Background
Treatment with long-acting antiretroviral therapy (LA ART) with cabotegravir/rilpivirine (CAB/RPV) +/- lenacapavir (LEN) holds promise to achieve viral suppression (VS) in people with HIV (PWH) for whom oral ART fails. Although supported in certain scenarios by guidelines, scaling this approach in viremic PWH has lagged
Methods
We performed a retrospective review of PWH cared for at a large Ryan White-funded program in the urban South who initiated LA ART (CAB/RPV, LEN, and/or ibalizumab [IBA]) between 4/14/2021–8/31/2024 with follow-up through 12/31/2024. PWH were included if HIV-1 RNA was >50 c/mL (viremia) at time of first LA ART injection with at least 3 months of follow-up time. Primary outcome was achieving HIV-1 RNA <50 cp/mL
Results
Of 361 total PWH receiving LA ART, 81 (22%) initiated with viremia, among whom regimens were CAB/RPV only (n=56), CAB/RPV+LEN (n=23), and CAB/RPV+LEN+IBA (n=2). Of those initiated with viremia, median (IQR) age was 38 (30-49) yrs, median years since HIV diagnosis was 15.5 (8.8-20.5), and nine (11%) had perinatal acquisition. Seventy-five (93%) identified as Black race, 29 (36%) were cis-women (including four initiated in pregnancy) and three (3.6%) were trans-women. Median BMI was 24 (22-30) kg/m2. Median income was $25K ($20-33K) and social determinants of health were highly prevalent: 72% had unmet transportation needs, 51% had food insecurity, and 27% had high-risk of financial resource strain. Thirty-six (44%) had prior opportunistic infections, many recent due to ongoing viremia.
At LA ART initiation, median VL was log10 3.97 (2.91-4.80) c/mL and median CD4 was 186 (62-420) cells/mL. A total of 75 PWH (93%) achieved VS after a median of 1 (1-2) injections, resulting in median CD4 rise to 330 (172-483) cells/mL. Of 9 PWH who did not achieve VS, one was lost to follow-up; two had virologic failure with drug resistance; four have ongoing low-level viremia (<200 c/ml); and two have long-standing viremia despite CAB/RPV+LEN without resistance to RPV or CAB.
Of 645 CAB/RPV injections administered (500 q4wk; 145 q8wk), 99% were on-time (within 7-day window). CAB/RPV were covered by medical benefits (n=54), ADAP (n=22) and pharmacy benefits (n=5). Five discontinued LA ART in follow-up
Conclusions
This is the largest reported single cohort of PWH to initiate LA ART with viremia and 93% achieved VS despite significant barriers to care and burden of disease, underscoring the potential of LA ART to help achieve Ending HIV Epidemic goals