Timing matters: Examining the lag in Dolutegravir rollout among people living with HIV with Tuberculosis and advanced HIV disease in Rural South Africa (2019- 2023)

Background: While Dolutegravir (DTG)-based antiretroviral therapy (ART) has become the preferred regimen for people living with HIV (PLHIV), the pace and equity of its adoption—especially among subgroups with tuberculosis (TB) and advanced HIV disease—remain understudied in high-burden settings like rural KwaZulu-Natal (KZN), South Africa. Methods: We conducted a longitudinal cohort study using routine HIV program data from 69,916 PLHIV aged ≥ 15 years, followed across 19 HIV clinics in rural KZN between October 1, 2019, and December 31, 2023. Kaplan-Meier analysis estimated time to DTG transition. Cox proportional hazards models assessed the effect of TB and advanced HIV disease (CD4 count < 200 cells/mm³) on DTG transition. Mixed-effects logistic regression models estimated the odds of TB and advanced HIV disease by ART regimen. Results: Of the cohort, 49,365 (69.2%) were female, with a median age of 40 years (IQR: 32–49). By study end, 70.9% (n = 49,598) had transitioned to DTG. PLHIV with TB had a 22% lower hazard of transitioning to DTG compared to those without TB [adjusted hazard ratio (AHR) = 0.78; 95% CI: 0.76–0.82], while those with CD4 < 200 cells/mm³ had a 43% lower hazard [AHR = 0.57; 95% CI: 0.54–1.59]. DTG use was associated with significantly lower odds of advanced HIV disease (OR = 0.42; 95% CI: 0.40–0.43) and TB (OR = 0.73; 95% CI: 0.68–0.77). Conclusion: PLHIV with TB or advanced HIV disease were less likely to transition to DTG regimens. Strengthening adherence to clinical guidelines and improving integration of HIV and TB care are critical to ensure equitable access to DTG-based ART in rural settings