Use of long-acting injectable cabotegravir/rilpivirine in people with HIV and adherence challenges

Recent changes in US Department of Health and Human Services and International AIDS Society USA guidelines now endorse use of long-acting injectable cabotegravir and rilpivirine (LA-CAB/RPV) in people with HIV (PWH) who have adherence challenges, including those with viremia. We sought to summarize clinical trial and real-world study data on outcomes and implementation strategies, highlight key unanswered questions, and provide recommendations for best practices.

Studies of LA-CAB/RPV in PWH with adherence challenges demonstrate excellent virologic outcomes, although the rate of virologic failure is higher than that in registrational trials conducted in PWH with stable viral suppression. However, viral suppression is attainable on alternate antiretroviral regimen, including those that employ lenacapavir, another long-acting injectable antiretroviral drug, even after virologic failure on LA-CAB/RPV. Successful implementation strategies for long-acting programs include centralized multidisciplinary clinic teams (ideally with pharmacist/pharmacy technician involvement), small incentives to promote patient retention on injections, allowing for drop-in injections, outreach after late injections, and partnerships with home nursing, street medicine, and harm reduction sites.

Creating programs that can support PWH with adherence challenges, their providers, and their clinics to use LA-CAB/RPV in service of sustained viral suppression is an urgent priority, particularly for PWH with CD4+ cell count <200 cells/mm3.