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Consideration, Not Contraindication: LA ART for People With Adherence Challenges to Oral ART

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Released: November 03, 2026

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Historically, long-acting (LA) antiretroviral therapy (ART) was studied and approved primarily for people living with virologically suppressed HIV on their current ART. However, emerging clinical experience and recent clinical trial evidence have revealed that people with oral ART adherence challenges or persistent viremia may stand to gain the most from LA ART. Read on to learn why adherence challenges, persistent viremia, and concerns about drug resistance are not necessarily contraindications to LA ART.

Onyema Ogbuagu
Onyema Ogbuagu, MD, FACP, FIDSA
LA ART for Adherence Challenges to Oral ART

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Historically, long-acting (LA) antiretroviral therapy (ART) was studied and approved primarily for people living with HIV who had already achieved virologic suppression on their current ART. However, emerging clinical experience and recent clinical trial evidence have challenged the assumption that success with daily oral therapy must be a prerequisite to LA ART initiation.

In real-world practice, many individuals living with HIV face significant barriers to taking oral ART consistently. These barriers range from housing instability and transportation challenges to mental health conditions, substance use disorders, and trauma histories. Internal and external stigma and competing life priorities also interfere with adherence to daily regimens. For some people, maintaining a daily medication routine adds an extra hurdle to a life that may already be complex.

LA ART can meaningfully reduce this burden of daily medication-taking and create new opportunities for treatment success, but I believe eligibility for LA ART should be considered within the broader context of someone’s lived experience. The most important question is not whether someone has struggled with oral adherence in the past, but why those challenges exist and whether an LA strategy may better align with that person's needs. Identifying the underlying barriers to ART adherence is essential to this process because injectable treatment alone does not eliminate all obstacles to care. 

What About Viremia?
One uncertainty frequently expressed by healthcare professionals (HCPs) is whether LA ART can be effective for individuals who have detectable viremia. For many years, HCPs were understandably cautious about using injectable therapy in these cases. However, growing real-world experience demonstrated that carefully selected patients with adherence challenges and ongoing viremia can achieve viral suppression after transitioning to LA ART. These findings have been particularly compelling among people with longstanding adherence difficulties, including those who had never previously experienced sustained viral suppression. 

What About Resistance?
Another common concern involves antiretroviral resistance. Resistance remains an important consideration, particularly when selecting specific long-acting regimens. Nevertheless, the possibility of resistance should not automatically exclude patients from consideration. Instead, candidacy should be evaluated thoughtfully, balancing resistance risk against the consequences of continued viremia. Before initiating LA ART, we should always carefully review treatment histories, prior resistance testing, and previous virologic responses. Thankfully, there is a growing repertoire of injectable ART that can be used in combination with other drugs to form full treatment regimens that can address and overcome resistance concerns.

What About Injection Visits?
HCPs also frequently ask whether patients who struggle with daily pills will reliably attend injection visits. This is a reasonable concern, but it can be overcome. Successful implementation depends on creating support systems around the individual. Reminder calls, text messages, transportation assistance, pharmacist-led tracking programs, outreach services, and strong therapeutic relationships all contribute to sustained engagement. Incentives, including financial ones, have also been shown to work in combination with other support mechanisms.  In many settings, the predictability of scheduled injection visits has actually improved adherence monitoring compared with relying on self-administered oral therapy.

LA ART should be viewed as part of a comprehensive care model rather than a standalone intervention. Multidisciplinary HIV care remains critical. Addressing mental health needs, connecting patients with social services, helping them navigate housing or transportation barriers, and maintaining consistent communication all enhance the likelihood of long-term success. When combined with these supportive strategies, LA ART has the potential to help individuals achieve treatment goals that previously seemed out of reach.

Individuals with adherence challenges are often among those who stand to benefit most from innovative treatment approaches. They should not be left behind as scientific progress marches forward. Improving clinical outcomes for these vulnerable populations is worth the investment in time, energy, and resources.

When determining whether to consider these people for LA ART, we should increasingly consider whether LA ART may be the strategy that finally enables durable viral suppression, improved health outcomes, and enhanced quality of life. For many individuals who have struggled with daily oral regimens, long-acting therapy represents not merely an alternative option, but a transformative opportunity for treatment success.

Your Thoughts
What are some examples of questions you would ask to determine if someone is a good candidate for LA ART? Leave a comment to join the discussion!

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