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Patients who struggle to take daily HIV pills should be switched to long-acting antiretroviral (LA-ART) injectable treatments sooner to help stop the spread of HIV, a study has concluded.
The paper, published in JAMA on 6 March 2025, suggests that patients who cannot control their HIV infections with pills — either because they have trouble swallowing or remembering to take their pills, or experience life challenges such as substance use disorder — could be moved to long-acting treatment to prevent the spread of virus.
LA-ART injectable treatment, a combination of long-acting cabotegravir (Apretude; ViiV Healthcare) and rilpivirine (Rekambys; Janssen), was first approved in the United States in 2021, but only for HIV patients who already had their infection under control with oral antiretrovirals.
Also in 2021, the National Institute for Health and Care Excellence (NICE) recommended patients move on to cabotegravir with rilpivirine once their viral load had stabilised.
Researchers studied data from 370 patients on the ‘Special Program on Long-Acting Antiretrovirals to Stop HIV’ at Ward 86 of the University of California San Francisco (UCSF) HIV/AIDS clinic in Zuckerberg San Francisco General Hospital.
From January 2021 until September 2024, 129 patients had detectable viral load levels when they started on injectables and 241 patients did not.
The researchers gave these patients monthly or bi-monthly injections and compared their viral loads with other patients who already had their viral loads controlled with oral medicines before starting injectable HIV therapy.
After 11 months, 99% of patients who were virally suppressed when they started the injectable medicine continued to have no detectable HIV in their blood. The results were almost the same for the group that started injectables before getting the virus under control, with 98% of patients achieving viral suppression in that period.
Study author Monica Gandhi, professor of medicine, associate division chief of UCSF’s division of HIV, infectious diseases and global medicine and medical director of the Ward 86 HIV clinic, said: “The US Department of Health and Human Services and the International Antiviral Society–USA have already updated guidance to recommend this strategy, partially as a result of UCSF’s data.
“We hope our results will encourage providers around the country to use LA-ART in those with detectable viral loads and adherence challenges. It really works.”
Commenting on the study on behalf of the HIV Pharmacy Association, Heather Leake Date, consultant pharmacist at University Hospitals Sussex Foundation Trust, said the 2021 NICE guidelines were “appropriately based on the available clinical trial evidence and the indications in the product licence, and reflect the optimal use of long-acting injectables with respect to maintenance of virological suppression”.
She added: “But the excellent work by the team in San Francisco addresses the significant unmet need for these medicines in people who don’t meet the ‘ideal world’ criteria.
“In Brighton, we have successfully used their approach in two people living with HIV who were unable to maintain adherence to oral antiretrovirals.
“The main concern about using long-acting injectables outside NICE guidance is the risk of resistance development, either due to starting treatment when the HIV RNA (viral load) is detectable, or due to stopping treatment and disengaging with care (because of the drugs’ very long half lives).
“It’s therefore essential that a treatment programme like this includes additional measures to actively support patients to attend regularly and address barriers to them remaining engaged in care.”
