Analysis of a clinical pathway for the use of long-acting injectable antiretroviral therapy in adherence challenged people living with HIV

BackgroundLong-acting injectable cabotegravir/rilpivirine (LA-CAB/RPV) is approved for people with HIV (PWH) who have achieved virological suppression; however, evidence remains limited for individuals with adherence challenges including those with persistent viraemia. We evaluated the implementation of a structured clinical pathway delivering LA-CAB/RPV to such individuals, including initiating therapy for individuals with detectable viraemia, across two Irish HIV centres.MethodsThis prospective service evaluation assessed a multidisciplinary pathway designed to support LA-CAB/RPV delivery for adults unable to sustain adherence to oral antiretroviral therapy. Clinical and service outcomes during the first 16 months of implementation were analysed. We present results relating to virological control within the cohort, treatment discontinuation, and injection timeliness as a surrogate marker of retention in care.ResultsFifty-one individuals underwent suitability screening, of whom 12 initiated LA-CAB/RPV and had available follow-up data for this early analysis. Median age was 46 years. The cohort had substantial social complexity, including homelessness, unstable housing, substance use, and previous disengagement from care. Nine participants initiated treatment with detectable viraemia and three were virologically suppressed at baseline. Median follow-up was 24 weeks. All participants who commenced treatment with virological suppression maintained suppression throughout follow-up. Among those initiating with viraemia, three achieved virological suppression and three demonstrated substantial virological improvement; three discontinued treatment due to death, patient choice, or loss of contact. No confirmed virological failure or emergent resistance was observed. Thirty-four delayed injections were recorded, although most occurred within accepted dosing windows and retention in care remained favourable.ConclusionsA structured multidisciplinary pathway enabled delivery of LA-CAB/RPV to adherence-challenged individuals, including those with detectable viraemia at treatment initiation. Encouraging virological outcomes were observed despite substantial social complexity and imperfect attendance. These findings support further evaluation of LA-CAB/RPV in vulnerable populations traditionally underserved by conventional HIV care models.