Viral Suppression Rates at 48 Weeks in People With HIV Starting Long-Acting Cabotegravir/Rilpivirine With Initial Viremia
BACKGROUND: We previously demonstrated at the Ward 86 human immunodeficiency virus (HIV) clinic in San Francisco that long-acting (LA) cabotegravir (CAB)/rilpivirine (RPV) (LA-CAB/RPV) can rapidly lead to viral suppression in people with HIV (PWH) with viremia due to adherence challenges. We now evaluate the durability of viral suppression in this population. METHODS: We conducted a retrospective cohort study of PWH who started LA-CAB/RPV with viremia (HIV RNA viral load ≥50 copies/mL) before December 2022. Our primary outcome was viral suppression (viral load <50 copies/mL) with LA-CAB/RPV persistence (not discontinued or late by >14 days) at 48 weeks, using the viral load closest to 48 ± 8 weeks. We also describe viral failure, defined as a <2-log decline in viral load at 4 weeks or a viral load ≥200 copies/mL after initial viral suppression with emergent CAB- or RPV-associated resistance mutations; overall 48-week viral suppression including those switched to alternative antiretroviral therapy (ART). RESULTS: Fifty-nine PWH initiated LA-CAB/RPV with viremia and were included in the analysis; 49% had a CD4 cell count <200/µL, and the median baseline viral load was 42 900 copies/mL (quarter 1-quarter 3, 5272-139 038). At 48 weeks, 47 PWH met the primary outcome of viral suppression with LA-CAB/RPV persistence (80% [95% confidence interval, 67%-89%]). Five had viral failure with resistance (3 with RPV-associated and 2 with CAB- and RPV-associated mutations), and 1 was lost to follow-up. At week 48, 2 of those with viral failure were suppressed on alternative regimens (lenacapavir + bictegravir/tenofovir alafenamide/emtricitabine and CAB + lenacapavir). The overall viral suppression at week 48 with either LA-CAB/RPV or alternative ART was 92% (54 of 59). CONCLUSIONS: In PWH initiating LA-CAB/RPV with initial viremia, 48-week viral suppression (<50 copies/mL) was seen in 92%. LA ART can be an important tool for improving viral suppression among patients who face adherence challenges to oral ART.