Provider perspectives on ideal candidates for long-acting injectable antiretroviral therapy (LAI ART) for HIV treatment: a multi-site qualitative study in the United States


BACKGROUND: Since long-acting injectable antiretroviral therapy (LAI ART) was approved in the U.S. in January 2021, clinics have been developing approaches to facilitate its distribution and implementation. While highly anticipated, existing inequities in treatment access may limit LAI ART uptake, particularly among the most marginalized. Medical and social service providers play a key role in determining LAI ART access as they evaluate patients and are primary prescribers. It is therefore necessary to understand how providers perceive and determine patients' LAI ART candidacy, and how this may influence who is offered LAI ART as it is being scaled-up.
METHODS: Starting in Sept 2021, we conducted 35 in-depth interviews with HIV providers across 4 U.S cities. Providers shared how they decided which patients should be offered LAI ART and reasons why they may not offer it to patients with clinical indications. Interviews were recorded and transcribed; thematic content analysis was used to identify key findings.
RESULTS: Provider perspectives regarding who should be offered LAI ART reflected three main themes:
1) Suppression-based eligibility: patients struggling with viral suppression on oral ART may benefit most from LAI ART but are ineligible under current guidelines. While acknowledging the risks of drug resistance, providers wanted more flexibility in prescribing to non-suppressed patients ('Anybody that''s positive is the ideal candidate'). Providers also worried that some virally suppressed patients may struggle with LAI ART ('They know that what they're on works, and don't want to mess with it');
2) Patient assessment: Providers preferred to assess patients individually based on their structural barriers and co-occurring health issues ('Each provider has to know their patient to know if this would be an option for them');
3) Gender differences: Providers described female patients as more reliable ('[Men] aren''t as attentive as women'), which might affect success on LAI ART, but were concerned with limited pregnancy-related data.
CONCLUSIONS: Providers utilized multiple factors in assessing patients for LAI ART. There is immediate need for standardized guidance and decision support tools that incorporate these factors to ensure consistent implementation and equitable offering of LAI ART to all patients.

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