Long-acting ART, support services could increase HIV viral suppression, survival
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Key takeaways:
- Pairing LA CAB/RPV with extensive support would likely increase viral suppression, engagement in care and improve survival.
- Benefits would be greatest in people with lower CD4 counts at ART initiation.
Long-acting injectable cabotegravir/rilpivirine paired with extensive support services for nonsuppressed people with HIV with adherence barriers would likely increase viral suppression and improve survival, researchers found.
“Several clinical trials showed the noninferiority of long-acting cabotegravir/rilpivirine (LA CAB/RPV) compared with oral integrase inhibitor-based (INSTI) ART in people with HIV (PWH) who have sustained viral suppression, which led to FDA approval in this population,” Wanyi Chen, PhD, research scientist at the Massachusetts General Hospital Mongan Institute, told Healio.
Results from the SOLAR phase 3b trial, published earlier this year, are among those showing long-acting ART (LA-ART) is noninferior to daily oral treatments and been called a “game-changer” preferred by many patients who make the switch.
Another previous trial, the phase 3 FLAIR study, also found patients were more satisfied with LA-ART than with daily oral therapy.
“However, [long-acting ART (LA-ART)] is not approved for PWH who are not virologically suppressed, who might benefit from LA-ART if they are experiencing barriers to taking a daily pill,” Chen said.
Using the Cost-effectiveness of Preventing AIDS Complications model — a validated microsimulation model of HIV disease and treatment — Chen and colleagues compared three treatment strategies for nonsuppressed PWH experiencing adherence barriers with mean baseline CD4 count of 150/L (SD 75/L): standard of care using oral integrase inhibitor-based ART (INSTI), INSTI-based ART with supportive social services (INSTI/WS) and CAB-RPV with WS (CAB-RPV/WS).
According to the study, assessed model outcomes included viral suppression and engagement in care at 3 years, and life expectancy, or life years (LYs).
Chen and colleagues found that projected viral suppression at 3 years varied widely across the three strategies — 16% for INSTI, 38% for INSTI/WS, and 44% for CAB-RPV/WS.
Engagement in care at 3 years would range from 45% for INSTI to 57% for INSTI/WS to 58% for CAB-RPV/WS. The study also showed that life expectancy was 7.4 LYs for INSTI, 9 LYs for INSTI/WS and 9.4 LYs for CAB-RPV/WS, whereas projected survival at 3 years would be 73%, 77%, and 79%, respectively.
Additionally, the study showed that the projected benefits over oral ART would be greater for PWH initiating CABRPV/WS at lower CD4 counts.
The authors wrote, for example, that for a cohort with mean baseline CD4 count 50/L, 3-year survival with CAB-RPV/WS would increase by 12 percentage points vs. with INSTI and by 3 percentage points vs. with INSTI/WS, whereas in a cohort with higher CD4 count (mean, 500/L), 3-year survival would increase by only 1 percentage point with CAB-RPV/WS vs. with INSTI and would be the same with INSTI/WS.
Based on these results, Chen concluded that a clinical trial or multisite, prospective study is “urgently needed” to confirm model-based results, as well as to determine the safety and efficacy of prescribing LA-ART to PWH who are not virologically suppressed.
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