Survival in advanced AIDS patients treated with efavirenz or dolutegravir in Brazil: a multicenter, observational study

BACKGROUND: Most of studies on integrase inhibitors efficacy were conducted on healthy patients. There is scarce information on DTG use in late-presenters HIV patients. We compared the effect of ART regimens based on Efavirenz (EFV) or Dolutegravir (DTG) on survival of patients with advanced AIDS.
METHODS: We enrolled symptomatic AIDS patients starting therapy with a CD4 count<50 cells/ml in 5 Brazilian cities. We compared patients starting DTG-based ART (2018 to 2020) or EFV-based regimens (2013 to 2016), as controls regarding early mortality, rates of viral suppression at 24 and 48 weeks, changes in CD4 count, incidence of adverse events, and therapy discontinuation.
RESULTS: We included 92 patients per arm mean age 39.4 (DTG) and 37.3 years (EFV), 68 % males, mean baseline CD4 count=23 cells/ml, mean HIV viral load= 5.5 copies/ml log₁₀. Viral suppression rates (<50 copies/ml) were higher in DTG than in EFV group at 24 (67% vs 42%,) and at 48 weeks (65% vs 46%, p<0.01). At 48 weeks median CD4 count was similar for DTG and EFV groups (213 cells/ml vs. 222 cells/ml), but more patients in DTG group presented with CD4 >200 cells/ml (45% vs. 29%, p=0.03). Levels of total cholesterol(189 vs 168 mg/dL), triglycerides (188 vs 129 mg/dL) and VLDL cholesterol(35 vs 26 mg/dL) were higher in EFV than in DTG group (p<0.01 for comparisons). Creatinine levels were higher in DTG (0.97 mg/dL) than in EFV (0.86 mg/dL, p=0.02) group. Survival was higher in DTG group (figure 1), mostly driven by treatment changes (1% vs. 17%, p<0.0001) or loss to follow up (11% vs. 15%).
CONCLUSIONS: Advanced AIDS patients treated with DTG had a higher proportion of viral suppression/survival rate/ immune restoration, less lipids changes, and lower discontinuation rates after 48 weeks than patients treated com EFV. DTG is confirmed as a preferential option to treat advanced AIDS patients.