The Guilt is Gone - A Clinical Pathway for the Use of Long-Acting Injectable antiretroviral therapy (LAI-ART) in Adherence Challenged People Living with HIV

Background: Intramuscular injection of long-acting cabotegravir and rilpivirine (LA-CAB/RPV) is an approved HIV-1 treatment. It allows people living with HIV (PLWH) to receive two monthly injections instead of daily tablets, a novel option, particularly for adherence challenged populations. [1, 2, 3] Successful use of LA–CAB/RPV in such individuals, including those with detectable HIV viraemia has been demonstrated and resulted in expansion of international guidelines. [9 – 11] This data encouraged us to develop and implement a clinical pathway to introduce LA-CAB/RPV for adherence-challenged patients who have not achieved or maintained viral suppression with conventional therapy. This pathway has been implemented at two tertiary hospital centres in the Republic of Ireland.

Methods: This pathway is aligned with existing evidence-based care models; namely from Ward 86, San Francisco. The pathway outlines eligibility criteria, site approval processes, dosing schedules, and follow-up requirements. Using existing clinical information, individuals were assessed and selected for multidisciplinary eligibility review; 20 screened at St James Hospital and 27 at Galway University Hospital. Cases are discussed at a HIV resistance multidisciplinary team meetings to review virological suitability for LA-CAB/RPV.

Results: Between December 2024 and December 2025, eligibility for LA-CAB/RPV was reviewed for 47 patients across two clinical sites, with 10 patients having available virological data to include in this interim analysis. Median age was 43 years (IQR 27–57); 70% were cisgender women and 60% were White Irish. At initiation, 10% experienced homelessness or unstable housing and 30% reported active substance use. All patients transitioned to 8-weekly injections, with a median follow-up of 27 weeks (range 3–48) so far. Seven patients (70%) initiated LA-ART with detectable viremia and three were virologically suppressed. All suppressed patients maintained viral suppression throughout follow-up. Among those with viremia at initiation, median baseline viral load was 32,268 copies/mL and 5/7 (71%) achieved suppression.  A median of 1 dose achieved suppression amongst these patients (range 1 – 2 doses). The remaining two have declining viral loads. Sixty percent received injections on time; delays averaged 3 days. No virologic failure related to delayed dosing occurred.

Conclusion: LA-CAB/RPV offers a transformative option for PLWH facing structural and psychosocial barriers to daily oral therapy. In our adherence-challenged population, including those viraemic at initiation, treatment with injectable ART achieved rapid and sustained viral suppression. Ongoing follow-up will evaluate durability of suppression, engagement in care, and implementation challenges. These findings highlight the benefits to individual health, but also the public health potential of structured, low-barrier treatment models to expand equitable access, reduce community viral load, and strengthen prevention. Scalable implementation could help close gaps in the care continuum and accelerate progress toward global HIV targets.

To be updated shortly..