Segment Description: An overview on the challenges with the use of first-generation long-acting injectables.
Joseph Eron, MD: Let’s talk about cabotegravir and rilpivirine in more detail.
Allison Agwu, MD, ScM: Sure.
Joseph Eron, MD: Remind people about how it’s administered.
Allison Agwu, MD, ScM: It’s a 2-drug regimen: cabotegravir and rilpivirine. One is an integrase inhibitor and the other is a nonnucleoside; they are currently being studied. It’s injected in the upper back thigh. And eventually, it will be administered at home. It’s an intramuscular injection in the gluteus medius, in the triangle that’s formed.
Allison Agwu, MD, ScM: The dose is 2-mL injections. It’s not a small amount. There have been studies for every 4 weeks, but it may be administered as infrequently as every 8 weeks, after orals are taken.
Joseph Eron, MD: Yes, you have to be suppressed.
Allison Agwu, MD, ScM: Right.
Joseph Eron, MD: It’s only been studied after HIV-1 suppression.
Allison Agwu, MD, ScM: It’s for people who are either initiating therapy or transitioning who are suppressed and take the oral component for suppression. It is also to make sure that they’re not going to have a reaction before they have an intramuscular injection.
Joseph Eron, MD: There’s the stigma of having to take a pill every day and the chance to be free from that. Colleen, can you comment?
Colleen Kelley, MD, MPH: Yes. Internalize stigma—it’s a constant reminder when you have that pill bottle on your bathroom stand that says, “I am HIV positive.” And if someone’s coming over to your home and maybe doesn’t know that about you and you don’t want them to know, but your pills are there and you’ve got to take them every single day, it’s a constant reminder that you’re sick and you’re HIV positive.
I know people are very excited to think that they’re not going to have to be reminded every single day when they take their pills that, “I’m HIV positive.”
Joseph Eron, MD: Because you’ve changed someone to an injectable, it doesn’t mean you’ve committed them to 30 years of an injectable, maybe 1 or 2 years. There are some risks with injectables.
Ian Frank, MD: Yes, these drugs do last a long time. After your most recent injection with cabotegravir, it can last for a year. People will need to come in and get their injections at the recommended frequency. If they miss their injections, there is a risk of developing resistance. We don’t know exactly what those risks are—we’ll learn in the near future more about the risk for integrase resistance in people who are failing on the regimen.
It is a major risk. And although there may be some adherence problems that get solved by the injections, I think that there are other adherence risks that get created. It’ll be more incumbent upon us as providers to ensure that our patients are coming in at the appropriate frequency, and we may need to modify our practices.
Colleen Kelley: A lot.
Ian Frank, MD: In Atlanta, your 6000-patient clinic. If just 10% of individuals elect for this, you would need a nurse available all the time.