June 30th, 2023

The Yin and the Yang of Cabotegravir-Rilpivirine: Part One, the Good News

British advertisement, 1950.

Long-acting cabotegravir-rilpivirine (CAB-RPV) is the biggest advance in HIV therapeutics in years. It’s also creating quite the challenge for ID and HIV clinicians, which makes its availability a fascinating example of the importance of education, patient communication, and shared decision-making.

This post will be the good news about this groundbreaking treatment; in the next post, I’ll give the other side of the story.

For those of you who don’t do HIV treatment on a regular basis, here’s a brief summary of its development and intended use. In two prospective clinical trials (ATLAS and FLAIR), people with virologic suppression and no history of treatment failure or HIV resistance were randomized to receive their current daily oral ART or switch to once-monthly injections of cabotegravir (an integrase inhibitor) and rilpivirine (a non-nucleoside reverse transcriptase inhibitor already available in pill form).

The results showed that CAB-RPV was noninferior to oral ART. Later, a study (ATLAS-2M) demonstrated that these two injections could be given every 2 months. After a delay of several months due to manufacturing issues, it was FDA-approved in January 2021 as a switch strategy for “virologically suppressed adults.”

Seems simple, right? A straightforward option to offer people with HIV who no longer want to take their daily pill or pills. Progress!

Indeed, in the clinic for some patients, offering them this option has been wonderful. For reasons often having to do with convenience, privacy, stigma, or pill fatigue, they find the injections a tremendous improvement in their quality of life.

Some examples, drawn from our clinic (certain details changed for confidentiality):

  • A person who works nearby and takes no other medications, she loves just dropping by every 2 months to get her shots — she forgets entirely between visits that she has any medical problems at all.
  • Someone who lives with his family hated that his HIV medications had to be hidden since he wasn’t ready to disclose HIV to them; now he doesn’t worry about that at all.
  • Another describes CAB-RPV as “simpler” — which is his code for “I no longer have to go to the pharmacy each month and ask for a refill of these meds I’m embarrassed I need to take.”
  • A man who never could take oral ART consistently — with a declining CD4 cell count and multiple symptoms suggestive of advancing HIV disease — now is virologically suppressed and healthier than ever on monthly injections of CAB-RPV.

I have no doubt that the first three patients above would be fine on oral ART had CAB-RPV never been approved. But they are so much happier now.

And the fourth? It could have saved his life, or prevented HIV transmission to his partner, even though use of CAB-RPV is explicitly discouraged in HIV treatment guidelines for patients just like him. Trust me, like most HIV treaters out there, we would only use CAB-RPV for people with viremia when all other efforts to get someone on lifesaving treatment had failed.

As these examples demonstrate, this is what a big advance in ART looks like, and we’re all better for it!

Time to celebrate with a spectacular classic clip that I happened upon while you-tubing deep into the evening. Warning — don’t try this at home!

(Apparently they filmed this in one take. Amazing.)

Next post — the limitations of CAB-RPV. Sneak preview:  there’s a lot to consider before offering this to your patients.

3 Responses to “The Yin and the Yang of Cabotegravir-Rilpivirine: Part One, the Good News”

  1. Edward Traver says:

    Good post. Phenomenal dance number.

  2. Somenick says:

    Anti HIV treatments have advanced a lot in these years. Javing said this, there is still no definitive cure for it, yet some people out there act as if HIV is no longer a thing at all…

    Example of what I mean: Some friends where talking about how cool unprotected sex is. When I did not get on board with this enthusiasm one of them told me: Relax, this is not 1986 anymore, you know…

    What the?

  3. Harley Cox says:

    The “what the?” pearl clutching comment makes the mistake of equating condoms with protection and lack of condoms with lack of protection.

    At 0 transmissions world wide over many years treatment as prevention is much safer than any amount of condoms usage.

HIV Information: Author Paul Sax, M.D.

Paul E. Sax, MD

Contributing Editor

NEJM Journal Watch
Infectious Diseases

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