Long-acting antiretrovirals: research and implementation considerations in Africa.

We applaud Jean B Nachega and colleagues1Nachega JB Scarsi KK Gandhi M et al.Long-acting antiretrovirals and HIV treatment adherence.Lancet HIV. 2023; 10: e332-e342Summary Full Text Full Text PDF PubMed Scopus (1) Google Scholar on their recent review of long-acting antiretroviral therapy (ART) and adherence. This issue is particularly important for the WHO African region, which bears two-thirds of the global HIV/AIDS burden and has more than 20 million people on ART.2UNAIDSGlobal HIV & AIDS statistics—fact sheet.https://www.unaids.org/en/resources/fact-sheetDate accessed: February 19, 2023Google Scholar To date, Botswana is the only African nation that has approved long-acting cabotegravir plus rilpivirine, citing potential adherence benefits.3VOA NewsBotswana introduces injectable antiretrovirals for HIV treatment.https://www.voanews.com/a/botswana-introduces-injectable-antiretrovirals-for-hiv-treatment/6845496.htmlDate accessed: May 3, 2023Google Scholar However, delivery has not yet commenced, pending data to guide implementation. Clinical trials of long-acting cabotegravir plus rilpivirine in this setting, including in children, adolescents, and pregnancy, are planned or already underway (appendix). We are currently conducting the Improving HIV outcomes in Africa with Long-acting Antiretrovirals (IMPALA) trial, investigating the effectiveness of 2-monthly cabotegravir plus rilpivirine among adults with a history of suboptimal virological control. This population could particularly benefit from more adherence-friendly long-acting ART with the least additional risk of emergent resistance, as shown in modelling studies.4Phillips AN Bansi-Matharu L Cambiano V et al.The potential role of long-acting injectable cabotegravir-rilpivirine in the treatment of HIV in sub-Saharan Africa: a modelling analysis.Lancet Glob Health. 2021; 9: e620-e627Summary Full Text Full Text PDF PubMed Scopus (26) Google Scholar Long-acting cabotegravir plus rilpivirine is in high demand for its potential benefits in reducing stigma and pill burden, and there is an urgent need to make long-acting products accessible given the ongoing epidemic. However, there are important implementation challenges to address, including careful targeting of individuals at low risk of virological failure despite limited access to drug resistance testing, HIV viral load monitoring frequency, cold-chain requirements, and exclusion of hepatitis B co-infection. The studies listed in the appendix will provide critical data to inform a maximum impact of this paradigm shift in HIV treatment, essential to reaching the UNAIDS target of ending the AIDS epidemic by 2030.5UNAIDSFast-track: ending the AIDS epidemic by 2030.https://www.unaids.org/sites/default/files/media_asset/JC2686_WAD2014report_en.pdfDate: 2014Date accessed: May 2, 2023Google Scholar FVC has received grant funding from Janssen, ViiV, and Gilead and is on the steering committee of a ViiV-funded implementation trial. LAO has received grant funding from ViiV and Gilead, travel support from Mylan, and is on a GSK-led scientific advisory board. All other authors declare no competing interests. Download .pdf (.2 MB) Help with pdf files Supplementary appendix Long-acting antiretrovirals and HIV treatment adherenceIntramuscular injection of long-acting cabotegravir and rilpivirine is a novel, long-acting antiretroviral therapy (ART) combination approved for use as a fully suppressive regimen for people living with HIV. Long-acting cabotegravir with rilpivirine ART has reduced required dosing frequency from once daily to once every month or every 2 months injections. This new era of long-acting ART, which includes other antiretrovirals and formulations in various stages of clinical development, holds tremendous promise to change the standard of HIV treatment. Full-Text PDF