Long-acting injectable cabotegravir/rilpivirine in a pregnant woman living with HIV with hyperemesis gravidarum:a case report and review of literature

IntroductionLong-acting injectable cabotegravir/rilpivirine (CAB/RPV LA) represents a novel antiretroviral strategy that bypasses gastrointestinal absorption, potentially advantageous in pregnant individuals unable to tolerate oral therapy. However, its use in pregnancy remains off-label due to limited pharmacokinetic (PK), safety and clinical outcome data.Case presentationWe report the case of a 26-year-old woman from Ghana living with HIV-1 (subtype CRF02_AG), with a longstanding history of social vulnerability, poor adherence and multiple treatment interruptions. She presented at gestational week (GW) 20 with an ongoing oral regimen of bictegravir/emtricitabine/tenofovir alafenamide (BIC/FTC/TAF), initiated weeks earlier. Despite an initial viral load decline, virological rebound to 57,950 copies/mL was documented at GW 28, attributed to severe hyperemesis gravidarum (HEG) impairing drug intake and absorption. No resistance-associated mutations were detected. Given the inability to tolerate oral therapy, CAB/RPV LA (600/900 mg) was initiated intramuscularly at GW 29, with a second injection 4 weeks later. Virological suppression (<20 copies/mL) was achieved within 4 weeks of the first injection. At GW 36, an elective caesarean section was performed with intravenous zidovudine prophylaxis and neonatal zidovudine syrup, resulting in the delivery of a neonate who has tested HIV-negative on all assessments to date. No adverse maternal or neonatal outcomes were observed.DiscussionThis case highlights HEG as an underrecognised cause of antiretroviral treatment failure mediated by impaired absorption rather than virological resistance, and supports CAB/RPV LA as a viable rescue strategy in this setting.ConclusionIt also underscores the urgent need for prospective pharmacokinetic and safety data in pregnancy.