Long-acting HIV treatment still out of reach in low- and middle-income countries, says UCSF's Monica Gandhi | AIDS 2026
Key Takeaways
- Access to long-acting ART in LMICs remains delayed, paralleling pre-2000 inequities in oral ART availability and prompting renewed pressure on manufacturers, advocates, and global health stakeholders.
- UNAIDS-reported suppression gaps persist across regions, with Eastern Europe and the Middle East near 50%, reinforcing the urgency of adherence-supportive modalities beyond daily oral regimens.
Monica Gandhi, M.D., M.P.H., of UCSF, told AIDS 2026 that five years after approval, long-acting HIV drugs remain largely confined to wealthy countries.
Five years after long-acting cabotegravir-rilpivirine, sold under the brand name Cabenuva, was approved by the FDA for HIV treatment, the drug combination and the other longer-acting antiretroviral therapies that followed it are not as available in low- and middle-income countries as they should be, Monica Gandhi, M.D., M.P.H., said in a talk today at AIDS 2026, the 26th International AIDS Conference, in Rio de Janeiro, Brazil.
Gandhi, professor of medicine at the University of California, San Francisco, and medical director of the HIV clinic at Zuckerberg San Francisco General Hospital known as Ward 86, said the pattern of lagging availability in some countries with the greatest HIV burden has occurred before. Oral antiretroviral therapy was also confined to wealthy countries until advocates at the International AIDS Conference (IAS) in Durban in 2000 forced a change.
“This feels to me like that 96 to 2000 moment when IAS erupted and said, ‘How can we not have these drugs available in low- and middle-income countries four, five, six years on? And what's the role of drug companies? What's the role of us as a community? What's the role of protest? What's the role of resistance?’ We are not where we need to be with the accessibility of long-acting [treatments]. I leave you with that as a call to action,” Gandhi told the AIDS 2026 audience at an afternoon session.
Gandhi referenced data in a UNAIDS report released yesterday showing wide variation in the rates of HIV virologic suppression rates in those who are infected across regions, including rates as low as 48% in Eastern Europe and 49% in the Middle East, against a global figure of 74% and a U.S. rate of 69%. She outlined the 30-year history of antiretroviral treatment (ART), including milestones such as the advent of the nucleoside reverse transcriptase inhibitors and, in 2008, the first integrase inhibitor, raltegravir. Early in the epidemic, in 1993 and 1994, recognition of the latency of HIV infection made it clear that long-term treatment was likely going to be necessary, she said. “We knew we were going to need lifelong ART, and lifelong ART means that we have to think about how hard it is to take ART lifelong and make it better.”
Gandhi said researchers are grappling with the adherence challenge, pointing to the LATITUDE and IMPALA trials. Results of the LATITUDE trial reported in February 2026 in the New England Journal of Medicine showed that participants randomly selected for once-monthly injections of cabotegravir and rilpivirine — they are separate shots but given together — were half as likely to develop high viral loads (“regimen failure”) than those on daily oral ART. Findings from the IMPALA study, an open-label trial conducted in Uganda, Kenya and South Africa, showed that cabotegravir and rilpivirine were noninferior to oral ART.
But Gandhi noted that both of those trials were designed to assess long-acting ART in those who had been virologically suppressed. Data on people who are viremic, rather than suppressed, have come from observational studies, including some groundbreaking research done with study participants recruited at her clinic.
“As soon as we got those drugs in 2021, we said we want to use them in people who have a hard time taking pills, and ‘Absolutely, you can be viremic. The only thing is, please come into the clinic, and we’ll give you these medications," she said.
Gandhi and her colleagues reported results several times, including in a research letter published in JAMA in 2025 that showed that after 48 weeks of treatment with cabotegravir and rilpivirine, 98% of patients with initial viremia had undetectable viral loads compared with 99% of individuals without viremia. HHS and IAS-USA guidelines now endorse the use of long-acting ART in viremic patients, based partly on data reported by Gandhi and her colleagues.
“What I can't explain in a publication is what it feels like to get someone suppressed for the first time,” Gandhi said, “and what they feel like, and how internally motivated they actually are to come back, and how we're not chasing people all over the city. They want to come back and get these injections.”
Gandhi noted the keen interest in a combination of lenacapavir and cabotegravir as long-acting ART treatment, partly because rilpivirine needs to be refrigerated. So far, she says evidence for the combination has come from case series, and her group has a report coming out about 46 patients treated with the combination. At 100 weeks they were all virologically suppressed. “It seems powerful,” said Gandhi, noting the need for more studies on the lenacapavir-cabotegravir combination.
Looking ahead, Gandhi pointed to a pipeline of additional long-acting agents in development, including islatravir and MK-8527 for monthly pre-exposure prophylaxis (PrEP). She mentioned that data from the ISLEND-1 and ISLEND-2 studies that assessed weekly islatravir and lenacapavir treatment are scheduled to be presented tomorrow at the conference.
