Initial Antiretroviral Third-Drug Class and Time to Loss of Virologic Suppression: A Real-World Colombian Cohort Study

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Abstract
Background: Real-world comparisons of initial antiretroviral third-drug classes are limited in middle-income settings. We evaluated whether the initial third-drug class predicts time to loss of virologic suppression in Colombia. Methods: Historical cohort of 609 ART-naïve adults (2016-2020). Outcome: first HIV RNA ≥200 copies/mL. We compared NNRTI, PI, and INSTI regimens using adjusted and IPTW-weighted Cox models. Results: Regimens were NNRTI (72%), PI (20%), and INSTI (8%); 19.9% lost suppression. Compared with NNRTI, PIs showed higher but nonsignificant hazards (aHR 1.50, 95% CI 0.98-2.27). For INSTIs, we did not detect significant differences (aHR 1.22, 95% CI 0.64-2.31). Diagnosis-to-ART delays and treatment interruptions were associated with loss of suppression. Conclusions: Treatment continuity and timely initiation predicted sustained suppression better than drug class. Low INSTI usage limits statistical power to detect differences. Structural barriers to continuity may limit the real-world benefit of newer regimens.

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