Real-World Patterns of Discontinuation and Virologic Failure with Long-Acting Cabotegravir-Rilpivirine

Long-acting injectable cabotegravir-rilpivirine (LA CAB/RPV) is an antiretroviral option for virologically suppressed people with HIV, but real-world discontinuation and failure patterns remain incompletely described. We retrospectively reviewed 201 adults who received LA CAB/RPV at a large academic infectious diseases clinic (January 2022-April 2025). Median time on therapy was 380 days (IQR 206-729). At the end of follow-up, 160 (80%) remained on LA CAB/RPV and 30 (15%) discontinued, most commonly due to insurance barriers (n = 8, 27%); adherence issues and patient preference each accounted for 23% (n = 7). Virologic failure occurred in 4 patients (2%) and was often accompanied by emergent or pre-existing non-nucleoside reverse transcriptase inhibitor and/or integrase strand transfer inhibitor resistance mutations; all patients achieved resuppression after switching back to oral ART. LA CAB/RPV was generally well tolerated, but system-level access and care-continuity barriers were major drivers of discontinuation, underscoring the importance of robust support systems and resistance-informed patient selection.