Background
Long-acting injectable cabotegravir/rilpivirine (LAI CAB/RPV) has changed the landscape of antiretroviral therapy (ART) by creating an alternative to daily oral ART. While FDA approval is currently limited to individuals with viral load suppression (VLS), there is growing evidence that CAB/RPV may also benefit virally unsuppressed patients who face adherence challenges taking oral ART. Our study evaluated LAI use in the country’s largest municipal health system and compared patient characteristics and viral load outcomes of people starting LAIs with unsuppressed viral loads to those starting LAIs with baseline VLS.
Methods
From 1/2021-6/2024, electronic medical record data was extracted for all NYC Health+Hospitals patients with HIV who had at least 1 HIV primary care visit in the preceding 12-months and who received at least 1 dose of LAI CAB/RPV. Baseline viral loads were obtained prior to the initial order for LAI CAB/RPV, and descriptive statistics were used to compare individuals whose baseline viral load prior to LAI initiation was not suppressed (>/=200 cp/mL) to those whose baseline viral load was <200 cp/mL.
Results
325 patients received at least 1 dose of LAI CAB/RPV during the study period. 14 individuals had unsuppressed viral loads and 311 were virally suppressed at the time LAI CAB/RPV was initially ordered. Those starting LAI CAB/RPV when viremic were more likely to be female (64% vs. 36%), have baseline CD4 <200 cp/mL (71% vs. 5%) and to screen positive for a social determinants of health (SDOH) need (36% vs. 15%). The most common SDOH needs identified those patients were financial insecurity (21%), housing insecurity (21%) and un/under-employment (14%). VLS at the end of the study period using the most recent available viral load was expectedly lower in the baseline viremic group (79% vs. 98%) (Table 1).
Conclusions
CAB/RPV initiation in patients with baseline viremia led to high rates of VLS in a population with low baseline CD4 and high rates of unmet social needs. This supports the growing body of evidence that LAIs are a vital option for patients with adherence challenges on oral ART. One limitation of our study is that the period of observation for follow up VLS varied for each patient, (e.g. our assessment included most recent viral load). Addressing barriers to LAI access, including expanding current FDA labeling to include certain patients with baseline viremia, is crucial to achieve VLS and improved health outcomes in this population.
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