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LA ART to Empower Patients
Unlocking Long-Acting ART to Empower Patients With Choice

Released: December 12, 2023

Ann Avery
Ann Avery, MD
Activity Information

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Key Takeaways
  • A multidisciplinary approach involving not only healthcare professionals, but also pharmacy, informatics, and clinic administration teams can ease the burden of LA ART implementation in clinic settings.
  • Once initiated, most people choose to continue LA ART, but reasons for switching back to oral ART include disliking the injections and increased clinic visits.

Long-acting (LA) injectable antiretroviral therapy (ART) can be a game changer for people living with HIV. These new ART options can offer decreased stigma and freedom from taking pills every day and eliminate the stress of possible missed doses. Many patients report that their lives feel comparable to a time when they did not have HIV.

However, LA ART is not for everybody. These options must be administered in a clinic setting every 2 months at minimum, and some people cannot come in more often than they currently do. It also takes significant logistical coordination to successfully implement LA ART in clinical practice. Herein, I review innovative approaches from my clinic to bring LA ART to patients.

A Team Effort for LA ART Implementation
Working collaboratively, we figured out ways to streamline implementation of LA ART in our clinic. We engaged our pharmacy, nursing, provider, informatics, and administrative teams. This approach was essential given the complex process to procure and administer the medication.

When candidates for LA ART come into the clinic, they first see their provider, who will explain the pros and cons so that patients may make their own choice. For the approximately 10% of people who are interested, we put in a referral to our pharmacy team, and they work with the insurance company to get approval, which takes from a few days to 2 weeks. Unfortunately, we need to make sure that individuals are approved by their insurance prior to starting medication, so this is not something that people can start the same day.

There are differences between insurance companies in how this medication is approved. LA ART is becoming more commonly approved as a pharmacy benefit as opposed to a medical benefit, which allows our affiliated pharmacy to fill the prescription, deliver it to the clinic, and administer it as a simple nursing appointment. By contrast, if LA ART were approved by a medical benefit, it would need to be given during an infusion-level appointment.

Once the medication is approved, the patient is contacted and given the option of an oral loading dose. Most opt out, but if patients opt in for the oral loading dose, it would be sent to their house, or they could come and pick it up. Then, they come in during the loading-dose period to start their medication by injection.

To relieve some of the burden on the provider team, at my clinic, nurses administer all the injections. In addition, we are working with our pharmacy team to have them administer injections under a collaborative practice agreement.

To help with logistical coordination, we added a special type of visit label to track the visits in the electronic health record. To ensure that patients receive follow-up doses at the correct time, we developed a tracking process to facilitate scheduling, contact patients with reminders, and proactively sort reimbursement and billing issues. When patients are due for a visit, we can see if they are scheduled, and if they cancel a visit, we can see that they are overdue. To further streamline this process, one of the nurses is in charge of seeing that people are getting their medication on time. If people are missing appointments, this nurse will contact them and help troubleshoot the barriers that might be preventing them from accessing their medication.

Alternating doctor visits with the injection visits where a provider is not needed can be logistically challenging, so we try to use the electronic health record to its fullest potential. For example, it is easy to forget when viral loads are due. For each injection appointment, our nurses note the last time a viral load was drawn to remind the provider to order when necessary.

Implementing these processes has been helpful for ensuring that patients are successful on LA ART. The last thing we want is somebody becoming viremic, developing drug resistance, and eliminating ART options that were previously successful.

Real-world Experience With LA ART Persistence
Once people start LA ART, most have continued, although a handful decide to stop after the first several months because they dislike the shots or the frequency of having to come in for injections every 1-2 months.

We do not see many people discontinuing LA ART because of adverse events. LA ART is generally well-tolerated, but a primary adverse event is injection-site pain. It does not seem to prohibit people from doing their daily activities and seems comparatively milder than injection-site reactions seen with previous forms of injectable ART, such as enfuvirtide. However, it may factor into an individual’s decision to stop LA ART.

In my experience, most people who start injectable ART love it because of the freedom from the daily reminder that they have HIV. An injectable option also has been vital for people I have seen who struggle with adherence to oral medications because of swallowing difficulties.

In our practice, we consistently ask people if they want to continue LA ART, and the resounding answer is “yes.” I think that comes down to figuring out whom LA ART is right for; when I discuss LA ART, I emphasize that LA ART is better for some people, but it is no more effective than oral ART. Oral ART can be better for people who hate getting shots or who cannot come in more frequently. I make sure that choosing the right ART is based on a personalized decision and not just my recommendation.

I think as we look to the future, the options for medications and delivery methods are going to continue to grow to the point where LA ART lasts up to 6 months. The goal is to improve LA ART to the point where people are down to 1 or 2 visits per year. Wouldn’t that be great?

Your Thoughts?
Have you used this multidisciplinary approach to LA ART implementation for your own practice? What other methods have you used to overcome logistical barriers to LA ART? Leave a comment to join the discussion.