Learning from the first: a qualitative study of the psychosocial benefits and treatment burdens of long-acting cabotegravir/rilpivirine among early adopters in three U.S. clinics

Abstract

Introduction: Perspectives on long-acting injectable cabotegravir/rilpivirine (CAB/RPV-LA) from HIV health disparity populations are under-represented in current literature yet crucial to optimize delivery.

Methods: Between August 2022 and May 2023, we conducted in-depth interviews with people with HIV (PWH) at four HIV clinics in Atlanta, Chicago and San Francisco. Eligibility criteria were current CAB/RPV-LA use with receipt of ≥3 injections or CAB/RPV-LA discontinuation. We purposefully sampled for PWH who initiated with viraemia (plasma HIV RNA >50 copies/ml) due to adherence challenges, discontinuers, and cis and trans women. Interviews were coded and analysed using thematic methods grounded in descriptive phenomenology. Clinical data were abstracted from the medical record.

Results: The sample (San Francisco n = 25, Atlanta n = 20, Chicago n = 14 for total n = 59, median number of injections = 6) consisted of 48 PWH using CAB/RPV-LA and 11 who had discontinued. The median age was 50 (range 25-73) and 40 (68%) identified as racial/ethnic minorities, 19 (32%) cis or trans women, 16 (29%) were experiencing homelessness/unstable housing, 12 (20%) had recently used methamphetamine or opioids and 11 (19%) initiated with viraemia. All participants except one (who discontinued) had evidence of viral suppression at interview. Typical benefits of CAB/RPV-LA included increased convenience, privacy and freedom from being reminded of HIV and reduced anxiety about forgetting pills. However, PWH who became virally suppressed through CAB/RPV-LA use also experienced an amelioration of feelings of shame and negative self-worth related to oral adherence challenges. Regardless of baseline viral suppression status, successful use of CAB/RPV-LA amplified positive provider/clinic relationships, and CAB/RPV-LA was often viewed as less "work" than oral antiretroviral therapy, which created space to attend to other aspects of health and wellness. For some participants, CAB/RPV-LA remained "work," particularly with regard to injection site pain and visit frequency. At times, these burdens outweighed the aforementioned benefits, resulting in discontinuation.

Conclusions: CAB/RPV-LA offers a range of logistical, psychosocial and care engagement benefits, which are experienced maximally by PWH initiating with viraemia due to adherence challenges; however, benefits do not always outweigh treatment burdens and can result in discontinuation. Our findings on rationales for persistence versus discontinuation can inform both initial and follow-up patient counselling.

Keywords: adherence; antiretroviral agents; cabotegravir; injections; rilpivirine drug combination; viral suppression.