The landscape of HIV treatment and prevention is undergoing a significant transformation with the advent of long-acting injectables (LAIs). These innovative therapies are proving to be game-changers for many individuals living with HIV (PLWH), offering an alternative to daily oral medications that can be cumbersome, stigmatizing, or difficult to adhere to due to various challenges.

Why Choose Long-Acting Injectables?

Despite fears surrounding needle use and logistical barriers like transportation to healthcare facilities, many patients are opting for LAIs. The reasons are compelling: convenience, fewer injections compared to daily pills, and reduced stigma. For individuals grappling with the complications of daily medication adherence or the embarrassment of storing HIV medications at home, LAIs can significantly enhance their quality of life and provide a more manageable approach to their care.

LA Cabotegravir/Rilpivirine: A New Hope for Treatment

Approved by the FDA in January 2021, LA cabotegravir/rilpivirine (Cabenuva; ViiV Healthcare) serves as a complete regimen for treating HIV in patients who are already virologically suppressed. This drug can be administered every 4 or 8 weeks by a healthcare professional, easing the burden of daily medication. Notably, recent findings indicate that LA CAB/RPV may also benefit patients who struggle to achieve or maintain viral suppression on standard oral antiretroviral therapy (ART).

A demonstration project in San Francisco included 57 patients who had not achieved viral suppression. Remarkably, 95% of them reached virologic suppression within a median of just 33 days. Additionally, various studies indicate that LA CAB/RPV could significantly enhance patient engagement in care and improve survival rates, particularly among those with lower CD4 counts.

The Evolution of PrEP: LA Cabotegravir for Preventative Care

The approval of LA cabotegravir (Apretude; ViiV Healthcare) in December 2021 ushered in a new era for HIV pre-exposure prophylaxis (PrEP). Administered every 8 weeks, Apretude has been shown to surpass traditional daily oral options in efficacy, reducing the incidence of HIV by 65% in high-risk populations, including cisgender men and women according to clinical trials.

Importantly, safety assessments in pregnant women suggest that Apretude poses no significant risks to infant outcomes. This reassurance opens up yet another pathway for individuals seeking effective HIV prevention strategies.

Lenacapavir: The Groundbreaking New Hope

As the newest antiretroviral agent, Lenacapavir (LEN) made its debut in December 2022, representing a first-of-its-kind capsid inhibitor for HIV treatment. With its longest-acting formula, LEN could revolutionize how patients manage their HIV, with subcutaneous injections occurring every 6 months after an initial oral lead-in period.

Current applications of LEN focus on heavily treatment-experienced adults with multidrug-resistant HIV, but promising preliminary studies are underway to explore its effectiveness further, potentially expanding its use to treatment-naive patients.

The Future of LEN in HIV Prevention

The excitement continues as five phase 3 trials known as the PURPOSE trials are exploring LEN's efficacy in various populations for PrEP. Preliminary results from PURPOSE 1, which focused on high-risk cisgender African women, demonstrated astounding results: 100% efficacy in preventing HIV. Meanwhile, findings from PURPOSE 2 indicate similar success rates among gender-diverse individuals.

Despite its impressive efficacy, LEN's high cost poses significant challenges, with rough estimates suggesting a financial burden of $15,600 per dose for U.S. patients. However, initiatives to provide generic access in low-resource countries offer a ray of hope for broader global access.

Conclusion: A Collaborative Path Forward

As the field of HIV treatment evolves, pharmacists and healthcare professionals play a crucial role in navigating the complexities of these new therapies to enhance the lives of PLWH and those at risk. Utilizing a multidisciplinary approach, supported by robust case management, ensures that the benefits of LAIs, including CAB/RPV, CAB, and LEN, are fully realized—offering patients not just improved clinical outcomes but a renewed sense of hope and empowerment in managing their health.

It's clear: long-acting injectables are not just changing the game; they are rewriting the rules for HIV treatment and prevention.