Acceptability of Long-Acting Antiretroviral Treatment in Adolescents and Young People Living With HIV

Long-acting antiretroviral treatment (LA-ART) may overcome barriers to long-term adherence and improve HIV survival among adolescents and young people living with HIV. However, research on the acceptability of LA-ART in this age group is limited. Using data from the South African study of 953 AYLHIV, we sought to determine their preferences for and experiences with LA-ART in the context of a clincal trial.

Adolescents and young people living with HIV who prefer LAART over pill regimens had a variety of HIV-related factors associated with their preference, including stigma, high ART pill burden and low adherence to their current regimens. They were also more likely to have experienced mental illnesses or substance use disorders than their peers who did not prefer the new LA ART formulations.

Despite the significant barriers to accessing LA-ART in the South African setting, one in eight (12%) AYLHIV preferred it over pills, suggesting that there is high acceptability of this mode of delivery. These results suggest that a multi-level strategy to bring LA-ART from clincal trials to routine care is critical.

Individual and clinic level barriers included provider concerns with identifying appropriate candidates for LA-ART, challenges with adhering to frequent injection appointments, and patient adherence issues. Proposed solutions to these barriers include enhancing patient education, identifying designated staff for clinic visit retention and providing flexibility with appointment scheduling.

Health system level barriers were associated with cost and logistics considerations, such as payment authorizations, increased staffing needs and medication procurement and storage. Proposed solutions to these barriers included implementing multi-tiered support systems, strengthening clinic infrastructure and increasing provider readiness for LA-ART.

Clinical trial findings indicate that maintaining virologic suppression on LA-ART is feasible and sustainable, with rates of virologic suppression exceeding 93% for patients who started on daily oral ART and switched to monthly injections in the ATLAS and FLAIR trials. Findings from this NIAID-supported study are important to inform further implementation of the new LA-ART formulations and other strategies to support individuals experiencing barriers to achieving and sustaining virologic suppression.

The findings from this NIAID-supported study highlight key considerations for implementing LA-ART in settings with high HIV prevalence, where the adherence barrier to oral ART is particularly prominent. Identifying those with the greatest unmet need is important for prioritizing the use of this treatment modality in both resource-rich and constrained health systems. Additionally, understanding the broader role of LA-ART in promoting long-term HIV survival and reductions in AIDS-related mortality is essential for scaling up LA-ART to meet HIV prevention goals in low- and middle-income countries.