Successful transition to tenofovir/lamivudine/dolutegravir (TLD) in PEPFAR-supported countries


BACKGROUND: PEPFAR begun supporting the transition to tenofovir/lamivudine/dolutegravir (TLD) for people living with HIV (PLHIV) in 2017. In 2018, the possible association of maternal DTG use and offspring neural tube defects delayed uptake of TLD. In 2019, based on reassuring additional data, PEPFAR renewed efforts to transition several million supported clients to TLD. We describe the lessons learned and the results of a massive multisectoral effort to provide optimized treatment to all PLHIV.
DESCRIPTION: From 2017 to 2021,PEPFAR promoted policies and programmatic interventions among its 35 supported countries to increase the uptake of TLD. Key elements were the removal of programmatic barriers such as pre-transition viral load (VL) test and the streamlining of technical guidance by recommending TLD as preferred regimen for naïve, suppressed, non-suppressed and individuals with unknown VL status, and to male and female adults, adolescents and eligible children, thus simplifying supply chain and implementation at site level.
LESSONS LEARNED: Based on routine PEPFAR programmatic data on antiretroviral dispensation, TLD made up 41% of drugs dispensed to adults in PEPFAR-supported countries in April 2020, this proportion doubled to 81% by October 2021.For all but one PEPFAR-supported country with >1 million PLHIV, TLD accounted for at least 80% of antiretrovirals dispensed. Viral suppression has increased in all age bands since TLD rollout begun, but remains lowest among children.

CONCLUSIONS: Roll out of DTG-based regimens to children should be prioritized with the recent pediatric formulations approval. Strategies to improve adherence among PLHIV non-suppressed on TLD may be needed to achieve the 3rd 95 UNAIDS target.