Lingering sex and age disparities in dolutegravir uptake among adults with HIV: a multicountry observational cohort study

Introduction Since July 2019, the WHO has recommended dolutegravir (DTG)-based regimens as preferred first-line antiretroviral therapy (ART) for adults and adolescents living with HIV (DTG-for-All), a reversal of a 2018 safety alert on use of DTG-based regimens by women of reproductive age (WRA). We examined sex and age disparities in DTG uptake before and after DTG-for-All in the International epidemiology Databases to Evaluate AIDS. Methods We included patients ≥16 years on or initiating treatment between January 2017 and July 2021 in 14 low- and middle-income countries where initial guidelines on DTG-based regimens for first-line ART either restricted use by WRA or had no such restrictions. We estimated the cumulative incidence of DTG uptake (CI-DTG) by sex and age group (aged 16–49 years vs 50+ years), stratified by patient, clinic and setting characteristics. Results Among 177 706 patients on ART during the study period, 51% were females aged 16–49 years, with 25% males aged 16–49 and 13% and 11%, respectively, females and males aged 50+. At the time of DTG-for-All, overall CI-DTG was 29.6% (95% CI 29.4% to 29.8%); it was lower among females aged 16–49 (16.2%; 95% CI 16.0% to 16.5%) than males (41.1%; 95% CI 40.6% to 41.5%), with no sex disparities among patients aged 50+ (females: 46.0%; males: 47.0%). While DTG uptake subsequently increased among all groups, by July 2021, it remained substantially lower among females 16–49 (66.4%; 95% CI 66.1% to 66.7%), compared with males 16–49 and older females and males (75.8% to 77.5%). Concentrated in countries where initial guidelines on DTG restricted use by WRA, disparities in DTG uptake persisted at all health system levels and in both low-income and lower-middle-income countries. Conclusions While sex-age differentials in DTG uptake narrowed after WHO’s DTG-for-All recommendation, lingering disparities in uptake underscore the difficulty of policy de-implementation when new evidence emerges.