Long-acting injectable treatment can be an effective option for people who cannot maintain viral suppression on daily pills, researchers reported at the Conference on Retroviruses and Opportunistic Infections (CROI).

 

The LATITUDE trial enrolled more than 400 people who had a persistent detectable viral load on oral treatment or had been lost to clinical follow-up. They first used a standard oral regimen while receiving comprehensive adherence support and financial incentives. Those who achieved viral suppression were then randomly assigned to stay on the pills or switch to once-monthly Cabenuva (injectable cabotegravir and rilpivirine). After a year, 24% of people on Cabenuva experienced virological failure or stopped treatment, compared with 39% of those on the daily regimen.

 

But some people are not able to achieve viral suppression using daily pills. For them, starting injectables directly could be a feasible alternative. The team at the Ward 86 HIV clinic in San Francisco previously reported early results from a pilot study showing that 55 of 57 people who started Cabenuva with a detectable viral load achieved viral suppression. At CROI, they reported that 81% were still on Cabenuva with viral suppression after a year of treatment.

 

Based on this and other small studies, the International Antiviral Society-–USA recently released updated guidelines stating that Cabenuva may be considered for people with a detectable viral load who are unable to take pills consistently, have a high risk of HIV disease progression and have virus susceptible to both drugs “when supported by intensive follow-up and case management services.”

 

A major limitation of Cabenuva, however, is resistance to NNRTIs like rilpivirine. A case series of 34 patients suggested that combining injectable cabotegravir with the long-acting HIV capsid inhibitor lenacapavir (Sunlenca) could be an effective alternative. Ward 86 medical director Monica Gandhi, MD, MPH, and colleagues called for clinical trials of this regimen, which could be especially beneficial for people living with HIV in low- and middle-income countries where NNRTI resistance is more common.