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Over 80% With Detectable HIV Load Respond to CAB + RPV LA
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IDWeek 2023, October 11-15, 2023, Boston
Mark Mascolini
More than 4 in 5 people with an HIV load above 50 copies when they started long-acting injectable cabotegravir plus rilpivirine (CAB + RPV LA) reached a sub-50-copy load in a 229-person observational study, even though CAB + RPV LA is not licensed for use in people with detectable HIV RNA [1]. US researchers who conducted this study suggested "long-acting injectables may have a role for individuals with [a viral load at or above 50 copies] who may be struggling with adherence or tolerability of oral therapy." (there were comments during Q&A that this treatment approach should be reserved for patients with advanced disease, were there is concern about health, mortality, because viral failure can result in INSTI resistance and losing the class.)
The FDA licensed CAB + RPV LA in 2021 for antiretroviral-experienced people with a viral load below 50 copies. But a demonstration project in a San Francisco hospital found that 97.5% of people with several adherence barriers who started CAB + RPV LA with a load above 30 copies had a sub-30 load after 26 weeks [2].
To further assess the impact of CAB + RPV LA in people who start the combination with a detectable viral load, researchers turned to the OPERA Longitudinal Cohort, which at the time of this study included more than 155,000 people, about 14% of everyone with diagnosed HIV in the United States. Participants in this analysis had to be 18 or older and have antiretroviral experience and a viral load at or above 50 copies when first receiving CAB + RPV LA between January 21, 2021 and February 28, 2023. They could not have participated in a CAB + RPV LA clinical trial. Researchers tracked these people until they stopped CAB + RPV LA, stopped keeping cohort visits, died, or reached the study end date of March 25, 2023.
The investigators counted 229 of 1843 people (12%) starting CAB + RPV LA who had an initial viral load at or above 50 copies; 93 of them (41% of 229) had a starting load at or above 200 copies. In the 229 at or above 50 copies and the 93 at or above 200 copies, median age stood at 41 and 40 years, 31% and 47% were women, 57% and 70% were black, and 17% and 9% were Hispanic. Both groups had been diagnosed with HIV a median of 9 years earlier, and median viral loads stood at 2.1 and 4.2 log copies/mL (about 125 and 16,000 copies). While 65% of the study group took the drugs every 2 months, 31% took them monthly, and 3% had no dosing data.
Median follow-up stood at 6 months in the group who started CAB + RPV LA with a viral load above 50 copies and at 8 months in those who started with more than 200 copies; 80% in both groups had at least 1 follow-up viral load, and most had several.
Among 176 people with a viral load at or above 50 copies when starting CAB + RPV LA, 82% had any follow-up load below 50 copies, 94% had a last viral load below 200 copies, and 75% had a last viral load below 50 copies. Among 69 people with a starting load at or above 200 copies, 74% had any follow-up load below 50 copies, 90% had a last load under 200 copies, and 74% had a last load under 50 copies.
Among 107 participants with a viral load between 50 and 200 copies when they started CAB + RPV LA plus 65 people who reached a viral load below 200 copies during follow-up, 7 (4%) had study-defined virologic failure. Among those 7, 2 had 2 viral loads at or above 200 copies and continued CAB + RPV LA, 3 had 2 viral loads at or above 200 copies then switched regimens, 1 had 1 viral load at or above 200 copies then stopped treatment and later switched to another combination, and 1 had 1 viral load at or above 200 copies then stopped treatment and later started a different regimen, and 1 had 1 viral load at or above 200 copies then stopped treatment and later resumed CAB + RPV LA.
The researchers hope to collect more follow-up data since only one quarter of people studied so far took CAB + RPV LA for at least 10 months. They added that records did not explain why clinicians prescribed the long-acting injectables for people with a detectable viral load, a strategy outside of licensed indications. They cited the strengths of their analysis as a large population of new CAB + RPV LA users providing real-world data through electronic records and representing diverse regions across the United States.
References
1. Hsu RK, Sension M, Fusco JS, et al. Real-world use of long-acting cabotegravir + rilpivirine in people with HIV with detectable viral loads at initiation: findings from the OPERA Cohort. IDWeek 2023, October 11-15, 2023, Boston.
2. Gandhi M, Hickey M, Imbert E, et al. Demonstration project of long-acting antiretroviral therapy in a diverse population of people with HIV. Ann Intern Med. 2023;176:969-974. doi: 10.7326/M23-0788. https://www.acpjournals.org/doi/10.7326/M23-0788
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