Expanding Access to Long-Acting ART in Europe

Key Takeaways:

• Long-acting antiretroviral therapy has been focused on a specific subset of people with HIV who have access to pharmacies and clinics.
• Other more challenging populations, including those who are migrant, also may benefit.
• Messaging, education, and follow-up initiatives must be developed to serve these populations so that expansion of this option can take place.

Consider New Patients for Long-Acting ART
When considering target populations for long-acting antiretroviral therapy (ART), I believe we have been narrow in our thinking. There are specific populations of people with HIV (PWH) who are not generally considered among our target populations but who would greatly benefit from long-acting ART. The specific population with which I deal are migrants.

The patients who have been included in clinical trials and real-life studies of long-acting ART are primarily men who have sex with men who are well suppressed and who have access to pharmacies and clinics. Expanding use of long-acting ART to more difficult-to-treat populations should be our next challenge. In my home country of Belgium, we have a large migrant population from sub-Saharan Africa and Latin America. These persons might be very interested in the long-acting strategy because of fear of stigma and having to hide their disease. They often have unstable living situations. It is very difficult to regularly obtain pills, move with them, and take them daily without being observed. This also is a population with a high rate of loss to follow-up.

Challenge: Access and Follow-up
We must carefully consider how to access this patient population. These patients have less access to information, and they are not involved in patient associations and communities. We would have to make a concerted effort to develop messaging and programs to make them aware of this treatment option.

Once people are aware, we in Belgium do have the infrastructure in place to manage them. We have 12 HIV reference centers, which are integrated into a network and cover approximately 85% of all PWH in the country. Patients can easily move from one center to another, and their records are obtainable by any physician. Therefore, these centers can easily accommodate migrant patients. The bigger concern would be if these persons returned to their home countries outside of Belgium, because then they would be lost to our system.

We do have a well-developed system of contacting patients who may become lost to follow-up. Nurses receive an automated warning when a patient does not come in for a certain period of time, and the patient is then contacted. We actually have a notice specific for patients receiving long-acting ART. However, getting in touch with the migrant population may require some effort, because they generally do not have the usual contact points that other patients might have (eg, email, home address, or phone). One of the challenges of adding migrant PWH to the long-acting ART program will be to develop a system to manage the loss of follow-up of these patients.

Disease Parameters for Expanding Use of Long-Acting ART
Many of the people who receive long-acting ART have been virologically suppressed for a period of time. If we were thinking about broadening the group of eligible patients, I would at this time only consider those with low-level viremia (ie, HIV-1 RNA <2000 copies/mL). We also would need to be careful in terms of treatment history and consider previous treatment failure and resistance. The prescribing information for long-acting cabotegravir and rilpivirine indicates that patients should be virologically suppressed with no history of treatment failure, so if we included PWH outside those parameters, we would have to follow them carefully. Among those with low-level viremia where adherence is a challenge, however, injectable long-acting ART might be of great benefit.

A Look to the Future
For future developments, newer regimens with less-frequent injections would be welcome and may help us overcome some of the challenges with expanding long-acting ART to more populations. Many patients tell us that coming in for their injection every 2 months is a burden and that they would welcome an extended dosing schedule. Infusion devices also might be desirable over injections to minimize the need for frequent clinic visits.

Learn More at Glasgow HIV 2022
To hear more perspectives on how to implement long-acting ART in the clinic, join our interactive symposium at the forthcoming Glasgow HIV 2022 meeting in person or by live webcast. The symposium will bring together a panel of pioneering European healthcare professionals and a patient receiving long-acting ART to share their experiences, practical insights, and recommendations on using injectable ART.

Your Thoughts?
Do you have some nontraditional patients who might benefit from long-acting ART? Add a comment and join the conversation.