by Carolyn Chu, MD, MSc, AAHIVS, AAHIVM Chief Medical Officer

February 28, 2023

Featured Literature:

Hill LA, Abulhosn KK, Yin JF, Bamford LP.  Single-center experience evaluating and initiating people with HIV on long-acting cabotegravir/rilpivirine.  AIDS.  2023 March 15; 37(4): 605-609.  PMID: 36730069.    

This retrospective analysis describes a single-center’s experience evaluating individuals who expressed interest in cabotegravir/rilpivirine (CAB/RPV).  Patients received care at a Ryan White-funded, HIV primary care clinic affiliated with an academic institution.  The center’s protocol involved referral to the pharmacy team for clinical assessment to determine appropriateness of CAB/RPV consideration, additional work-up as indicated, insurance coverage assessment, patient education (this included discussion of the oral lead-in option), and CAB/RPV initiation.  If a baseline or prior resistance test was available and the patient had maintained viral suppression, no resistance testing was conducted.  By contrast, if no prior resistance testing was available, a proviral DNA resistance test was pursued regardless of prior ART and viral suppression history.  383 individuals were referred for evaluation and had a definitive decision about whether to transition to CAB/RPV between April 2021 to June 2022; 201/383 (52.5%) ultimately initiated CAB/RPV.  Univariate analyses indicated that patients initiating CAB/RPV were younger, more likely to be on a two-drug regimen, and less likely to be on a multi-class or PI-based regimen.  Reasons for not initiating CAB/RPV included inconsistent clinic attendance or difficulty contacting the patient (19.8%), patient decision (18.7%), previously known (15.4%) or newly identified (12.1%) NNRTI resistance, detectable viral load (8.2%), incomplete resistance work-up (8.2%), insurance coverage challenges or out-of-pocket cost concerns (7.1%), previously known (2.7%) or newly identified (1.6%) INSTI resistance, active hepatitis B (2.2%), or other reasons (3.8%).

Author’s Commentary:

These results describe the largest cohort to date of people referred for CAB/RPV evaluation and initiation in a real-world clinical setting.  Just over half of those referred ultimately transitioned to the new combination; among people who did not initiate CAB/RPV, reasons varied across both clinical and logistical considerations.  Patient choice was the second most common reason for not initiating CAB/RPV among this center’s population, an observation that warrants further exploration as noted by authors.  Authors also indicate their experience suggests that “use of proviral DNA resistance testing may be an important tool to avoid potential virologic failures when switching [patients] to CAB/RPV”. 

The author has no conflicts of interest to disclose.

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