Background
Adherence to antiretroviral therapy (ART) is independently associated with viral load (VL) suppression among people living with HIV (PLHIV). Previous studies have demonstrated that dolutegravir-based regimens (DBR) have forgiveness for strict adherence to achieve VL suppression (VLS) as measured by pharmacy refill and electronic drug monitoring, where 75% and 80% adherence, respectively, can achieve VLS for 90% of PLHIV. We sought to investigate forgiveness to DBR in a programmatic setting in India using medication possession ratio (MPR).
Methods
We analysed program data of PLHIV transitioned from non-nucleoside reverse transcriptase inhibitors (NNRTI) or protease inhibitors (PI) to DBR or initiated on DBR (as a fixed dose combination) in Andhra Pradesh, India for at least 12 months during November 2020-September 2023 with a VL result. MPR was calculated by dividing the number of days of ART dispensed by 365 days multiplied by 100. MPR was calculated back from the date of the latest VL. We further ordinally categorized MPR (<50%, 50-79%, 80-84%, 85-89%, ≥90%). Bivariate and multivariable binomial regression analyses were used to determine factors associated with VL suppression (HIV RNA <200 copies/mL) after adjusting for all covariates and within Pearson correlations. We used Probit regression models to create dose-response plots and to estimate the adherence required to achieve VL suppression in 90% of HIV VL tests
Results
Of the 120,397 PLHIV included in the analysis, 75.8% were aged <50 years, 56.2% were women, 94.3% had VL <200 copies/mL, 58.2% had MPR ≥90% and 84.6% had been transitioned to DBR. PLHIV aged ≥50 years (adjusted odds ratio [aOR] 1.36; 95% CI: 1.28 to 1.45), female (aOR 0.91; 0.87, 0.96), and transitioned to DBR (aOR 1.17; 1.10, 1.25) had greater odds of being virally suppressed compared with persons aged <50 years, men, and initiated ART with DBR, respectively. All four categories of MPR >50% had increasing significant aOR compared to <50%. The MPR level required to achieve viral suppression in 90% of HIV viral load tests was 60% (figure).
Conclusions
DBRs achieved >90% of VLS even at MPR of 60%, indicating high durability of DBRs across variable MPR levels. However, effectiveness was highest for adherence >90%
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