Pre-Switch Assessment for Stribild to Cabenuva Transition
Before switching a virally suppressed HIV patient from Stribild to Cabenuva, you must verify: (1) no history of treatment failure or resistance to cabotegravir or rilpivirine, (2) hepatitis B status with continuation of HBV treatment if positive, and (3) current viral suppression with HIV RNA <50 copies/mL. 1, 2
Mandatory Resistance and Treatment History Review
Review complete antiretroviral treatment history and all prior resistance testing results to ensure no documented or suspected resistance to either cabotegravir or rilpivirine, as this is an absolute contraindication to Cabenuva use 1, 2
If prior resistance testing is unavailable and the patient has incomplete treatment history, consider proviral DNA genotyping to detect archived mutations, though this has not been validated and rilpivirine-associated mutations on any genotype testing should preclude the switch 1, 3
Confirm no history of virologic failure on any prior regimen, as patients with previous treatment failures may harbor archived resistance mutations not detectable on standard testing 1
Hepatitis B Screening and Management
Screen for hepatitis B surface antigen (HBsAg) before switching, as Stribild contains tenofovir which treats HBV, while Cabenuva has no anti-HBV activity 1, 3
If HBsAg positive, either continue separate HBV treatment or do not switch to Cabenuva, since discontinuing tenofovir without HBV coverage risks severe hepatitis B flare 1
For patients with cleared HBV (HBsAg negative), vaccination may be warranted if not immune 1
Viral Suppression Confirmation
Document current HIV RNA <50 copies/mL (ideally <50 copies/mL for at least 6 months) before initiating the switch, as Cabenuva is only indicated for virologically suppressed patients 2
Ensure stable viral suppression on current regimen without recent viral blips or adherence concerns 1
Risk Factor Assessment for Cabenuva Failure
Assess body mass index (BMI), as BMI >30 is associated with increased risk of virologic failure on Cabenuva (1-2% failure rate even with adherence) 1, 3
Document HIV subtype if known, as subtype A6 carries higher failure risk with cabotegravir/rilpivirine 1
Counsel patients about the 1-2% risk of virologic failure with emergence of 2-class resistance even with perfect adherence to injection schedule, and discuss implications for future treatment options 1, 3
Additional Pre-Switch Considerations
Verify patient ability to attend monthly or every-2-month injection appointments, as missed injections require complex oral bridging strategies and close monitoring 1
Review all concomitant medications and supplements for potential drug interactions, though this is less critical when switching from Stribild (which contains cobicistat with extensive interactions) to Cabenuva 1
Consider optional oral lead-in with cabotegravir/rilpivirine tablets for approximately 1 month to assess tolerability before committing to long-acting injections, though this is not mandatory 2
Common Pitfalls to Avoid
Never switch patients with any documented NNRTI resistance (including rilpivirine mutations K101E, E138A/G/K/Q/R, Y181C/I/V, H221Y, F227C, M230I/L) as this dramatically increases failure risk 1, 3
Do not overlook hepatitis B coinfection, as abrupt tenofovir discontinuation without alternative HBV therapy can cause life-threatening hepatitis flares 1, 3
Avoid switching patients with poor adherence history or inability to attend scheduled clinic visits, as the long half-life of cabotegravir means delayed detection of virologic failure and potential for extensive resistance development 1