Everything You Ever Wanted to Know About the Long-Acting Injectable HIV Medication Cabenuva

Words by Daniel Hirsch

 

For many, living with HIV has meant living with daily pills. However, the January 2021 FDA approval of Cabenuva radically changed antiretroviral HIV treatment.

 

Cabenuva is the first long-acting, injectable HIV medication. It is typically administered every eight weeks. However, there are instances where it must be provided every four weeks, depending on the treatment plan decided by the health care provider and the patient’s specific needs. The regimen involves two injections — one of cabotegravir and one of rilpivirine — given on the same day.

 

To understand the pros and cons of Cabenuva, I spoke with DAP Health Director of Specialty Programs Dr. Jason Halperin. As a longtime advocate for better and more accessible HIV care, Dr. Halperin considers himself a Cabenuva proponent.

 

Who is Cabenuva for?

It’s really for anyone living with HIV who is interested in injectable medication. There are a lot of patients who meet the criteria for Cabenuva. It’s much fewer who don’t. I would say to people living with HIV, “Don’t be afraid to ask your provider if you think injectables might be right for you.”

 

What makes an injectable drug preferable to an oral medication?

I’d first say that we are at such an amazing place in terms of HIV medications — they’re incredibly effective and well-tolerated. Typically, one pill per day is all that most people living with HIV require. That said, though oral medication is well-tolerated, I often hear patients complain about nausea. And you have no nausea at all from the injectable medication. Other than occasional reaction or soreness at the injection site, there are fewer side effects.

 

And you don’t have to worry about forgetting to take a daily pill, correct?

A missed pill here and there is never going to lead to resistance. The barrier to resistance for our newer medications is extremely high. But yes, you don’t need to worry about that at all with the injectable.

 

In fact, we have our first trial population where injectable outperformed oral medication. This was in a population that has struggled taking oral medication before — 50% struggling with substance use, almost 40% were unhoused. They were randomized to either start an injectable or continue with oral medication. Those who were randomized to the injectable did so much better that the study was stopped early because it was considered unethical to continue [with patients on oral medication].

 

I’ll often have a patient come in and say, “I’ve been missing medicine,” “I’ve lost a job,” “I’m struggling with methamphetamine use,” or “I’m having difficulty with housing.” Before this study, I would’ve said, “Let’s get you back on oral and get you stabilized.” I’m really going the other way now. I’m telling my patients, “If a lot is happening in your life, injectables might be the right decision for you today.”

 

Can anyone who wants it access Cabenuva? Does insurance cover it?

Our insurance system in California has been very supportive. It’s very rare that I cannot get approval from insurance companies for Cabenuva for my patients. However, we are seeing equity issues around the country. We’re seeing that higher-income patients — those more likely to be White and to self-identify as a gay man — being started on Cabenuva over other populations.

 

Besides having to get poked with a needle, are there downsides to Cabenuva?

The one frustrating thing for me with this medication is it was not approved for self-administration. It has to be administered within the clinic setting. Oral medication does allow for more flexibility.

 

Also, let’s say one of my HIV patients moves to Los Angeles. They may not be able to just see another provider there and seamlessly start back on their injectable medication at that new clinic with that new provider. It’s not impossible, but it’s difficult. Cabenuva uncovers the layers of how disjointed our insurance system is. We really just need to have a health system where people are insured at all times and can access medical care at all times.

 

If you would like to investigate HIV treatment with Cabenuva, please speak to your DAP Health clinician. If you are not yet a patient at DAP Health, and would like to become one, click this link.