Back Back
Real-World LA ART
Long-term, Real-world Safety and Efficacy of LA ART: Perspectives From Europe

Released: April 02, 2025

Expiration: April 01, 2026

Marta Boffito
Marta Boffito, MD, PhD, FRCP, MBA
Activity Information

Activity

Progress
1
Course Completed
Key Takeaways
  • With long-term, real-world safety and efficacy data, LA ART has the potential to be a paradigm shift for HIV care in Europe

Of all the impactful and exciting abstracts presented at the Conference on Retroviruses and Opportunistic Infections (CROI) 2025, the 2 datasets that I found most informative for my clinical practice are the Week 96 reports from the CARES clinical trial and the OPERA cohort data on long-acting (LA) antiretroviral therapy (ART) effectiveness in the real world, conducted in Sub-Saharan Africa and in the USA, respectively.

LA ART in the Real World
The long-term data from the CARES trial demonstrated that, at Week 96, LA cabotegravir plus rilpivirine (LA CAB + RPV) maintained virologic suppression in most participants managed under a public health approach, (eg, sparse viral load monitoring). The study population included high rates of obesity, prior NNRTI exposure, RPV resistance mutations (7% among the total study population), and prevalence of different viral subtypes (A1 in 55% of the total study population).

In detail, a sustained high level of efficacy was observed, with HIV-1 RNA <50 copies/mL in 97% of participants, thereby confirming noninferiority to oral ART. Virologic failure was seen in only 4 participants receiving LA CAB + RPV (1.6%), and 3 of these people resuppressed on dolutegravir/tenofovir disoproxil fumarate/emtricitabine, suggesting that a boosted PI-containing ART regimen is not always necessary to achieve viral resuppression after failure of LA ART.

The LA treatment was also well tolerated, with only 2% of participants having a severe (greater than grade 3) adverse event related to LA CAB + RPV. Injection-site reactions were mainly grade 1 and 2, and only 1 led to discontinuation.

Of importance, participants’ treatment satisfaction score increased from baseline to Week 96 to a greater extent in those on LA CAB + RPV vs those who continued oral ART.

The OPERA cohort data also showed high rates of virologic suppression among 3304 people living with HIV on LA CAB + RPV over up to 3 years, with HIV-1 RNA <50 copies/mL in 95% of participants overall at their last follow-up. The rate of confirmed virologic failure was 1% (after a median of 7 months) and having a BMI greater than 30 did not seem to change this outcome.

Promoting Acceptance of LA ART
I think these data will reassure healthcare professionals (HCPs) and increase confidence in the efficacy of injectable LA ART on a global scale, while further optimizing treatment options for people with HIV. LA ART offers a promising solution for people struggling with oral ART adherence, including those with issues like malabsorption or swallowing difficulties. Both studies showed very high rates of adherence to injection appointments.

I find that hesitancy in prescribing LA CAB + RPV may be due to fear of virologic failure with resistance. After all, we already have many potent integrase inhibitors characterized by a high genetic barrier to resistance and highly effective single-tablet combinations. The more hesitant HCPs might ask whether using ART combinations with lower genetic barrier and unknown long-term efficacy is a risk worth taking.

However, HCPs’ concerns about rare virologic failure with LA CAB + RPV—or concerns about implementation or operational challenges—should not supersede the great enthusiasm for these treatments from people living with HIV. Although more data are still needed to fully understand the long-term rate of virologic failure with LA CAB + RPV in the real world, numerous clinical trials have shown that the rates of virologic failure with LA ART are low, and the noninferiority criteria have been met across all trials to date.

People living with HIV who are considering these treatments should, of course, be informed of these data—and how the rates of virologic failure compare across different ART regimens—but it should be their choice to make. Ultimately, I think LA ART will bring a paradigm shift to HIV care in several countries, including across Europe.

Future Questions
Finally, we as investigators need to address some key data gaps around the safety and efficacy of LA CAB + RPV during pregnancy, and how to address oral bridging. If someone is unable to visit the clinic within 7 days of the due date of their next injection, they will need to start oral bridging therapy. This may not be problematic for planned visit interruptions but could prove challenging in cases of unplanned non-attendance. Further research is needed to determine whether it is feasible or affordable to provide emergency bridging ART to all people living with HIV on LA ART.

Your Thoughts
Does this long-term safety and efficacy data improve your confidence in prescribing LA CAB + RPV for people living with HIV who experience challenges adhering to oral ART? Leave a comment to join the discussion!