Background
We sought to examine reasons for discontinuation of long-acting injectable cabotegravir/rilpivirine (LA-CAB/RPV) and subsequent clinical outcomes in a cohort of people with HIV (PWH) in routine care.
Methods
We conducted a retrospective chart review of PWH who initiated LA-CAB/RPV at Ward 86 in San Francisco through April 2024, censoring data on September 23, 2024. We coded free text notes using content analysis and summarized demographic and clinical characteristics overall and stratified by viral suppression (VS) vs. viremia, defined as HIV viral load (VL) < vs. ≥30 copies/mL) at LA-CAB/RPV initiation. We defined discontinuation as intended cessation of LA-CAB/RPV without documented plan to resume or loss to follow-up (LTFU). VS post-discontinuation was defined as VL<200 copies/mL.
Results
Of 346 PWH, 50 (14%) discontinued, of whom 17 (34%) initiated LA-CAB/RPV with viremia. Median age was 44, 92% male, 30% Latine, 22% Black, 44% unstably housed, and 35% using stimulants. Median number of injections at discontinuation was 5 (min 1, max 20), with 82% on q4 week dosing. Discontinuation occurred after the first injection for 7 (14%) and for 11 (22%) after ≥10 injections. All were prescribed alternate antiretroviral therapy (ART). Median time from discontinuation to database closure was 379 days (IQR 277, 642). Of the 33 PWH initiating LA-CAB/RPV with VS, the most common reason for discontinuation was injection site pain, with or without another side effect/concern (Table). All 28/28 with VL measured after discontinuation had continuous VS while 5 had no VL measurement (2 LTFU, 1 relocation, 1 incarcerated, 1 adherent per provider). Of the 17 PWH initiating with viremia, reasons for discontinuation were pain (n=5), virologic failure (n=4), LTFU (n=3), lateness leading to provider discontinuation (n=2), declined ART (n=1), injection site abscesses (n=1), and relocation (n=1). Of 15 with measured VL after discontinuation, only 3 had continuous VS, however, at last observation, 11 had VS and 4 had viremia off ART (including 1 who died). NNRTI and/or INSTI resistance mutations developed in 3/16 while on injections, 3/16 with missed/late injections, and 1 with VS for 3 months after discontinuation who subsequently discontinued alternate ART.
Conclusions
Overall, discontinuation was low, and injection site pain was the most common reason. For PWH initiating LA-CAB/RPV with viremia, VF and missed/late injections accounted for over half of discontinuations, although most ultimately attained VS.
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