Feasibility and Implementation Considerations for Long-Acting Antiretroviral Therapy in Pakistan: A Qualitative Study of Healthcare Providers and Programmatic Stakeholders.

Abstract

IntroductionLong-acting injectable antiretroviral therapy (LAI-ART), especially cabotegravir plus rilpivirine, is primarily recommended as a switch option for virally suppressed individuals and may improve adherence, privacy, and treatment satisfaction. Contemporary international guidance notes a restricted, closely monitored role for selected viraemic patients with persistent adherence challenges. Feasibility in low-resource systems remains uncertain. We explored perceived feasibility and acceptability of LAI-ART among HIV care providers and regulatory stakeholders in Pakistan.MethodsWe conducted semistructured in-depth interviews with 17 providers and stakeholders from ART centers, tertiary hospitals, the National AIDS Control Program, and a community-based organization in Islamabad and Rawalpindi. Interviews were audio recorded, transcribed, translated, and analyzed using reflexive thematic analysis.ResultsParticipants viewed LAI-ART as promising for improving adherence, treatment fatigue, confidentiality, and workflow. Barriers included travel distance, needle phobia, missed dose risks, staffing constraints, cold chain and storage needs, infrastructure limitations, and weak biomedical waste management.ConclusionStakeholders expressed cautious interest in LAI-ART while highlighting significant structural, financial, and sociocultural barriers. Participants emphasized that phased pilot implementation, sustainable financing, cultural acceptability, integration into differentiated service delivery, and stronger counselling and digital support would be necessary to support future introduction.