Clinical outcomes after viraemia among people receiving dolutegravir versus efavirenz-based first-line antiretroviral therapy in South Africa

Abstract

AbstractIntroductionWe aimed to compare clinical outcomes after viraemia between dolutegravir versus efavirenz-based first-line antiretroviral therapy (ART) as evidence is lacking outside clinical trials in resource-limited settings.MethodsWe conducted a retrospective cohort analysis with routine data from 59 South African clinics. We included people living with HIV ≥15 years old receiving first-line tenofovir disoproxil fumarate, lamivudine, dolutegravir (TLD) or tenofovir disoproxil fumarate, emtricitabine, efavirenz (TEE), and with first viraemia (≥50 copies/ml) between June to November 2020. We used multivariable modified Poisson regression models to compare retention-in-care and viral suppression (<50 copies/ml) after 12 months between participants on TLD versus TEE.ResultsAt first viraemia, among 9657 participants, 6457 (66.9%) were female, median age was 37 years (interquartile range [IQR] 31-44); 7598 (78.7%) were receiving TEE and 2059 (21.3%) TLD. Retention-in-care was higher in the TLD group (84.9%) than TEE (80.8%), adjusted risk ratio (aRR) 1.03, 95%CI 1.00-1.06. Of 6569 participants retained in care and had a 12-month viral load, viral suppression was similar between TLD (78.9%) and TEE (78.8%) groups, aRR 1.02, 95%CI 0.98-1.05. However, 3368 participants changed ART during follow-up; the majority from TEE to first-line TLD (89.1%) or second-line (TLD 3.4%, zidovudine/emtricitabine/lopinavir-ritonavir 2.1%). In sensitivity analysis among the remaining 3980 participants who did not change ART during follow-up and had a 12-month viral load, viral suppression was higher in the TLD group (78.9%) than TEE (74.9%), aRR 1.07, 95%CI 1.03-1.12.ConclusionsAmong people with viraemia on first-line ART, dolutegravir was associated with better retention-in-care and similar or better viral suppression than efavirenz.