Q and A

Question

Who can use injectable CAB/RPV-LA in the UK

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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