Long-Acting Injectable Therapy for People with HIV: Looking Ahead with Lessons from Psychiatry and Addiction Medicine

Abstract

Long-acting injectable antiretroviral medications are new to HIV treatment. People with HIV may benefit from a treatment option that better aligns with their preferences, but could also face new challenges and barriers. Authors from the fields of HIV, substance use treatment, and mental health collaborated on this commentary on the issues surrounding equitable implementation and uptake of LAI ART by drawing lessons from all three fields. We employ a socio-ecological framework beginning at the policy level and moving through the community, organizational, interpersonal, and patient levels. We look at extant literature on the topic as well as draw from the direct experience of our clinician-authors.

Low Uptake of Long-Acting Injectables in the First 2.5 Years Following Approval Among a Cohort of People Living With HIV

“…Insurance coverage for LAI is limited and insurers may institute cost-containment conditions, including requirements for prior authorization, patient cost sharing, step therapy, and formulary exclusions that can further impede LAI prescribing [ 25 ]. The only option for many PLWH to access treatment is through the Ryan White HIV/AIDS program [ 26 ]. One study found that financial coverage for LAI and staffing challenges caused barriers to LAI administration at Ryan White–funded HIV clinics [ 27 ].…”

Psychiatry and Family Medicine Residents’ Likelihood of Prescribing HIV Pre-Exposure Prophylaxis (PrEP) to Patients with Mental Illness and HIV Vulnerability

“…Patients with chronic psychotic disorders may be prescribed LAI-antipsychotic medications that are prescribed by psychiatrists and administered in outpatient psychiatric care settings. 55 LAI-antipsychotics have been shown to improve medication adherence and lower relapse rates in psychiatric practice. [56][57][58] Co-location of services for administering LAI-PrEP and psychotropic medications may be a promising model to make HIV prevention more accessible.…”

“…14,18 A similar model may also be amenable to adaptation to substance use treatment facilities where LAI anticraving medications like buprenorphine and naltrexone are administered. 55 This clinical infrastructure (e.g.,. refrigerated storage, dedicated staff, and patient panel tracking) is more likely to be pre-existing in psychiatric clinical contexts as compared with primary care settings, 55 where FM physicians are more likely to work, which may help explain the finding that psychiatry residents were more likely to recommend LAI-PrEP than FM residents for the SCZ-LAI condition.…”

The Phenomenon of Antiretroviral Drug Resistance in the Context of Human Immunodeficiency Virus Treatment: Dynamic and Ever Evolving Subject Matter

“…As of 2021, CAB/RPV is the first long-acting injectable antiretroviral therapy authorized for use in HIV patients who are treatment-naive or experienced [99,226]. Moreover, there has been a notable surge in research on the creation of long-acting pharmacological formulations for people diagnosed with HIV [104,227]. In addition to CAB/RPV, research focuses on alternative long-acting injectables, including long-active capsid inhibitors and long-acting slow-effective release antiretroviral therapy (LASER ART).…”