Long-Acting Antiretroviral Therapy for HIV via Drop-in Community-Based Care

Importance: People with HIV (PWH) experiencing homelessness face barriers to daily oral antiretroviral therapy (ART) adherence and often lack access to HIV specialty care. Data are needed on the feasibility and outcomes of long-acting ART (LA-ART) delivery within low-barrier, community-based settings. Objective: To evaluate the implementation and effectiveness of LA-ART delivery at a community-based drop-in clinic for people experiencing homelessness (PEH). Design, Setting, and Participants: This quality improvement study included PWH experiencing homelessness or housing instability, among whom substance use and psychiatric disorders were prevalent, receiving care at the Maria X. Martinez Health Resource Center, a municipal clinic serving PEH in San Francisco, California. Programmatic outcomes of LA-ART were evaluated from November 2021 through October 2025, with a secondary descriptive evaluation of PWH receiving standard treatment vs LA-ART between January 2023 and December 2024. Intervention: Intramuscular cabotegravir-rilpivirine injection, with or without lenacapavir, delivered within a high-touch model incorporating reminders, outreach, and flexible delivery compared with standard treatment consisting of oral ART when accepted. Main Outcomes and Measures: Outcomes were viral suppression (HIV RNA <200 copies/mL) and clinical encounters per person-year between 2023 and 2024. Among LA-ART recipients, additional outcomes included retention, injection timeliness, out-of-clinic administration, and virologic failure over the full program period. Results: Among 128 PWH included in the 2023-2024 descriptive cohort, 24 individuals (mean [SD] age, 44.6 [12.2] years; 15 cisgender males [63%]) received LA-ART, and 123 individuals (mean [SD] age, 42.6 [12.1] years; 69 cisgender males [66%]) received standard treatment (due to treatment transitions, treatment conditions were not mutually exclusive). All 24 (100%) individuals receiving LA-ART achieved and maintained viral suppression. Among those receiving standard treatment, 89 of 123 (72%) ever achieved viral suppression and 69 of 123 (56%) had viral suppression at last follow-up. The mean (SD) number of clinical encounters per person-year was higher for LA-ART recipients (23.0 [11.1] vs 9.1 [11.5]). Across the full program period, 30 individuals initiated LA-ART, and all continued receiving therapy through October 2025 (median duration [range], 106 [8-206] weeks). Of 637 injection visits, 43 (7%) were delayed by more than 7 days and 21 (3%) by more than 14 days, and 121 (19%) were administered outside the clinic. Three individuals experienced virologic failure while receiving cabotegravir-rilpivirine and achieved resuppression after the addition of lenacapavir. Conclusions and Relevance: In this quality improvement study, LA-ART delivery within a high-touch, flexible care model in a drop-in clinic serving PEH was associated with high rates of viral suppression. These findings highlight the potential for nonspecialty, community-based settings to deliver LA-ART to structurally vulnerable populations, while underscoring the substantial programmatic support required.