Clinical consequences of delaying implementation of long-acting antiretroviral therapy for people with HIV and persistent viremia in the US.
Academic Article
Overview
abstract
BACKGROUND: People with HIV (PWH) with persistent viremia and adherence challenges to oral antiretroviral therapy (ART) can achieve viral suppression (VS) with long-acting cabotegravir/rilpivirine (LA-CAB/RPV). US guidelines, however, recommend CAB/RPV only in limited situations. We projected the impact of delaying LA-CAB/RPV implementation while awaiting trial data. METHODS: Using a microsimulation model, we considered 2 approaches for PWH with persistent viremia and intermittent care engagement: daily first-line oral ART or LA-CAB/RPV, both with intensive-support-services (ISS) to maximize adherence. We evaluated 4 CAB/RPV implementation scenarios: 1) Current practice (1% on CAB/RPV); 2) hypothetical Immediate/Delayed complete implementation (100% CAB/RPV after 0-4 yr); 3) two Post-trial implementation scenarios: Post-one-arm-trial implementation (1yr-trial, 5% uptake/yr thereafter), Post-randomized-trial implementation (3yr-trial, 15% uptake/yr thereafter; 4) Immediate incomplete implementation (1-20% uptake/yr). Outcomes were virologically-suppressed person-years (VSPY) and 5yr-mortality. Inputs included cohort size 33,600, initial CD4 count 150/µl, 6-month-VS from observational data: 23% (oral ART), 65% (LA-CAB/RPV). RESULTS: Current practice projects 35,810 VSPY and 17,640 deaths at 5yrs. Immediate complete implementation increases VSPY by 26,830 and averts 3,980 deaths; Delayed complete implementation produces 5,370 fewer VSPY and 800 more deaths/delayed year. Post-one-arm-trial implementation yields 1,700 more VSPY and 330 fewer deaths than Current practice; Post-randomized-trial implementation yields 1,280 more VSPY and 270 fewer deaths. Immediate incomplete implementation at 3% and 2% uptake/yr is similar to Post-one-arm-trial implementation and Post-randomized-trial implementation. CONCLUSIONS: LA-CAB/RPV for US PWH with persistent viremia and intermittent care engagement would increase VS and decrease mortality. Increased LA-CAB/RPV implementation with intensive-support-services should be undertaken while awaiting trial results.
