Only a small share of people with HIV who have Medicare coverage are using the long-acting treatment Cabenuva (injectable cabotegravir and rilpivirine), according to a study published in JAMA Network Open. While the number is slowly rising, Cabenuva use remains low, and cost appears to be a barrier even among covered individuals.

 

Medicare primarily provides health coverage for people ages 65 and older, but it also covers certain individuals with long-term disabilities. Medicare is the second-largest source of federal financing for HIV care and treatment, after Medicaid, and many people with HIV are dually eligible for both programs. According to KFF, 28% of people living with HIV were covered by traditional Medicare in 2020 (not including those on Medicare Advantage plans), and the number is rising as this population ages. Compared with the traditional Medicare population overall, Medicare beneficiaries living with HIV are more likely to be people under 65 with disabilities and more likely to be dually eligible for Medicaid due to low income.

Daily oral HIV treatment is highly effective, but some people prefer long-acting injectable regimens that don’t require them to think about HIV every day and can help improve adherence. Cabenuva—the only approved complete long-acting antiretroviral regimen—is administered by a health care provider once monthly or every other month.

Jose Figueroa, MD, MPH, of Harvard T.H. Chan School of Public Health, and colleagues conducted a cross-sectional study looking at the use of long-acting antiretroviral therapy among HIV-positive Medicare beneficiaries and differences between people receiving oral and long-acting treatment.

The researchers identified people enrolled in Medicare Part B (covering outpatient medical care) and Part D (prescription drug coverage) from 2021—the year Cabenuva was approved—through 2023. The analysis did not include other long-acting HIV medications, such as lenacapavir (Sunlenca), which didn’t get a billing code until mid-2023 and must be used in combination with daily pills. Just over half were ages 65 or older, while about a third were ages 55 to 64, and nearly 20% were under 55.

In 2021, 638 people (0.4%) were using long-acting treatment, while 162,495 (99.6%) were on oral regimens. In 2022, the corresponding numbers were 3,202 (1.9%) and 165, 059 (98.1%). In 2023, the number of people on Cabenuva rose to 5,162 (3.0%) compared with 167,836 (97.0%) on oral treatment. Since then, the number of people using long-acting injectables has risen, but the proportion likely still remains low.

Those using long-acting injectables were more likely than those on oral treatment to be younger people with disabilities; 33.3% versus 18.2%, respectively, were under 55, and 32.8% versus 30.2% were ages 55 to 64. In contrast, 33.9% and 51.6%, respectively, were 65 and older.

In an adjusted analysis, American Indian and Alaska Native people were less likely than white people to receive long-acting treatment, but there were no significant differences by sex or for other racial and ethnic groups. People living in rural areas and those in the South were also significantly less likely to receive Cabenuva. In addition, Cabenuva users were more likely than those on oral therapy to be dually eligible for Medicaid or on Medicare Advantage plans. Of note, people with dementia, heart disease or kidney disease were less likely to receive long-acting therapy, while those with mental health conditions and substance use disorders were more likely.

Despite potentially greater benefit from reduced daily pill burden and lower risk of potential adverse effects of oral treatment containing tenofovir, older Medicare beneficiaries and people with complex chronic conditions were less likely to receive long-acting treatment, possibly reflecting clinician concerns about drug interactions, the researchers suggested.

They also noted that dually eligible individuals (who automatically qualify for subsidized drug coverage) and people with Medicare Advantage plans (who have maximum caps on out-of-pocket costs and reduced cost sharing) were more likely to use Cabenuva, suggesting that affordability remains a barrier to injectable treatment. But the greater use of Cabenuva among people with mental health concerns is encouraging, given the potential of long-acting treatment to address adherence challenges in this population.

“[T]hese early patterns suggest the need for strategies that ensure equitable access to long-acting antiretroviral therapy through affordability protections, outreach to marginalized populations and an improved understanding of treatment decisions for older people with HIV with complex multimorbidity,” the study authors concluded.

Click here for more news about HIV and aging.