Outcomes and implementation considerations for optimizing dolutegravir based antiretroviral therapy among PLHIV in Northern Uganda

BACKGROUND: In 2018, Ministry of Health (MOH) Uganda adopted WHO's guidance to switch 1^st line ART from NNRTIs to dolutegravir (TLD/DTG) following optimal efficacy and safety. This study assesses the outcomes and implementation considerations for TLD/DTG optimization to guide policy action.
DESCRIPTION: Setting: 70 health facilities in nine districts of Lango sub-region, post'conflict northern Uganda with 78,000 people living with HIV (PLHIV) supported by USAID Regional Health Integration to Enhance Services-North, Lango (RHITES-N Lango) project.
Intervention design: An implementation study was conducted between March'December 2018 (before) and January 2019'September 2021 (after). The phase one trainer'of'trainer TLD/DTG course for 30 participants was followed by onsite facility-based trainings in 18 priority hospitals. This informed phase two of 52 health facilities. MOH and RHITES-N Lango supervised and provided hands-on mentorship.
Outcome measures: Viral load suppression and uptake of TLD/DTG.
Data analysis: The DHIS-2 was used for data management and analysis.
LESSONS LEARNED: All 70 health facilities optimized TLD/DTG by September 2021, within three years. Emerging safety data permitted inclusion of reproductive age women mid-implementation, doubling targets from 40,000 to 80,000 PLHIV; with a slow initial uptake of TLD/DTG during phase one that markedly improved in phase two (15% to 92%, Figure 1). PLHIV with suppressed viral load increased from 85% to 94% after optimization of TLD/DTG (figure 2). Key implementation concerns were the national guidelines, laboratory systems, knowledge, and perceptions of healthcare providers. These included:

• Initial deficits in DTG'specific knowledge among providers
• The requirement for baseline viral load testing
• Stock outs from multi-month dispensing
• Hesitancy to transition thriving PLHIV on NNRTI regimen to TLD/DTG.

However, the MOH guidelines were unclear around effective contraception for women of childbearing age; had a discrepancy of weight bands (30kgs versus 35 kgs in checklist versus guidelines) and there was a delay in providing official consent forms.
CONCLUSIONS: This study depicts successful optimization of TLD/DTG with high viral load suppression in a resource'constrained setting. Health systems bottlenecks contributed to the initial lag in TLD/DTG optimization that were effectively circumvented. Formative evaluations at start of ART optimization could inform future programming.

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