Background
Ward 86, a safety-net HIV clinic in San Francisco for ~2,600 publicly insured patients, has been using long-acting antiretroviral therapy (LA ART) for people living with HIV (PWH) with adherence challenges to oral ART. Since the approval of cabotegravir/rilpivirine (CAB/RPV) in 2021 and lenacapavir (LEN) in 2022, PWH have been referred to the Special Program on Long-Acting Antiretrovirals to Stop HIV (SPLASH) through a centralized, pharmacist-led process, regardless of viral suppression status. This retrospective study evaluates the disposition of referrals to Ward 86’s LA ART program over its first 3.5 years to guide future implementations.
Methods
Disposition (started, did not start, discontinued, etc.) and demographic data for PWH referred to the SPLASH program from January 2021 to August 2024 were extracted from electronic medical records and verified by clinician review.
Results
Of 699 PWH referred, 390 started LA ART (55.8%). The median referral age was 45; 81.6% identified as cisgender male, 69.0% non-Hispanic, 38.2% White, 34.2% unstably housed, and 41.9% reporting substance use. Among those that started LA ART, 74.1% (289/390) remained in the SPLASH program while 6.2% (24/390) continued LA ART after transferring clinics. Most participants are on CAB/RPV (89.6%), with smaller proportions on LEN+CAB (5.2%), LEN+CAB/RPV (4.8%), and LEN alone (0.3%). Seventy-seven (77/390, 19.7%) PWH stopped LA ART due to death (20), loss to follow-up (16), and switching to oral ART (41), with 4.9% (19/390) experiencing adverse effects on LA ART. Of the 308 (44.1%) PWH who did not start LA ART, 13 were found ineligible, and 7 were lost to follow-up or deceased, while 288 are awaiting clinical review (68), have yet to complete initial injection appointment (83), or are on hold due to various barriers, such as difficulty with patient engagement, lack of access, or fear of side effects (137) (Figure).
Conclusions
Approximately 25% of PWH at Ward 86 have been referred to the SPLASH program, indicating increasing acceptance of LA ART among PWH and their providers. Despite this, a significant portion of referrals (290/699, 41.5%) remain on hold due to various system and patient -level factors. In a clinic of publicly insured PWH with several barriers to oral ART adherence, comfort with LA ART is increasing among patients and clinicians, further demonstrating that LA ART is effective among a diverse population of PWH struggling with daily adherence.