Comparative Evaluation of Longitudinal Programmatic Outcomes of Efavirenz- and Dolutegravir-Based First-Line ART during India’s Adoption Period (2019–2023)
Abstract
Objective: To compare the programmatic outcomes—retention in care, viral suppression, adherence, and regimen durability—between individuals receiving efavirenz (EFV) and dolutegravir (DTG)-based first-line antiretroviral therapy (ART) during India’s transition period (2019–2023), and to identify predictors of regimen change.
Material and Methods: A retrospective cohort study was conducted at a district ART centre in Karnataka, India, analyzing treatment-naive adults initiating first-line ART between January 2019 and December 2023. Primary outcome was time to regimen switch, with secondary outcomes including retention in care, viral load testing uptake, viral suppression rates, adherence, mortality, and loss to follow-up at 6, 12, and 24 months. Cox proportional hazards regression identified predictors of regimen switching.
Results: Among 2,709 participants, 1,740 (64.2%) initiated EFV-based and 969 (35.8%) DTG-based regimens. DTG recipients demonstrated superior 24-month retention (93.4% vs 89.8%, p-value=0.002), higher viral load testing uptake (86.0% vs 72.1%, p-value<0.001), and greater viral suppression among tested patients (96.0% vs 90.9%, p-value <0.001). DTG had consistently higher proportions of optimal adherence (≥95%) at all timepoints (85.3% vs 77.8%, p-value <0.001 at 24 months). The proportion of patients with a cumulative regimen switch was significantly lower for DTG (3.0% vs 7.0%, p-value<0.001). In multivariable analysis, starting DTG was associated with a 45% reduced hazard of switching from the initial regimen among those ever treated with ART (adjusted HR 0.55, 95% CI: 0.42-0.72, p-value<0.001).
Conclusion: DTG-based fixed-dose combination first-line therapy yielded better programmatic outcomes on several fronts during India’s transition phase and warrants prioritization for treatment-naive patients in similar resource-limited settings.
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