Projected Benefits of Long-Acting Antiretroviral Therapy in Nonsuppressed People With Human Immunodeficiency Virus Experiencing Adherence Barriers

Background: In a demonstration project, long-acting, injectable cabotegravir-rilpivirine (CAB-RPV) achieved viral suppression in a high proportion of people with HIV (PWH) who were virologically nonsuppressed with adherence barriers. We projected the long-term impact of CAB-RPV for nonsuppressed PWH experiencing adherence barriers. Methods: Using the Cost-Effectiveness of Preventing AIDS Complications (CEPAC) model, we compared 3 strategies: (1) standard of care oral integrase inhibitor-based ART (<em>INSTI</em>); (2) INSTI-based ART with supportive social services ("wraparound services" [WS]) (<em>INSTI/WS</em>); and (3) CAB-RPV with WS (<em>CAB-RPV/WS</em>). Model outcomes included viral suppression (%) and engagement in care (%) at 3 years, and life expectancy (life-years [LYs]). Base case cohort characteristics included mean age of 47y (standard deviation [SD], 10y), 90% male at birth, and baseline mean CD4 count 150/&micro;L (SD, 75/&micro;L). Viral suppression at 3 months was 13% (<em>INSTI</em>), 28% (<em>INSTI/WS</em>), and 60% (<em>CAB-RPV/WS</em>). Mean loss to follow-up was 28/100 person-years (PY) (SD, 2/100 PY) without WS and 16/100 PY (SD, 1/100 PY) with WS. Results: Projected viral suppression at 3 years would vary widely: 16% (<em>INSTI</em>), 38% (<em>INSTI/WS</em>), and 44% (<em>CAB-RPV/WS</em>). Life expectancy would be 7.4 LY (<em>INSTI</em>), 9.0 LY (<em>INSTI/WS</em>), and 9.4 LY (<em>CAB-RPV/WS</em>). Projected benefits over oral ART would be greater for PWH initiating <em>CAB-RPV/WS</em> at lower CD4 counts. Across plausible key parameter ranges, <em>CAB-RPV/WS</em> would improve viral suppression and life expectancy compared with oral INSTI strategies. Conclusions: These model-based results support that long-acting injectable CAB-RPV with extensive support services for nonsuppressed PWH experiencing adherence barriers is likely to increase viral suppression and improve survival. A prospective study to provide further evidence is needed.