Programmatic DTG switching in Egypt: Challenges and considerations

Al Sehemy, Lamiaa; Sherif, Mirella; Mohamed, Rahma; Alsharif, A. M.; Saweres, Andrew; Alshayeb, Engee; El Khateeb, Engee; Said, Aml; Cordie, Ahmed

doi:10.21608/mid.2025.375102.2693

	Programmatic DTG switching in Egypt: Challenges and considerations
Microbes and Infectious Diseases
Articles in Press, Accepted Manuscript, Available Online from 20 May 2025
Document Type: Letter to the Editor
DOI: 10.21608/mid.2025.375102.2693
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Authors
Lamiaa Al Sehemy ¹^{, 2}; Mirella Sherif¹^{, 2}; Rahma Mohamed¹^{, 2}; A. M. Alsharif¹^{, 2}; Andrew Saweres¹^{, 2}; Engee Alshayeb³; Engee El Khateeb⁴; Aml Said⁵; Ahmed Cordie¹^{, 2}
¹Cairo University, Cairo University Hospitals HIV Clinic, Endemic Medicine Department, Cairo, Egypt
²Kasr Al-Aini HIV and Viral Hepatitis Fighting Group, Cairo University Hospitals, Egypt
³School of medicine, New Giza university (NGU), Giza, Egypt .
⁴Cairo, Egypt, Department of Clinical and Chemical Pathology, Cairo University, Cairo, Egypt,
⁵Department of Clinical and Chemical Pathology, Faculty of Medicine, Cairo University
Abstract
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.
Keywords
HIV; ART; DTG; ART resistance; second line ART


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