Long-Acting Cabotegravir/Rilpivirine for HIV Antiretroviral Therapy Throughout Pregnancy: A Case Report and Literature Review

TL;DR

A patient maintained HIV control with long-acting injectable treatment during pregnancy, though fetal issues were observed.

Contribution

Reports on the use of CAB/RPV during pregnancy and reviews existing literature on its safety and efficacy.

Findings

Patient maintained undetectable viral load with CAB/RPV during pregnancy.

Infant showed fetal pyelectasis and growth restriction but no HIV transmission.

Literature review reveals mixed outcomes but no perinatal HIV transmission reported.

Abstract

Cabotegravir/rilpivirine (CAB/RPV) is a long-acting injectable antiretroviral therapy (ART) with limited data on safety and efficacy during pregnancy. We report a patient who maintained viral suppression on CAB/RPV every 2 months throughout pregnancy. MV was a 33-year-old G4P1021 with HIV and hypertension. She was infected perinatally and treated with multiple ART regimens due to inconsistent adherence to oral ART. Prior to this pregnancy, she switched to long-acting intramuscular CAB (600 mg)/RPV (900 mg), which allowed her to maintain an undetectable viral load. In preconception counseling, we advised her of the unknown efficacy and safety during pregnancy. She elected to continue CAB/RPV every 2 months and maintained 100% adherence with an undetectable viral load throughout pregnancy. Fetal pyelectasis was identified by ultrasound and persisted throughout pregnancy. A male infant with growth restriction (2.33 kg) was delivered via scheduled 37-week cesarean and admitted to the neonatal ICU for respiratory support for two days. Postnatal ultrasound confirmed hydronephrosis. The infant had negative HIV testing at one, two, and 10 months. There are limited reports of CAB/RPV continuation throughout pregnancy. One previous report identified fetal growth restriction and ptosis of the neonate. Another reported normal birthweight and no congenital anomalies. Most recently, an abstract presented 22 pregnancies continued on CAB/RPV. Anomalies in this series were pyelectasis, ventriculomegaly, and Trisomy 21. None of these reports observed perinatal HIV transmission. Primary concerns for the use of CAB/RPV during pregnancy are the possibility of reduced drug efficacy and adverse neonatal outcomes. The existing literature is sparse, but multiple studies have shown reduced RPV concentrations during pregnancy, raising concern for ineffective viral suppression. There is no evidence of teratogenic effects. Benefits of CAB/RPV during pregnancy include improved drug adherence and discretion. Based on our experience and review of the literature, long-acting intramuscular CAB/RPV may be of value in treatment-experienced patients experiencing difficulties with pill adherence.