Financial Impact of a Long-Acting Injectable Cabotegravir/Rilpivirine Program: A Real-World Experience

BACKGROUND: Long-acting injectable (LAI) cabotegravir/rilpivirine (CAB/RPV) is an effective HIV treatment, but barriers, such as financial considerations limit implementation. Understanding the real-world financial impact is essential for program sustainability and equitable access. METHODS: This retrospective cohort study at the University of Nebraska Medical Center, Specialty Care Center (May 2022 to December 2024) evaluated people with HIV (PWH) receiving LAI CAB/RPV via buy-and-bill acquisition. We assessed annual staff time, program income (PI), and patient costs (PC). The primary endpoint was annual PI adjusted for staff time per patient compared to a modeled oral antiretroviral therapy (ART) comparator (bictegravir/emtricitabine/tenofovir alafenamide) using Wilcoxon Signed-Rank test. PI and PC were compared across study years and payer mix with Kruskal-Wallis test. Multivariate regression models explored factors predicting PI losses. RESULTS: The study included 110 PWH receiving 862 injections. LAI CAB/RPV required more annual staff time per participant than oral ART (7.4 hours vs. 3.7 hours). Median annual PI per participant hour managed was significantly lower for LAI CAB/RPV versus oral ART model across all study years (p<0.001). Despite this, the LAI program remained financially viable (median PI of $2,163/injection) with minimal PC; 91% of injections had $0 cost-sharing. PI losses occurred in 4.9% of injections and was associated with Medicaid coverage, lack of AIDS Drug Assistance Program (ADAP) coverage, and insurance changes. CONCLUSIONS: Although LAI CAB/RPV requires double the staff time and generates less time-adjusted PI than oral ART, buy-and-bill LAI programs can remain financially viable. Payer mix and insurance stability are essential to ensuring sustainability and equitable access.