Programmatic DTG switching in Egypt: Challenges and considerations

HIV remains a major global health challenge, with sub-Saharan Africa bearing the highest burden. Egypt, however, is a low-prevalence country, with ~13,000 people living with HIV (PLHIV) in 2022. Dolutegravir (DTG)-based antiretroviral therapy (ART) is a cornerstone of HIV management, offering high efficacy and reduced transmission. The WHO recommends DTG as second-line ART without pre-switch viral load testing, based on trials like DAWNING and NADIA. However, emerging reports indicate rising DTG resistance (4–20% in unsuppressed individuals), raising concerns about treatment failure. We retrospectively analyzed 95 Egyptian PLHIV shifted to DTG without baseline resistance testing. At follow-up, 80% achieved viral suppression, while 20% had detectable viremia (8 with high-level viremia ≥1000 copies/mL). Enhanced adherence counseling led to re-suppression in most cases, except for two individuals who required darunavir-based therapy after persistent viremia. Notably, some initially suppressed patients later developed detectable viremia, suggesting possible delayed resistance emergence. These findings highlight the importance of resistance testing for PLHIV with persistent viremia on DTG, particularly in resource-limited settings. While baseline testing may not be feasible, ensuring access to resistance testing for those failing DTG regimens is critical to guide clinical decisions. The study underscores the need for WHO and global health stakeholders to prioritize affordable INSTI resistance testing in low-income countries, optimizing HIV management and limiting resistance.