Maintain, not obtain: rethinking HIV care in sub-Saharan Africa in the era of dolutegravir.

Over the past four decades, the HIV epidemic in sub-Saharan Africa has shifted from an acute, high-mortality phase to an era of widespread antiretroviral therapy (ART), driven by global scale up and the introduction of potent regimens such as dolutegravir-based combinations. While viral suppression is now increasingly achievable, the central challenge has evolved toward maintaining durable virological control across the life course. We argue that program success can no longer be defined by the mere attainment of suppression, but by the sustained maintenance of undetectable viral load and preservation of drug effectiveness at the population level. From a virological perspective, incomplete suppression, including persistent low-level viremia, creates predictable conditions for resistance selection over time, even with high-genetic barrier agents. In settings where CD4 monitoring is infrequent, gradual immune deterioration may go unnoticed despite apparently acceptable viral load thresholds. Emerging integrase inhibitor resistance should therefore be interpreted as a systems-level warning signal rather than an isolated clinical event. We discuss dolutegravir as an extraordinary yet finite therapeutic resource, the risks of functional monotherapy when nucleoside backbones are compromised, and the role of postfailure strategies, including protease inhibitor-anchored regimens, within optimized care pathways. Central to this approach is recognizing diagnostics-viral load monitoring, CD4 assessment, and targeted genotypic resistance testing-as essential clinical infrastructure. Sustaining ART gains in Africa requires moving from "minimum for all" toward differentiated, high-quality lifelong care integrated within broader public health platforms.