Low-Level Viremia and Spatial Heterogeneity Among Individuals on Dolutegravir-Based Antiretroviral Therapy in Botswana: A Nationwide Study (2016–2022)

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BACKGROUND: The study uses spatial analysis to identify factors associated with human immunodeficiency virus (HIV) detectable viremia in dolutegravir (DTG)-based first-line antiretroviral therapy (ART), which is crucial for targeted interventions to sustain epidemic control in Botswana. METHODS: This was a longitudinal observational cohort utilizing a dataset of 42 546 people with HIV on DTG-based first-line ART from June 2016 to December 2022 enrolled in the Botswana National Treatment Program. Detectable viremia was defined as viral load (VL) >50 copies/mL and further classified into low-level viremia (LLV; VL from 51 to 999 copies/mL) and virologic failure (VF; VL ≥1000 copies/mL). The rates of detectable viremia, LLV, and VF were stratified by year from 2017 to 2022 and mapped by districts in Botswana. Generalized estimating equation (GEE) models were utilized to evaluate odds of detectable viremia. RESULTS: There was an overall trend of increasing detectable viremia, with rates of 6.7% (2017), 5.6% (2018), 4.7% (2019), 7.1% (2020), 13.5% (2021), and 11.2% (2022) (P < .001). The linear annual trend showed that each additional year from 2017 was associated with 23% increased odds of detectable viremia and 50% increase in the odds of LLV, while odds of VF decreased by 6% per year. Repeated-measures GEE models showed that male sex (adjusted odds ratio [aOR], 1.36 [95% confidence interval {CI}, 1.30-1.43]) and rural residence (aOR, 1.10 [95% CI, 1.05-1.16]) were consistently associated with higher odds of detectable viremia, LLV, and VF over follow-up. CONCLUSIONS: While VF is declining, LLV is increasing. We observed spatial heterogeneity in detectable viremia, and higher odds in males, those with rural residence, and young individuals (18-35 years). Targeted interventions are necessary for high-risk groups and regions to further suppress viremia and achieve sustained epidemic control beyond the UNAIDS 95-95-95 targets.

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