hinkin et al. reported that mean ART adherence rate was significantly greater in patients ≥ 50 years of age than in younger patients, and that HIV-infected persons ≥ 50 years of age were three times more likely than their younger counterparts to achieve adherence rates of 95% or greater [23].

The present results suggest that a lower proportion of patients aged over 50 years may have requested the Q8W formulation because they are more likely to be taking concomitant medications other than anti-HIV drugs, and that this daily administration requirement would remain if their anti-HIV drugs but not their other drugs were switched to injectable drugs. We also speculated that whereas patients with longer medication histories were accustomed to taking anti-HIV drugs, those with shorter medication histories were not accustomed to daily medication, and accordingly may have wished that the burden of daily medication for a medicine required for the rest of their lives could be eliminated.

The strength of our study is that, because it was conducted to investigate patients’ needs for anti-HIV drugs before the approval of long-acting injection drugs in Japan, we were able to obtain their honest thoughts. Nonetheless, limitations also exist. First, we can only infer associations because of the cross-sectional design. Second, the findings may have limited generalizability because participants were limited to PLWH with reading and writing ability in Japanese, and only a limited number of countries were included. Third, the PLWH Satisfaction and Needs for Anti-HIV Drugs Questionnaire was developed by discussion between the researcher and an HIV infection specialist pharmacist regarding the content, so it is possible that satisfaction with anti-HIV drugs was not perfectly assessed. Despite these limitations, this study offers the opinion of anti-HIV drugs held by PLWH, which can serve as a reference for future anti-HIV drug development and in the selection of new anti-HIV drug formulations sought by patients.