# Dolutegravir rollout for treatment of HIV with a focus on advanced disease and tuberculosis coinfection: findings from rural KwaZulu-Natal, South Africa (2019–2023)

## TL;DR

This study examines how quickly people with HIV in rural South Africa switched to Dolutegravir-based treatment, finding that those with tuberculosis or advanced HIV disease transitioned more slowly.

## Contribution

The study provides new insights into the rollout of Dolutegravir in high HIV-burden rural areas, focusing on subgroups with tuberculosis and advanced HIV disease.

## Key findings

- PLHIV with TB symptoms transitioned to Dolutegravir 8 months slower than those without TB symptoms.
- PLHIV with advanced HIV disease (CD4 < 200) had a 43% lower likelihood of transitioning to Dolutegravir.
- Over 25% of PLHIV in rural KwaZulu-Natal remained on non-Dolutegravir regimens by the end of 2023.

## Abstract

While Dolutegravir (DTG) containing antiretroviral therapy (ART) has become the preferred regimen for people living with HIV (PLHIV), the pace and equity of its adoption, especially among subgroups with tuberculosis (TB) symptoms and advanced HIV disease (AHD), remain understudied in high-burden settings like rural KwaZulu-Natal (KZN), South Africa. This study describes the transition to DTG and examines the effect of TB and AHD (CD4 count < 200 cells/mm3) on the likelihood of transitioning to DTG in rural KZN, South Africa.

We conducted a longitudinal cohort analysis using routine HIV program data from 69,916 PLHIV aged ≥ 15 years attending 19 HIV clinics in rural KZN, between 1st October 2019, and December 31st 2023. Kaplan-Meier analysis estimated time to DTG transition, while a multivariate mixed-effect Cox proportional hazards model evaluated factors associated with transitioning to DTG.

Of the 69,916 PLHIV included in the cohort, 49,365 (70.6%) were female, and the median age of the PLHIV was 40 years (IQR: 32–49). By the end of the follow-up period, 70.9% (n = 49,598) of the PLHIV transitioned to DTG in 165,880 person-years. The median time to DTG transition was 14 months among PLHIV without TB symptoms, compared to 22 months among those with TB symptoms. Similarly, PLHIV with CD4 counts ≥ 350 cells/mm³ transitioned at a median of 14 months, while those with CD4 < 200 cells/mm³ transitioned 14 months later. The likelihood of transitioning to DTG was 22% lower among PLHIV with TB symptoms (aHR = 0.78, 95% CI: 0.76, 0.82) compared to their counterparts without TB symptoms, and 43% lower among PLHIV with AHD (aHR = 0.57, 95% CI: 0.54,1.59) compared to their counterparts without AHD.

Our analysis showed that over a quarter of the PLHIV in rural KZN remained on non-DTG-containing regimens by 31st December 2023. PLHIV coinfected with TB and having AHD transitioned at a slower pace than their counterparts.