Determinants of staff-perceived feasibility for long-acting injectable antiretroviral therapy implementation for patients with HIV in rural and non-metropolitan areas

Long-acting injectable antiretroviral therapy (LAI-ART) with cabotegravir plus rilpivirine (CAB + RPV LA) offers an alternative to daily oral HIV treatment but requires substantial operational coordination, particularly in mixed urban–rural clinical settings. Limited evidence exists on the organizational and contextual determinants that shape staff-perceived feasibility during real-world implementation in non-metropolitan and rural care sites. A prospective observational implementation evaluation study was conducted between July 2024 and November 2025, among staff at an urban HIV specialty clinic and a rural primary care non-HIV clinic in Nebraska, participating in the IM-CAPABLE study. Surveys were administered at baseline and mid-study to assess primary implementation outcomes (Acceptability, Feasibility, Appropriateness), and secondary constructs (e.g., sustainability capacity, communication infrastructure, implementation burden, rural-context indicators). Changes in AIM and FIM were evaluated with Wilcoxon signed-rank tests; associations between mid-study FIM and secondary constructs were examined using Spearman correlations. Seventeen staff members participated at baseline, with 14 providing paired baseline–mid-study data. Acceptability and feasibility remained high but showed a non-significant downward trend over time. Feasibility at mid-study showed strong positive associations with sustainability capacity (ρ = 0.80) and communication modalities used (ρ = 0.79), while frequent communication was inversely associated with feasibility (ρ=–0.64). Rural context exerted a notable influence: serving more rural patients correlated with lower feasibility (ρ=–0.72), whereas stronger perceptions of rural-specific supports correlated positively with feasibility (ρ = 0.62). Training, preparedness, and perceived implementation burden were not significantly associated with feasibility. Early implementation of CAB + RPV LA across urban HIV clinic and non-metropolitan non-HIV clinic was perceived as feasible and acceptable, with feasibility shaped more by system-level determinants than by individual staff training or operational burden. Effective inter-clinic communication pathways and targeted rural support investments may be essential to the successful and equitable scale-up of LAI-ART, particularly in geographically dispersed care settings. Not applicable.