AIDS | 2019
Comparative effectiveness of first-line antiretroviral therapy: results from a large real-world cohort after the implementation of Dolutegravir.
Abstract
OBJECTIVE\nWe aimed to assess the effectiveness of first-line antiretroviral therapy (ART) regimens in achieving viral suppression at 12 months, from 2014 to 2017 in Brazil.\n\n\nDESIGN\nRetrospective cohort study utilizing programmatic data from the Brazilian HIV Program.\n\n\nMETHODS\nAdults (aged 15-80 years) who started ART from January/2014 to July/2017 and had a viral load 365 (±90) days after treatment initiation were included. Associations with achieving viral suppression (<50\u200acopies/mL) at 365 (±90) days were assessed using logistic regression. Our main study variable was ART regimen, and covariates included year of ART initiation, sex/exposure group, age, education, race, region, baseline CD4 and viral load counts, and adherence measured by pharmacy refill data. We performed both intent-to-treat and per-protocol-analogous analyses.\n\n\nRESULTS\nOf 107,647 ART-naïve patients, 71.5% initiated with tenofovir/lamivudine/efavirenz (TLE) and 10.5% with tenofovir/lamivudine/dolutegravir (TLD). Median age and CD4 counts were 34 (IQR 26-46) and 379\u200acells/mm (IQR 190-568), respectively; 68.0% were males. Viral suppression by 12 months was 84.0% (95%CI 83.7%-84.2%) with TLE and 90.5% (95%CI 90.0%-91.0%) with TLD, and below 80% for protease-inhibitor-based-regimens. In the multivariable intent-to-treat-analogous analysis, controlling for cofactors related to viral suppression including adherence, the adjusted odds ratio (aOR) for TLD s viral suppression relative to TLE was 1.56 (95%CI 1.40-1.75). Findings were robust to secondary per-protocol-analogous and sensitivity analysis.\n\n\nCONCLUSION\nOur results showed the superiority of dolutegravir- over efavirenz- and protease-inhibitor- based regimens in suppressing viral replication in a real-word cohort of HIV-positive adults. This superiority was not driven by higher levels of adherence with dolutegravir-based regimens.