Successful initiation of fully parenteral antiretroviral therapy in a treatment-naïve person with HIV-1 infection and intestinal failure

INTRODUCTION: In patients with severe surgical and gastrointestinal complications, standard oral combination antiretroviral therapy (ARV) may be temporarily impossible. Long-acting cabotegravir/rilpivirine (CAB/RPV LA) is approved for virologically suppressed individuals pretreated with oral therapy, but data on its use in treatment-naïve, critically ill patients with absent enteral absorption are extremely limited. CLINICAL PRESENTATION: We report a 26-year-old male admitted with fulminant hypertriglyceridaemic necrotizing pancreatitis complicated by abdominal compartment syndrome, multiple laparotomies, open abdomen with enteric fistulae, short bowel syndrome type I, chronic intestinal failure requiring parenteral nutrition, portal vein thrombosis, and prolonged intensive care. HIV-1 infection was diagnosed early (HIV RNA 5,000 copies/mL; CD4+ 780 cells/µL). Within three months, HIV RNA rose to 320,000 copies/mL and CD4+ declined to 570 cells/µL. Given absent gastrointestinal passage, standard ARV was initially deferred, but rapid virological rebound necessitated urgent treatment. An off-label fully parenteral regimen was initiated: intravenous zidovudine (AZT) with intramuscular CAB/RPV LA. Therapy was well tolerated alongside surgery, parenteral nutrition, antimicrobials, and anticoagulation. HIV RNA decreased to <20 copies/mL within 65 days and remained suppressed, with CD4+ recovery. Intravenous AZT was discontinued after 35 days, and CAB/RPV LA continued as maintenance during recovery and home parenteral nutrition. DISCUSSION: Fully parenteral ARV, including CAB/RPV LA, may provide a safe and effective bridge to durable viral suppression in patients with absolute contraindications to oral therapy, warranting further evaluation.