Background

We evaluated the treatment outcomes of individuals experiencing low-level viremia (LLV) on dolutegravir (DTG) based first-line antiretroviral therapy (ART) in Botswana by determining the trends of LLV over a period of 6 years.

Methods

We used a large national observational cohort of individuals (aged≥18yrs) who initiated on DTG-based first-line ART for at least 3 months from June 2016 to December 2022. The prevalence of viral suppression (VL ≤50copies/mL), low-level viremia (VL:51-999copies/mL) and virologic failure (VF) (any VL>1000copies/mL) were estimated among PLWH. The prevalence of LLV was further classified into LLV ranges (low-LLV:VL:51-200copies/mL, medium-LLV:201-400copies/mL and high-LLV:VL:401-999copies/mL). Univariate and multivariable Cox proportional hazards regression determined whether LLV (exposure) is associated with VF (outcome).

Results

Among 50,742 PLWH who have at least one VL measurement during the follow-up, the overall prevalence of LLV by duration strata was 2.2%, 1.8%, 1.7%, 2.3%, 3.1%, 3.7% and 3.9% at 0.25-<0.5, 0.5-≤1, 2, 3, 4, 5, 6+ years respectively. By LLV ranges, ≥90% had low-LLV in each duration strata. A total of 539 had reported LLV at year 0.25-<0.5 whereby 529(98.1%) had single instance of LLV, 9(1.7%) with 2-consecutive-LLV (confirmed) and 1 (0.2%) had at-least-3-LLV(persistent) measurements. The prevalence of PLWH with confirmed-LLV was 9.1%, 9.0%, 7.3%, 6.4%, 9.1% and 8.4% at 0.5-≤1, 2, 3, 4, 5, 6+ years of the follow-up period, respectively. The prevalence of persistent-LLV increased from 0.2% to 7.0% from year 0.25-<0.5 to 6+. PLWH with LLV had an increased risk of VF (adjusted-Hazards-Ratio [aHR] 2.65; 95%CI 2.16–3.26) at a later visit compared to suppressed VL group. High-LLV and persistent-LLV were the main LLV factors associated with VF.

Conclusion

The prevalence of LLV ranging from 1.7–3.9% was found in this cohort. Having a high or persistent-LLV is associated with a high risk of subsequent VF. Intensified clinical monitoring strategies are warranted for individuals with LLV.

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