Projected Benefits of Long-Acting Antiretroviral Therapy in Nonsuppressed People With Human Immunodeficiency Virus Experiencing Adherence Barriers

Wanyi Chen; Monica Gandhi; Paul E Sax; Anne M Neilan; Wendy H Garland; Timothy Wilkin; Rebecca Cohen; Andrea L Ciaranello; Sonali P Kulkarni; Joseph Eron; Kenneth A Freedberg; Emily P Hyle

doi:10.1093/ofid/ofad390

Projected Benefits of Long-Acting Antiretroviral Therapy in Nonsuppressed People With Human Immunodeficiency Virus Experiencing Adherence Barriers

Open Forum Infect Dis. 2023 Jul 22;10(8):ofad390. doi: 10.1093/ofid/ofad390. eCollection 2023 Aug.

Authors

Wanyi Chen¹, Monica Gandhi², Paul E Sax^{3

4}, Anne M Neilan^{1

3

5

6}, Wendy H Garland⁷, Timothy Wilkin⁸, Rebecca Cohen⁷, Andrea L Ciaranello^{1

3

5

9}, Sonali P Kulkarni⁷, Joseph Eron^{6

10}, Kenneth A Freedberg^{1

3

5

9

11

12}, Emily P Hyle^{1

3

5

9}

Affiliations

¹ Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, USA.
² Division of HIV, Infectious Diseases, and Global Medicine, University of California, San Francisco, San Francisco, California, USA.
³ Harvard Medical School, Boston, Massachusetts, USA.
⁴ Division of Infectious Diseases, Brigham and Women's Hospital, Boston, Massachusetts, USA.
⁵ Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA.
⁶ Division of General Academic Pediatrics, Massachusetts General Hospital, Boston, Massachusetts, USA.
⁷ Division of HIV and STD Programs, Los Angeles County Department of Public Health, Los Angeles, California, USA.
⁸ Division of Infectious Diseases, Weill Cornell Medicine, New York, New York, USA.
⁹ Center for AIDS Research, Harvard University, Cambridge, Massachusetts, USA.
¹⁰ Department of Medicine, Division of Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.
¹¹ Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.
¹² Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA.

Abstract

Background: In a demonstration project, long-acting, injectable cabotegravir-rilpivirine (CAB-RPV) achieved viral suppression in a high proportion of people with HIV (PWH) who were virologically nonsuppressed with adherence barriers. We projected the long-term impact of CAB-RPV for nonsuppressed PWH experiencing adherence barriers.

Methods: Using the Cost-Effectiveness of Preventing AIDS Complications (CEPAC) model, we compared 3 strategies: (1) standard of care oral integrase inhibitor-based ART (INSTI); (2) INSTI-based ART with supportive social services ("wraparound services" [WS]) (INSTI/WS); and (3) CAB-RPV with WS (CAB-RPV/WS). Model outcomes included viral suppression (%) and engagement in care (%) at 3 years, and life expectancy (life-years [LYs]). Base case cohort characteristics included mean age of 47y (standard deviation [SD], 10y), 90% male at birth, and baseline mean CD4 count 150/µL (SD, 75/µL). Viral suppression at 3 months was 13% (INSTI), 28% (INSTI/WS), and 60% (CAB-RPV/WS). Mean loss to follow-up was 28/100 person-years (PY) (SD, 2/100 PY) without WS and 16/100 PY (SD, 1/100 PY) with WS.

Results: Projected viral suppression at 3 years would vary widely: 16% (INSTI), 38% (INSTI/WS), and 44% (CAB-RPV/WS). Life expectancy would be 7.4 LY (INSTI), 9.0 LY (INSTI/WS), and 9.4 LY (CAB-RPV/WS). Projected benefits over oral ART would be greater for PWH initiating CAB-RPV/WS at lower CD4 counts. Across plausible key parameter ranges, CAB-RPV/WS would improve viral suppression and life expectancy compared with oral INSTI strategies.

Conclusions: These model-based results support that long-acting injectable CAB-RPV with extensive support services for nonsuppressed PWH experiencing adherence barriers is likely to increase viral suppression and improve survival. A prospective study to provide further evidence is needed.

Keywords: HIV; adherence; long-acting antiretrovirals; resistance; simulation modeling.

Abstract

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