Résumé
Introduction: WHO guidelines currently recommend switches in treatment for patients with HIV RNA persistently above 1000 copies/mL despite adherence counselling. Ongoing viraemia could increase the chance of drug resistance. However, patients can show re-suppression of HIV RNA after adherence counselling, with no change in treatment. We compared rates of virological failure (VF) and re-suppression in four randomised trials of dolutegravir (DTG), efavirenz (EFV) and protease inhibitors (PI/r).Methods: Data were analysed from four randomised trials: DolPHIN-2, ADVANCE, NAMSAL and VISEND. VF was defined as HIV RNA >1000 copies/mL after week 24. HIV RNA re-suppression was defined as HIV RNA <50 copies/mL at the next visit in DolPHIN-2, ADVANCE and VISEND, or <200 in NAMSAL. ‘Sustained viraemia’ was then subdivided into HIV RNA 50 to 99 or >1000 copies/mL at next visit. The percentage of participants with VF and HIV RNA re-suppression was then compared between treatment classes in a meta-analysis.Results: DolPHIN-2 was conducted in South Africa and Uganda, ADVANCE in South Africa, NAMSAL in Cameroon and VISEND in Zambia. Rates of VF were not significantly different between DTG and EFV in ADVANCE (DTG 12%, EFV 9%), DOLPHIN-2 (DTG 33%, EFV 30%), and NAMSAL trials (DTG 16%, EFV 15%) (Table 1). In VISEND, VF was significantly lower for DTG versus PI/r (DTG 16%, PI/r 24%, p = 0.0048). Following VF, HIV RNA re-suppression rates were significantly higher for DTG in ADVANCE (DTG 57%, EFV 23%) and NAMSAL (DTG 60%, EFV 29%), but not in DOLPHIN-2 (DTG 34%, EFV 34%). In the meta-analysis, overall re-suppression rates were significantly higher for DTG versus EFV (p = 0.04). In VISEND, HIV RNA re-suppression was significantly more common for DTG versus PI/r (DTG 38%, PI/r 19%, p = 0.0094).Discussion: In this analysis of 3116 patients in four randomised trials, episodes of viraemia >1000 copies/mL were seen for a range of treatments. However, HIV RNA re-suppression after initial viraemia was significantly more likely for participants taking DTG-based treat-ment, compared with either EFV- or PI-based treatment. For patients with VF on DTG, the benefits of switching to new drug classes are unclear, versus remaining long term on DTG with adherence counselling.