Table 4.

Checklist for consideration and implementation of LAI-ART in older persons with HIV.

Domains	Considerations	Checklist Items	Next Steps
1. Does the patient meet criteria for LAI-ART?*
Department of Health and Human Services guidelines [13]	Does patient meet baseline treatment qualifications?	□ Sustained virologic suppression (viral load <50 HIV-RNA copies/mL) for 3–6 months □ On a stable antiretroviral regimen □ No history of treatment failure □ No known or suspected resistance to CAB or RPV (may consider genotype resistance testing;	Proceed if all met (Step 2)
2. Determine potential benefits of LAI-ART
Patient and provider preferences	Perceived benefits	□ Convenience, increased freedom; reduced risk of inadvertent disclosure; pill aversion, fatigue, or intolerance; deprescribing (polypharmacy, concerns about inappropriate dosing); poor adherence*	Consider LAI-ART appropriateness and feasibility (Step 3)
	Perceived risks/harms	□ Patient preference for oral ART, hesitations about novel therapy, needle aversion, concerns about adverse effects; unreliable follow-up or transportation	LAI-ART likely not appropriate
3. LAI-ART appropriateness and feasibility
LAI-ART eligibility screening	Risk of CAB-RPV treatment failure and need for mitigating factors	□ Body mass index (BMI) < 30 kg/m2	Proceed if all met (Step 4)  If any are not met, reevaluate appropriateness of initiating CAB-RPV LAI-ART
Medical history, comorbidity, and functional status screening	Medical/surgical history	□ Willingness to adhere to monthly or every other month injections □ No history of chronic hepatitis B infection □ No increased baseline risk for hepatotoxicity □ No history of buttock implants or fillers
	Pharmacologic considerations	□ Contraindicated drugs: Certain anticonvulsantsa, antimycobacterialsb, systemic steroids, St. John’s Wort	Explore feasibility and potential need to change or deprescribe medications with respective providers; otherwise reevaluate appropriateness of initiating CAB-RPV LAI-ART
		□ Engage pharmacists to screen for risk of drug–drug interactions with other concomitant long-term medications: macrolide antibioticsd, methadonee
	Past and potential future needs for interacting medications (ex. steroids, antimycobacterials, methadone)	□ Chronic reactive or inflammatory conditions (ex. chronic obstructive pulmonary disease, multiple sclerosis, gout, other autoimmune or rheumatologic disease) or chronic pain (ex. lumbago, sciatica)?	Coordinate with PCP, other specialists to ensure other providers are aware of potential drug–drug interactions and contraindications in setting of LAI-ART
		□ Risk for tuberculosis (TB) or TB exposure (ex. travel and work exposure history)?
	Risk for LAI-ART adverse effects	□ Baseline impaired gait and/or ambulation?	Shared decision-making and anticipatory guidance on adverse effects including injection site pain, swelling, and potential impacts on function
		□ Past or current typical or atypical depression?	Psychobehavioral history, behavioral health screening (ex. PHQ9)
		□ Consider oral lead-in period (4 weeks) to ensure tolerability	Monitor for drug–drug interactions and adverse effects;if any suspected, reconsider appropriateness of LAI-ART
Financial feasibility	Potential for increased out-of-pocket costs for copays/coinsurance for both clinic visits and injections on a monthly or every other month schedule	□ Engage pharmacists and case managers	Determine if LAI-ART falls under a medical benefit, pharmacy benefit, or both
			Determine anticipated out-of-pocket costs to patient
			Determine if and for how long patient may qualify for manufacturer or RWHAP assistance programs
			Shared decision-making with patient on anticipated costs of regular visits and medication
4. Implementation considerations for older patients
Patient education	Cognitive decline or sensory impairment	□ Develop accessible printed and digital materials about treatment regimen, drug–drug interactions, side effects, patient expectations, and plan for missed doses □ Focused, educational clinic visits on LAI-ART process leading up to and with initial doses □ Involve caregivers in education and planning discussions, if appropriate
Patient scheduling and reminders	Lower technological literacy	□ Identify best means of communication (phone, letter, online portal) to ensure reliable contact for clinical updates and scheduling	Develop a communication and clinic scheduling plan with the patient (and/or caregiver); discuss back-up means of communication if primary method is unsuccessful
Patient transportation	Transportation barriers (ex. vision impairment, limited access, dependence on others for rides)	□ Screen for transportation challenges	If positive, engage social work if to explore transportation options
Plan for missed doses	Structural and socioeconomic barriers may increase risk for missed doses among older PWH	□ Anticipatory planning with patient (and caregivers, if appropriate) on best backup plan for oral bridge therapy (ex. prescribing a preemptive bridge dose; in-person vs. mail-order pharmacy)
Plan if LAI-ART resistance develops	Certain oral regimens have toxicities of particular relevance to older populations, resulting in higher rates of treatment changes (e.g., greater loss in bone mineral density)	□ Patient-provider discussion of risks of resistance to CAB-RPV and implications of toxicities of next-line therapies
Integrating with chronic disease management	Multiple comorbid conditions, preventive health	□ Consider coordinating injection visits with other health or lab monitoring (ex. blood pressure monitoring, A1c, mental health screening) through discussions with PCP and specialists

ART, antiretroviral therapy; CAB, cabotegravir; LAI, long-acting injectables; PWH, people with HIV; RPV, rilpivirine.

^*Limited studies have demonstrated benefits of CAB-RPV injectable therapy if paired with comprehensive wraparound services for virally unsuppressed or ART-nonadherent patients, such as those with psycho-behavioral or social barriers to adherence.

^aAnticonvulsants: carbamazepine, oxcarbazepine, phenobarbital, phenytoin.

^bAntimycobacterials: rifabutin, rifampin, rifapentine.

^cSystemic steroids: more than a single dose of dexamethasone.

^dIncreases risk for QT prolongation, Torsades de Pointes

^eCAB-RPV can reduce levels of methadone in some patients.