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As per the South African National  DTG not become ineffective easily, it   References:
       Department of Health updated 2019  also manages to suppress HIV rapidly,   1.   AVERT. HIV and AIDS in South Africa [Internet]. 2020 [cited
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       ART  guidelines,   viral  loads  should  first  allowing the patient’s immune system   professionals/hiv-around-world/sub-saharan-africa/south-
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       be performed at 6 months following ART  time to recuperate. This was seen in the   2.   Atta MG, De Seigneux S, Lucas GM. Clinical Pharmacology
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       can be expected to be high in the absence  previous standard of care, an EFV-based   [Internet]. In: Applied Pharmacology. Elsevier; 2011. p. 233–
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       of ARVs to suppress it.            regimen.  Whilst DTG and EFV were   4.   Kolakowska A, Maresca AF, Collins IJ, Cailhol J. Update on
                                          noted to both be effective in managing   Adverse Effects of HIV Integrase Inhibitors. Curr Treat Options
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       dependent on this initial result:  achieved  viral  suppression  sooner  than   5.   Zash, R; Holmes, L; Diseko, M; Jacobson, D; Mayondi G et al.
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          virus is suppressed, and the patient  in reducing disease progression and aid   6.   Venter WDF, Sokhela S, Simmons B, et al. Dolutegravir
                                                                                 with emtricitabine and tenofovir alafenamide or tenofovir
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                                                                                 tenofovir disoproxil fumarate for initial treatment of HIV-1
          as  prescribed,  with  a  repeat  VL                                   infection  (ADVANCE):  week  96  results  from  a randomised,
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          only required annually thereafter if  Guidelines on managing virological   Available from: https://linkinghub.elsevier.com/retrieve/pii/
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                                                                                 plus Two Different Prodrugs of Tenofovir to Treat HIV. N Engl J
       •  VL ≥ 50 cp/mL  - this is considered  more about  ARVs and  the likelihood of   Med [Internet] 2019;381(9):803–15. Available from: http://
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          a medical  emergency and must  developing resistance mutations. Because   8.   Walmsley SL, Antela A, Clumeck N, et al. Dolutegravir plus
                                                                                 Abacavir–Lamivudine for the Treatment of HIV-1 Infection.
          therefore be evaluated as soon as  of its high genetic barrier, resistance to   N Engl J Med [Internet] 2013;369(19):1807–18. Available
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          possible. This includes assessment of  DTG develops very slowly, and elevated   9.   Stellbrink H-J, Reynes J, Lazzarin A, et al. Dolutegravir
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          dosing, monitoring for drug-drug  As a result, patients should be on a DTG-  dolutegravir versus darunavir plus ritonavir for treatment-naive
                                                                                 adults with HIV-1 infection (FLAMINGO): 96 week results
          interactions,  and   considering based regimen for at least 2 years, with   from a randomised, open-label, phase 3b study. Lancet HIV
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          the presence of ARV resistance  at least 3 VL  ≥ 1000 cp/mL before   11.   Orrell C, Hagins DP, Belonosova E, et al. Fixed-dose
          mutations. 16  Once  adherence considering a switch to second-line ART.    combination dolutegravir, abacavir, and lamivudine versus
                                                                           16
                                                                                 ritonavir-boosted atazanavir plus tenofovir disoproxil fumarate
          counselling has been done, a repeat  This is in comparison to EFV-based first-line   and emtricitabine in previously untreated women with HIV-
                                                                                 1 infection (ARIA): week 48 results from a randomised,
          VL done 3 months thereafter is  ART, which requires only 2 consecutive   open-label. Lancet HIV [Internet] 2017;4(12):e536–46.
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          indicated and the patient managed  VL ≥ 1000 cp/mL before considering a   12.   Aboud M, Kaplan R, Lombaard J, et al. Dolutegravir versus
          accordingly.                    regimen switch because of EFV’s lower   ritonavir-boosted lopinavir both with dual nucleoside reverse
                                                                                 transcriptase inhibitor therapy in adults with HIV-1 infection
                                          barrier to resistance mutations.       in whom first-line therapy has failed (DAWNING): an open-
                                                                                 label, non-inferiority, phase 3b trial. Lancet Infect Dis [Internet]
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                                          Conclusion                          13.   Trottier  B, Lake  JE,  Logue K,  et  al. Dolutegravir/abacavir/
                                                                                 lamivudine versus current ART in virally suppressed patients
       HIV, if uncontrolled, is able to mutate or                                (STRIIVING): a 48-week, randomized, non-inferiority, open-
                                                                                 label, Phase IIIb study. Antivir Ther [Internet] 2017;22(4):295–
       adapt itself each time a new viral copy  Dolutegravir, despite recent concerns   305. Available from: https://www.intmedpress.com/journals/
                                                                                 avt/abstract.cfm?id=3166&pid=48
       is made. If this is done in the presence of  around weight gain, is an excellent   14.   van Wyk J, Ajana F, Bisshop F, et al. Efficacy and Safety of
                                                                                 Switching to Dolutegravir/Lamivudine Fixed-Dose 2-Drug
       ARVs, mutations to these drugs develop  addition to the South African ART   Regimen vs Continuing a Tenofovir Alafenamide–Based 3- or
                                                                                 4-Drug Regimen for Maintenance of Virologic Suppression
       and accumulate. A genetic barrier to  programme. Not only is it well tolerated,   in  Adults  Living  With  Human  Immunodeficiency  Virus
                                                                                 Type 1: Phas. Clin Infect Dis [Internet] 2020;71(8):1920–
       resistance, simply put, is the number of  its high genetic barrier allows it to   9.  Available  from:  https://academic.oup.com/cid/
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       mutations required to develop resistance to  largely evade resistance and remain   15.   Cahn P, Madero JS, Arribas JR, et al. Dolutegravir plus
                                                                                 lamivudine versus dolutegravir plus tenofovir disoproxil
       a specific ARV. A high barrier to resistance  active against HIV. The importance of   fumarate  and  emtricitabine  in  antiretroviral-naive  adults
                                                                                 with HIV-1 infection (GEMINI-1 and GEMINI-2): week
       allows  for  the  accumulation  of  many  this cannot be emphasised enough in   48 results from two multicentre, double-blind, randomised,
                                                                                 non-inferior. Lancet [Internet] 2019;393(10167):143–55.
       mutations before a drug can no longer  ensuring patients remain susceptible to   Available from: https://linkinghub.elsevier.com/retrieve/pii/
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       be used due to resistance and subsequent  first-line ART regimens, allowing for ease   16.   Republic of South Africa National Department of Health. 2019
       decreased efficacy.  HIV drug resistance  of use, and in doing so encouraging   ART Clinical Guidelines for the Management of HIV in Adults,
                      19
                                                                                 Pregnancy, Adolescents, Children, Infants and Neonates
                                                                                 [Internet].  [cited  2020  Nov  11];Available  from:  https://
       is able to severely impact the effectiveness  treatment adherence, preservation of   sahivsoc.org/Files/2019 ART Guideline 28042020 pdf.pdf
       of ART regimens and programmes,  future ART options, and preventing the use   17.   Meyer-Ruth, G; Jamieson, L; Masuku, S; Venter, F; Johnson
                                                                                 L. The impact of dolutegravir in first-line adult ART on HIV
       allowing for increased mortality, limited  of more costly second- and third-line ARVs.   transmission and cost of HIV in South Africa [Internet].
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       options for future regimens and increased  Concurrently, the timeous use of viral load   wp-content/uploads/2018/11/9C_Gesine-Meyer-Rath-DTG-
                                                                                 CEA-October-2018-.pdf
       cost implications.                 testing to monitor therapeutic response   18.   AVERT. What is an undetectable viral load? [Internet]. Living
                                                                                 with HIV. 2020 [cited 2020 Dec 10];Available from: https://
                                          remains vital  in  identifying  patients  with   www.avert.org/living-with-hiv/antiretroviral-treatment/what-
                                                                                 does-undetectable-mean
       DTG is one such drug with a high  adherence issues and addressing these   19.   Gega A, Kozal MJ. New technology to detect low-level drug-
                                                                                 resistant HIV variants. Future Virol [Internet] 2011;6(1):17–
       barrier  to  resistance.  Not  only  does  concerns early on.             26.  Available  from:  https://www.futuremedicine.com/
                                                                                 doi/10.2217/fvl.10.77
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