Question
Who can use injectable CAB/RPV-LA in the UK
23 August 2024. Related: Access to treatment, Adherence, All topics, Changing treatment, Injectable ART.
Hi there, I am interested in using injectable ART and I wanted to know about the guidelines for who can use this.
Answer
Hi there
CAB/RPV-LA is an HIV combination that is given by injection every two months.
As this is a relatively new – approved in 2021 – the British HIV Association (BHIVA) recommend the following guidelines for people who are interested in this option.
This is partly because of a small risk of viral rebound with drug resistance, even if you have all the injections on time.
BHIVA recommended criteria for long-acting cabotegravir/rilpivirine use
Based on the entry criteria for the ATLAS-2M trial, we recommend the following criteria for long-acting cabotegravir/rilpivirine use:
- Viral suppression to <50 copies/mL for at least 6 months and
- No known or suspected NNRTI or INSTI resistance and
- No history of virological failure on an NNRTI- or INSTI-containing regimen and
- No use of INSTI monotherapy and
- Ability to commit to 2-monthly attendance for intramuscular injections and
- Acceptance of a small risk of virological failure and resistance (approximately 1 in 70 at year 1 and 1 in 60 at year 2) and the implication for U=U and
- Where there are only one of the following: baseline rilpivirine polymorphisms, BMI >30 kg/m2 orsubtype A6/A1, and
- No requirement for a tenofovir-containing regimen for the treatment or prevention of hepatitis B.
People should be counselled that:
- Known or suspected resistance to the either drug or detectable viraemia are exclusions.
- They will require an oral lead-in and then two deep gluteal intramuscular injections 1 month apartfollowed by deep gluteal intramuscular injections every 2 months in clinic.
- Implementation work shows they can expect to spend 30–60 minutes in clinic at each visit.
- Adherence is critical with a maximum +/– 7-day window for early/late administration; oral bridging can be used but should be considered an exception rather than routine.
- In clinical trials, about 1 in 70 people on 2-monthly long-acting cabotegravir/rilpivirine experienced viral rebound at year 1, and 1 in 60 at year 2, despite 100% adherence, and most of those also developed resistance to one or both drugs.
Long-acting cabotegravir/rilpivirine and pregnancy
There is limited information about injectable treatment in pregnancy so it is not a recommended option. Individuals wishing to conceive can remain on long-acting cabotegravir/rilpivirine.
Those becoming pregnant on long-acting cabotegravir/rilpivirine should consult with their physician and come to a joint decision on whether to continue.
Reference
BHIVA guidelines on antiretroviral treatment for adults living with HIV-1 2022 (2023 interim update). Page 21.
https://www.bhiva.org/HIV-1-treatment-guidelines
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