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LA ART Adherence
Long-Acting Antiretrovirals: A Strategy to Support Adherence in Those With Complex Medical and Social Issues?

Released: September 06, 2023

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Key Takeaways
  • Long-acting ART may be a strategy to support adherence in those with complex medical and social issues.
  • In the JABS study, high rates of adherence and virologic suppression were found with long-acting cabotegravir plus rilpivirine as maintenance therapy in persons living with HIV with historical nonadherence.

During the 2023 IAS Conference on HIV Science in Brisbane, Australia, the WHO issued a statement that people living with HIV with an undetectable viral load on combination antiretroviral therapy (ART) have zero risk of transmitting HIV to their sexual partners and that people with a viral load that is suppressed to <1000 copies/mL on ART have almost zero or a negligible risk of transmitting HIV to their partners.

I practice in Great Britain, and the metrics would say that we are doing well at achieving viral suppression rates. As of 2019, 94% of people living with HIV in England knew their status. Of those, 92% were receiving ART, and of those, 89% were virally suppressed. All HIV care in England is free to residents, even for those who are not citizens. For most HIV clinics, however, a key challenge is supporting those for whom adherence may be a problem.

JABS: Supporting Adherence in Those With Complex Medical and Social Issues
JABS was a study that looked at the implementation of long-acting (LA) cabotegravir (CAB) + rilpivirine (RPV) in people living with HIV with complex medical needs, social vulnerability, and historical nonadherence. This was a 48-week, single-center, single-arm, open-label study of LA CAB + RPV maintenance therapy administered every 2 weeks to 60 persons living with treated HIV in Australia. The primary endpoint was proportion of attendance and delivery of injections within a 7-day window of appointment.

What is interesting to me is that this study included the people typically underrepresented in registrational trials. The median age was 40 years; 51% of males and 89% of females were immigrants. Other social needs included social isolation, mental health issues, and financial instability. Trials such as JABS contribute to our knowledge and confidence in the use of these injectable antiretrovirals (ARVs) to a broad spectrum of the population.

Indeed, a key factor that healthcare professionals take into consideration before prescribing injectable ARVs is the person’s history of adherence. However, some people may have difficulties in taking daily oral medications for various reasons that may be remedied by receiving long-term injectable ARVs. For such people, these injectable medications may provide enhanced engagement to care and adherence benefits.

Of 315 injections analyzed in JABS in 48 weeks, 97.8% were given within the 7-day window. The fact that adherence to the injection schedule was shown to be very high is reassuring, as is the high number of participants who maintained an undetectable viral load over 48 weeks. A similar study in San Francisco, which also included an adherence-challenged population, reported 74% adherence to on-time injection.

Multidisciplinary Support
Of interest, to ensure that participants were reached, the study also offered a multidisciplinary service comprising a senior social worker, an HIV nurse practitioner, and an immunology welfare assistant, who liaised with the medical team and other agencies to provide individualized support to participants. In total, 16 participants (27%) took advantage of enhanced support services.

Among the reports at IAS 2023, this study is key for me, as there is a high amount of interest in the use of injectable LA CAB + RPV among people living with HIV, including those who would benefit from nonoral, nondaily ART. Real-world data to enhance prescribers’ knowledge are very useful during this early period of introducing injectables into clinical practice. It is reassuring to me that—within the context of people with identified complex needs, social vulnerability, and historical nonadherence—we are able to provide an ART strategy that helps them achieve the same levels of adherence and virologic suppression as the wider population living with HIV. I believe that this knowledge will be implemented across the whole of the United Kingdom, where the strategy can be applied to people receiving oral treatment who would benefit from nonoral, LA ART.

Your Thoughts?
Which patients do you choose for LA ART? Would you consider patients with complex needs? Share your thoughts by leaving a comment below.