a systematic review and meta-analysis of programmatic evidence

Background: This systematic review and meta-analysis assessed viral suppression among adults receiving WHO-recommended first-line dolutegravir-based ART in programmatic settings in low- and middle-income countries (LMICs). Methods: A systematic search of Ovid MEDLINE, Embase, and major HIV conferences (IAS, AIDS, and CROI) from January 2019 to September 2024 identified cohort and cross-sectional studies reporting viral suppression among adults receiving WHO-recommended first-line dolutegravir-based ART in LMICs. Studies with follow-ups ≤ 4 months or using non-WHO-recommended regimens were excluded. Pooled estimates were calculated using random-effects meta-analysis. Sensitivity analyses excluded outliers. Subgroup analyses distinguished adults initiating versus transitioning to dolutegravir-based ART. Both on-treatment and intention-to-treat outcomes were assessed. Results: Twenty-two studies (n = 47 to 50,742) from 13 countries were included. On-treatment pooled viral suppression was 95% (95% CI: 91–97%, I²= 96%) at six months, 96% (94–98%, I² = 97%) at 12 months, and 98% (96–99%, I² = 94%) at 24 months. Sensitivity analysis removing outliers decreased heterogeneity and slightly lowered the 6‑month estimate (to 94%), with negligible change at 12 months. At 6 months, viral suppression was higher in those transitioning than initiating ART (98% vs. 94%, p < 0.01), with similar rates at 12 months (97%, p = 0.67). The pooled intention-to-treat 12-month viral suppression rate was 89% (82–93%, I² = 95%), with no significant difference by ART status (initiating 86% vs. transitioning 91%, p = 0.44). Conclusion: Adults retained in care receiving WHO-recommended first-line dolutegravir-based ART achieved viral suppression rates of ≥ 95% up to two years. These findings align with the UNAIDS 95% suppression target and reinforce the role of dolutegravir-based regimens in ending HIV as a public health threat. Trial registration: CRD42024557769.