Disparities in dolutegravir utilisation in children, adolescents and young adults (0-24 years) living with HIV: An analysis of the IeDEA Paediatric West African cohort.

Introduction: We describe the 24-month incidence of Dolutegravir (DTG)-containing antiretroviral treatment (ART) initiation since its introduction in 2019 in West Africa. Methods: We included all patients aged 0-24 years on ART from nine clinics in Côte d'Ivoire (n=4), Ghana, Nigeria, Mali, Benin, and Burkina Faso. Baseline varied by clinic and was defined as date of first DTG prescription; patients were followed up until database closure/death/loss to follow-up (LTFU, no visit ≥ 7 months), whichever came first. We computed the cumulative incidence function for DTG initiation; associated factors were explored in a shared frailty model, accounting for clinic heterogeneity. Results: Since 2019, 3,350 patients were included; 47.2% were female; 78.9% had been on ART ≥ 12 months. Median baseline age was 12.5 years (Interquartile range[IQR]: 8.4-15.8). Median follow-up was 14 months (IQR: 7-22). The overall cumulative incidence of DTG initiation reached 22.7% (95% Confidence Interval (CI): 21.3-24.2) and 56.4% (95% CI: 54.4-58.4) at 12 and 24 months, respectively. In univariate analyses, those aged <5 years and females were overall less likely to switch. Adjusted on ART line and available viral load (VL) at baseline, females >10 years were less likely to initiate DTG compared to males of the same age (adjusted Hazard Ratio [HR] among 10-14 years: 0.62, 95% CI: 0.54-0.72; among ≥15 years: 0.43, 95% CI: 0.36-0.50), as were those with detectable VL (> 50 copies/mL) compared to those in viral suppression (aHR: 0.86, 95% CI: 0.77-0.97) and those on protease inhibitors compared to those on non-nucleoside reverse-transcriptase inhibitors (aHR after 12 months of roll-out: 0.75, 95% CI: 0.65-0.86). Conclusion: Paediatric DTG uptake was incomplete and unequitable in West African settings: DTG use was least likely in children <5years, females ≥ 10 years and those with detectable viral load. Maintained monitoring and support of treatment practices is required to better ensure universal and equal uptake.