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Returning to HIV Care

CE / CME

Returning to HIV Care: Ensuring Services Are Inclusive and Equitable

Nurses: 0.75 Nursing contact hour

Pharmacists: 0.75 contact hour (0.075 CEUs)

Physicians: maximum of 0.75 AMA PRA Category 1 Credit™

Released: July 24, 2024

Expiration: July 23, 2025

CME/CE Information

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ACTG A5359 LATITUDE: LA ART as a Potential Tool for People With Challenges to Oral ART

So, what are the data, and what should we consider in terms of the use of long-acting (LA) ART, especially for those who have struggled with oral medication?

Many of you probably know about the LATITUDE trial by now. This is a significant trial because it randomized patients who had struggled with oral ART. These are patients with a history of nonadherence.

What I love about this trial is that it involved patients I see all the time—those returning to care, struggling with substance use disorder, or having unstable housing. The question was whether to start them on oral or LA ART. These patients were not refusing oral ART; they were open to either option, which is why they participated in the trial. So, let's take a look at what the data show.

In the study, participants started first on oral ART in step 1, with the goal of achieving viral suppression before randomization. Over time, step 1 was reduced to only 4 weeks by the end of the trial.

The most important takeaway is the positive impact of using LA ART. The combined outcomes showed higher rates of virologic and treatment-related failure in the standard oral care group.

This significant difference led the Data Safety and Monitoring Board to stop the trial early. This is practice-changing for me. When a patient returns to care and I ask if they prefer oral medication or want to consider LA ART—especially if they have had recurrent viremia and difficulties with retention in care—I can now confidently say that data support a higher benefit in moving quickly to LA ART.

In my practice, I start patients on treatment immediately when they return to care and transition them to LA ART within 4 weeks if they are interested.

If they prefer oral medication, we stick with that. However, when asked if they are interested in oral or LA ART, many of my patients say either one, acknowledging they need to do better and often feeling apologetic.

It is important for me to reassure them that managing HIV is not easy, and we are here to support them. I explain that for patients with challenges like them, we have seen better outcomes with LA ART.12

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Ward 86: LA CAB + RPV in People Without Virologic Suppression at Baseline

Ward 86 has conducted incredible research on this topic. They looked at patients who were viremic who explicitly did not want oral medication and started LA cabotegravir plus rilpivirine. This is a tough patient population: 44% had unstable housing, 9% were unhoused, 61% were using methamphetamine or cocaine, and 10% were using opioids.

In the study, they used an every-4-week dosing schedule, with high-intensity case management.

As you can see, despite the challenges of the population, 81% remained on LA cabotegravir/rilpivirine with a viral load <50 copies/mL at Week 48. These are stunning data for a very difficult-to-treat population.13-15

Hats off to Ward 86 for implementing this early with LA cabotegravir/rilpivirine and with high-intensity case management, allowing us all to learn from this model.

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Updated IAS-USA Recommendations for LA CAB + RPV March 1, 2024

This research has led to the IAS-USA recommendations supporting the use of LA cabotegravir/rilpivirine in patients who are viremic when no other treatment options are effective due to a patient’s persistent inability to take oral ART. And of course, we should only be starting LA cabotegravir/rilpivirine alone if the virus is susceptible to both cabotegravir and rilpivirine.

This approach must be paired with intensive follow-up and case management services.16

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