Shawnalyn W. Sunagawa

Long-acting injectable antiretroviral therapy (LAI ART) offers an alternative to daily ART by mitigating adherence barriers such as pill fatigue and stigma. However, it introduces new challenges, including the need for continued engagement, clear communication, and understanding of the consequences of missed or delayed doses. Patient knowledge of these issues remains poorly characterized. Between June 1 and October 2, 2025, we administered a structured survey to individuals receiving LAI ART at two academic medical centers to assess sociodemographic characteristics, knowledge of key treatment concepts (injection schedules, dosing windows, oral bridging indications, and consequences of delayed or missed doses), and treatment perceptions. Eight questions were used to assess LAI ART-related knowledge among participants. Associations were evaluated using Fisher’s exact tests ( p < 0.05). A total of 119 participants completed the survey (70.6% University of Nebraska Medical Center and 29.4% University of Chicago). Mean age was 45.8 years, and most identified as male (74.8%) and White (54.6%) or Black (41.2%). Nearly all (95.0%) reported receiving pre-LAI ART education, and 89.1% were satisfied or very satisfied with their treatment. Despite this, the mean knowledge score was only 3.4/8 (42.5%; SD = 1.66). In exploratory analyses, higher education was associated with better understanding of on-time injections, treatment windows, and oral bridging thresholds, while both education and income were associated with knowledge of drug interactions. Although satisfaction with LAI ART was high, we found substantial knowledge gaps among patients receiving LAI ART despite education before treatment initiation. These findings highlight opportunities to strengthen patient education and reinforce key aspects of LAI ART management, particularly for patients with lower educational attainment and income.

Background: Long-acting injectable (LAI) cabotegravir/rilpivirine (CAB/RPV) is an effective human immunodeficiency virus-1 (HIV) treatment, but barriers, such as financial considerations, limit implementation. Understanding the real-world financial impact is essential for program sustainability and equitable access. Methods: This retrospective cohort study at the University of Nebraska Medical Center, Specialty Care Center (May 2022 to December 2024), evaluated people with HIV (PWH) receiving LAI CAB/RPV via buy-and-bill acquisition. We assessed annual staff time, program income (PI), and patient costs (PCs). The primary endpoint was annual PI adjusted for staff time per patient compared with a modeled oral antiretroviral therapy (ART) comparator (bictegravir/emtricitabine/tenofovir alafenamide) using the Wilcoxon signed-rank test. PI and PC were compared across study years and payer mix with Kruskal-Wallis test. Multivariate regression models explored factors predicting PI losses. Results: The study included 110 PWH receiving 862 injections. LAI CAB/RPV required more annual staff time per participant than oral ART (7.4 vs 3.7 hours). Median annual PI per participant hour managed was significantly lower for LAI CAB/RPV versus the oral ART model across all study years (P < .001). Despite this, the LAI program remained financially viable (median PI: $2163/injection) with minimal PC; 91% of injections had $0 cost-sharing. PI losses occurred in 4.9% of injections and was associated with Medicaid coverage, lack of AIDS Drug Assistance Program (ADAP) coverage, and insurance changes. Conclusions: Although LAI CAB/RPV requires double the staff time and generates less time-adjusted PI than oral ART, buy-and-bill LAI programs can remain financially viable. Payer mix and insurance stability are essential to ensuring sustainability and equitable access.

Objectives: Long-acting injectable (LAI) cabotegravir/rilpivirine demonstrates substantial inter- and intraindividual variability in trough concentrations during the first year of use. We aimed to characterize trough concentration variability of cabotegravir and rilpivirine after >12 months of continuous use. Methods: We conducted a prospective pharmacokinetic study in virologically suppressed people with HIV receiving bimonthly LAI cabotegravir/rilpivirine 600 mg/900 mg. Plasma trough samples were collected prior to three consecutive doses over 6 months for drug quantitation. Primary outcomes were inter- and intraindividual variability defined as coefficient of variation (CV) and intraclass correlation coefficient (ICC). Secondary outcomes included concentrations below the proposed 4x-protein-adjusted 90% inhibitory concentration (PA-IC90) for cabotegravir (4x-PA-IC90 = 664 ng/mL) and rilpivirine (4x-PA-IC90 = 48 ng/mL). Results: Among 50 participants, 150 samples were collected. Participants were primarily male (80%) with a median age of 45 years and a body mass index of 28 kg/m2. Median interindividual CVs were high for both cabotegravir [58%, interquartile range (IQR): 15, 59] and rilpivirine (52%, IQR: 18, 59). Median intraindividual CVs were moderate for both cabotegravir (24%, IQR: 15, 39) and rilpivirine (23%, IQR: 15, 39), with ICCs indicating good intraindividual agreement for cabotegravir (0.82) and moderate intraindividual agreement for rilpivirine (0.72). Twelve (8%) cabotegravir concentrations in 8 participants and 24 (16%) rilpivirine concentrations in 16 participants were below 4x-PA-IC90; however, all participants maintained virologic suppression throughout the study period. Conclusions: After one year of continuous use, inter- and intraindividual variability persists for cabotegravir and rilpivirine, indicating that clinical decisions should not be based on only one trough concentration.

We present a case of emergent integrase strand transfer inhibitor resistance following rifamycin-based latent tuberculosis infection (LTBI) treatment in a patient with HIV. This case highlights the risks associated with modifying antiretroviral therapy during LTBI treatment and illustrates how archived genotype results can directly impact clinical decision-making.

Following the introduction of doxycycline post-exposure prophylaxis (doxy PEP), concerns regarding associated antimicrobial resistance have emerged. In this piece, we discuss a range of collaborative strategies between the historically siloed fields of antimicrobial stewardship and sexually transmitted infections to guide the stewardship of doxy PEP and diagnostics for STI care.

Optimal cephalexin and cefadroxil dosing for skin and soft tissue infections (SSTIs) is unclear. We summarize clinical and pharmacokinetic/pharmacodynamic (PK/PD) data that compare dosing strategies for SSTIs. Additionally, we conduct population PK target attainment simulations for varying doses of cephalexin and cefadroxil for Staphylococcus aureus and Group A Streptococcus . Although some clinical data support lower doses in mild SSTIs, higher doses optimize PK/PD parameters in moderate–severe SSTIs, especially due to Staphylococcus aureus . Further prospective clinical and PK/PD studies, especially in obese adults, would be beneficial.

The optimal laboratory monitoring frequency for outpatient parenteral antimicrobial therapy-related adverse events (OPAT-AEs) during daptomycin therapy is not well defined. We identified just 6.6 OPAT-AEs per 1000 sets of weekly laboratory tests in this population, suggesting that less intensive laboratory monitoring may be reasonable in patients receiving daptomycin for OPAT.

Our retrospective review included 186 patients who received a doxycycline postexposure prophylaxis (doxy-PEP) prescription, with 56% missing ≥1 quarterly sexually transmitted infection (STI) screening visit. Of attended visits, 63% included guideline-recommended multisite STI screenings. As doxy-PEP use grows, improving patient engagement is essential to ensure long-term effectiveness.