Durable viral suppression in the dolutegravir era: a data-enabled, risk-stratified model for integrated HIV care in...

Despite widespread rollout of dolutegravir-based (DTG) antiretroviral therapy (ART) in East Africa, viral non-suppression, advanced HIV disease (AHD), and multimorbidity persist, reflecting gaps in service response rather than regimen potency alone. In Uganda's The AIDS Support Organization (TASO) routine-care cohort (2014-2024; n = 54,348 people living with HIV), integrase inhibitor uptake is near universal, yet AHD remains common, and tuberculosis (TB) and non-communicable diseases (NCD) increasingly co-occur within HIV care. Among clients with a recorded most recent viral load, 6.4% (2,145/33,384) had viral non-suppression (VL ≥ 1,000 copies/mL). Second, our regional systematic review and meta-analysis (2016-2023; n = 29,829) estimates viral non-suppression at 19.4% and indicates that failure concentrates in predictable social and clinical risk strata. We propose that durable suppression may be strengthened by an accountable, time-bound viral load (VL) cascade, paired with targeted support for clients at elevated clinical and social risk. Building on WHO and national differentiated service delivery and AHD guidance, we outline a pragmatic, data-enabled, risk-stratified model that uses routine electronic health record (EHR) signals to trigger rapid viral non-suppression follow-up, guide delivery of a proposed time-limited adherence and socioeconomic stability bundle, and integrate TB and NCD management within HIV platforms. A minimum actionable dashboard focused on cascade timeliness, high-risk package delivery, and integrated care can translate ART scale-up into durable suppression, fewer preventable AHD complications, and faster progress toward 95-95-95.