How the multiple burdens of daily oral antiretroviral therapy shape the acceptability of long-acting injectable cabotegravir and rilpivirine among people living with HIV in Uganda and South Africa: a sub-study of the IMPALA trial

Long-acting injectable antiretroviral therapy (LAI-ART) has the potential to improve adherence and treatment outcomes among people living with HIV (PLHIV) who experience challenges with adherence to oral medication. We explored how experiences with daily oral ART shaped LAI-ART acceptability within a clinical trial in Uganda and South Africa. A qualitative methods sub-study was nested within a phase 3b randomised clinical trial evaluating long-acting injectable cabotegravir + rilpivirine among PLHIV with a history of suboptimal adherence to oral ART in Uganda and South Africa. Three in-depth interviews (months 1, 6 and 12) were conducted with a purposive sample of 40 participants (divided equally by country and study arm). Data were analysed thematically. Three themes shaped the perceived and experienced acceptability of LAI-ART: Burdens of daily oral ART, including emotional strain, stigma, fear of disclosure, treatment fatigue, mobility constraints, and gendered responsibilities. Experienced benefits of LAI-ART, including convenience, discretion, and reduced reminders of HIV status and the pressure of daily pill-taking. Finally, prior experiences with routine HIV care services were contrasted with trial-based care that emphasised privacy, efficiency, respectful communication, and reimbursement of transportation costs. LAI-ART was preferred to daily oral ART as it reduced treatment burden, improved privacy and supported adherence.