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Transition to TLD leads to decreased rates of virologic failure among PLWH in sub-Saharan Africa

Title
Transition to TLD leads to decreased rates of virologic failure among PLWH in sub-Saharan Africa
Presenter
Allahna Esber
Authors
A. Esber * (1,2), N. Dear (1,2), M. Iroezindu (3,1), E. Bahemana (1,4), H. Kibuuka (5), J. Owuoth (6,7), J. Maswai (1,8), T.A. Crowell (1,2), C. Polyak (1,2), J. Ake (1), AFRICOS Study Group
Institutions
(1) U.S. Military HIV Research Program, Silver Spring, United States, (2) Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc, Bethesda, United States, (3) HJF Medical Research International, Abuja, Nigeria, (4) HJF Medical Research International, Mbeya, Tanzania, United Republic of, (5) Makerere University Walter Reed Project, Kampala, Uganda, (6) U.S. Army Medical Research Directorate-Africa, Kisumu, Kenya, (7) HJF Medical Research International, Kisumu, Kenya, (8) HJF Medical Research International, Kericho, Kenya

BACKGROUND: Integrase inhibitors, particularly dolutegravir-based regimens, have a high genetic barrier to resistance and were found in clinical trials to perform better than efavirenz-based regimens in maintaining viral suppression. Subsequently, tenofovir disoproxil fumarate-lamivudine-dolutegravir (TLD) was recommended as preferred first line treatment by the WHO in 2018 and rolled out to President's Emergency Plan for AIDS Relief (PEPFAR) programs late 2018. We examined time to virologic failure across twelve HIV clinic sites in Africa two years after initial TLD rollout.
METHODS: We used data from the ongoing African Cohort Study where participants are seen every 6 months at HIV clinics in Kenya, Nigeria, Tanzania, and Uganda. Viral load measurements and extensive medical record reviews are conducted at each visit. Cox proportional hazards modeling estimated time to virologic failure (viral load >1000 copies/mL) comparing participants who switched to TLD and those who remained on non-TLD regimens. We further stratified by TLD transition and viral load status (<200 copies/mL vs > 200 copies/mL) at the visit prior to TLD switch or the first visit after the country transition date among those who did not switch. Only visits occurring after the respective country began transitioning to TLD were included. Models were adjusted for study site, age, sex, and self-reported ART adherence.
RESULTS: As of December 1, 2020, 2,097 ART-experienced participants had at least two visits with viral load data, among whom 115 (5%) experienced virologic failure. At the visit prior to TLD transition, 95% of participants who switched to TLD and 86% of participants who did not switch had a viral load <200 copies/mL (p<0.001). In the adjusted model, participants who did not switch to TLD had a 3.70 increased rate of virologic failure compared to those who switched (95% CI: 2.50-5.48). Even among participants who were virally suppressed, those who did not switch to TLD had a 2.57 increased rate of virologic failure (95% CI:1.47-4.52).
CONCLUSIONS: These data provide insight into the real world impact of the TLD transition in Africa, demonstrating that even among PLWH with high rates of viral suppression, TLD provides an additional benefit and can further reduce rates of virologic failure.