Using a paper-based checklist for promoting increased access to long-acting injectable cabotegravir/rilpivirine among people living with HIV in Toronto: Lessons learned from a quality improvement initiative

Long-acting injectable (LAI) cabotegravir/rilpivirine (CAB/RPV) offers a promising alternative to daily oral antiretroviral therapy for individuals with HIV, potentially addressing adherence challenges and pill fatigue. However, its implementation may inadvertently widen health disparities. We conducted a qualitative improvement project at a large hospital-based HIV clinic in Toronto to promote equitable access to CAB/RPV LAI. A one-page paper-based checklist was developed and piloted from September 2023 to June 2024 to streamline eligibility screening and guide discussions. Of 232 patients screened, 152 records included the checklist. Among those, 10% were ineligible, 33% eligible, and 5% had uncertain eligibility, with 52% lacking eligibility information. CAB/RPV was discussed in 48% of eligible cases, leading to a 6% initiation rate among those discussions (4/66), plus two additional initiations. This compares to a 2.5% initiation rate among other clinic patients without the intervention. Interviews with clinicians and pharmacists revealed the checklist integrated well, aiding systematic assessment and patient discussions, despite time constraints limiting full documentation. Clinicians cited patient preference for oral pills, needle aversion, and logistical concerns as reasons for declining LAI. Our findings suggest that a structured paper-based tool, while imperfect, can facilitate discussions and improve uptake of LAI HIV treatment, highlighting the potential for electronic medical records to further optimize this process and ensure equitable access.