How to Resume Cabenuva After a Missed Every-2-Month Injection
If your patient has missed their every-2-month Cabenuva injection, the approach depends entirely on how late they are: resume with the standard dose if ≤3 months late, but re-initiate with two loading doses one month apart if >3 months late. 1
Algorithmic Approach Based on Time Since Last Injection
For Injection 2 (the second dose at Month 2):
≤2 months late: Resume immediately with the standard every-2-month dose (600 mg cabotegravir + 900 mg rilpivirine IM), then continue the regular every-2-month schedule 1
>2 months late: Re-initiate the patient with two loading doses:
- Give 600 mg cabotegravir + 900 mg rilpivirine IM immediately
- Repeat the same dose 1 month later
- Then resume the every-2-month maintenance schedule 1
For Injection 3 or Later (Month 4 onwards):
≤3 months late: Resume immediately with 600 mg cabotegravir + 900 mg rilpivirine IM and continue the every-2-month schedule 1
>3 months late: Re-initiate with two loading doses:
- Give 600 mg cabotegravir + 900 mg rilpivirine IM immediately
- Repeat 1 month later
- Then resume every-2-month maintenance dosing 1
Critical Clinical Reassessment Required
Before resuming injections after any unplanned delay >7 days, you must clinically reassess the patient to ensure resumption of injection therapy remains appropriate. 1 This is particularly important because:
- The patient may have acquired HIV during the gap (if this was PrEP)
- Resistance could develop if viral suppression was lost
- The patient's circumstances may have changed
The 2025 IAS-USA guidelines note that for PrEP specifically, if injections are ≥8 weeks late for injection 2, or ≥16 weeks late for injection 3+, "reloading" with a 4-week interval between two injections is recommended before returning to every-8-week dosing 2. This guideline recommendation differs from the FDA label and represents expert consensus for PrEP use.
Oral Bridging Considerations
If the patient had been taking oral bridging therapy (VOCABRIA + EDURANT or another fully suppressive regimen) during the gap, this changes the calculation—the "time since last injection" clock essentially pauses while on effective oral therapy 1.
For planned delays >7 days, patients should ideally have oral bridging available, starting approximately 2 months after the last injection and continuing until injections resume 1.
Common Pitfalls to Avoid
- Don't simply resume regular dosing if the patient is significantly late—the reloading schedule exists because drug levels have fallen too low
- Don't forget both injections—Cabenuva requires both cabotegravir AND rilpivirine at separate gluteal sites
- Don't skip the clinical reassessment—this is explicitly required by the FDA label for unplanned delays 1
- The FDA label is more conservative than recent expert guidelines for PrEP use; for HIV treatment, follow the FDA label thresholds 2, 1