The 'magic bullet' for HIV viral suppression? How fixed-dose combination Dolutegravir (DTG) antiretrovirals are improving viral suppression among children aged 10-14 years on antiretroviral therapy (ART) in Zambia

BACKGROUND: The critical endpoint to achieving HIV epidemic control is attainment of the third 95 cascade target, viral suppression, among people living with HIV, who know their status and are on treatment (UNAIDS, 2015). Globally, only 40% of children living with HIV (CLHIV) are virally suppressed (UNAIDS, 2021). Before the change in pediatric ART guidelines in 2020, Zambia faced a similar challenge, which was compounded by limited availability of the more palatable and highly efficacious fixed-dose combination DTG-containing antiretrovirals.
METHODS: In November 2020, with increased availability of pediatric DTG-containing antiretrovirals in the national ART program, the USAID DISCOVER-Health Project, implemented by JSI, started initiating on and transitioning 10'14-year-old CLHIV to DTG-containing regimens, in line with national HIV care and treatment guidelines. The data were entered into SmartCare in supported clinics in Copperbelt, North-western and Central Provinces. Project level SmartCare data were analysed using the International Business Machine Corporation Statistical Product and Service Solutions (IBM SPSS^®).
RESULTS: The table below summarizes the findings.

Time period	CLHIV on ART	CLHIV on DTG	Virally suppressed	Not Virally suppressed	Viral Load (copies/mL)
November 2020	824	41% (n=338)	82% (n=671)	18% (n=153)	Mean=14,587, median=27, range=0-1.35 million
September 2021	697	89% (n=620)	93% (n=648)	7% (n=49)	Mean=3,865, median=20, range=0-345,983
	OR 3.01, 95% CI 2.14-4.23; p=0.002

In November 2020, 824 CLHIV, aged 10-14 years had viral load results on file ranging from 0- 1.35 million copies/mL with viral suppression at 82%. Only 41% of the CLHIV at the time were on antiretrovirals (ARVs) containing DTG. As of September 2021, after ten months of implementation: 89% CLHIV were on DTG-containing ARVs; 971 eligible CLHIV had a VL result on file ranging from 0-345,983 copies/mL with 93% virally suppression. With a higher proportion of CLHIV on ART accessing DTG-containing ARVs, viral suppression was significantly higher than at baseline.
CONCLUSIONS: Expanded access to DTG-containing regimens is an important intervention for increasing viral suppression rates in CLHIV for good individual health outcomes, and for fast-tracking achievement of HIV epidemic control.

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