Three Year Outcomes after Programmatic Transitioning to Dolutegravir in the Context of Severe Civil Unrest in Haiti

Background Dolutegravir (DTG) has been widely scaled-up worldwide. Data on long-term outcomes are limited. Methods We included all persons living with HIV (PLWH) ≥15 years of age who initiated or switched to DTG in Port-au-Prince, Haiti. We described treatment outcomes by pre-switch viral load and assessed predictors of virologic failure using multivariable logistic regression. Findings A total of 10,354 PLWH initiated or switched to DTG from November 5, 2018 to March 21, 2021, and were included in the analyses. Of these, 2217 (21.4%) were ART-naïve and 8137 (78.6%) switched from an NNTRI-based regimen. Median follow-up time on DTG was 2.8 years (IQR: 2.3, 3.1). Among PLWH with ≥2 tests on DTG, 83.5% of ART-naïve, 93.1% with pre-switch suppression, 64.8% with pre-switch failure, and 90.2% without pre-switch viral load had <1000 copies/mL at latest test. Among treatment-experienced patients, predictors of HIV-1 RNA ≥1000 copies/mL at latest test included younger age (adjusted odds ratio [aOR]: 2.33 for ≤30 vs. ≥50 years), shorter pre-switch time on ART (aOR: 0.91; 95% CI: 0.89, 0.94/year), lower education (aOR: 1.31; 95% CI: 1.10, 1.55), and higher pre-switch viral load: (aOR: 7.00; 95% CI; 5.74, 8.54 for ≥10,000 vs. <1000 copies/mL). Interpretation Virologic outcomes on DTG-based regimens are outstanding for PLWH with pre-switch suppression, even in the context of severe civil unrest in Haiti. However, rates of persistent viremia are high among PLWH who experienced pre-switch failure; additional interventions are critically needed, including access to genotypic resistance testing and provision of alternative regimens as clinically-indicated.