Final analysis of the BicDol study, presented at AIDS 2026, suggests that a first-line triple antiretroviral regimen containing dolutegravir suppresses HIV more rapidly than one containing bictegravir, particularly among patients with the highest viral loads.
More patients in the dolutegravir group achieved viral suppression (<50 copies/mL) than those in the bictegravir group. By 24 weeks of treatment, 74.9 percent of patients on a dolutegravir-based regimen had a viral load of <50 copies/mL, compared with 69.1 percent on a bictegravir-based regimen. [AIDS 2026, abstract OAB0102]
Study author Dr Antoine Chéret of the University Hospital of Guadeloupe in Guadeloupe, France said the findings could inform the selection of initial treatment regimens for patients with high viraemia.
Difference in viral suppression
The difference in viral suppression between dolutegravir and bictegravir was more pronounced in patients with acute HIV infection (81.8 percent vs 72.7 percent) and those with viral loads above 5.7 log10 (68.7 percent vs 58.7 percent).
In each case, the difference between groups was statistically significant in a Kaplan-Meier time-to-viral suppression analysis. This difference persisted in a Cox model with propensity scores estimated from age, sex, acute HIV infection, CD4 cell count, and baseline viral load.
Although the study found no difference in CD4 count recovery after starting treatment, there was a small but significant difference in the CD4/CD8 ratio by week 5 of treatment (p=0.024), but not at later time points, suggesting a slight advantage for dolutegravir in immune function, said Chéret. He added that a faster decrease in viral levels could also help limit the size of the HIV reservoir.
Predictor of HIV suppression
Viral load, defined as the amount of HIV RNA present in the plasma, is a strong predictor of HIV progression. High viral load at treatment initiation (>100,000 copies/mL) increases the risk of treatment failure, drug resistance, onward transmission, and even death. [Front Public Health 2022;doi:10.3389/fpubh.2022.800839]
Data on how well bictegravir reduces viral loads in patients with high viraemia is limited. Early research indicated that dolutegravir led to faster viral suppression compared to bictegravir when used alone.
Hence, using data from the French Dat’AIDS cohort (2009-2023), Chéret and his team compared the rates and speed of viral suppression among patients with high viral loads who started treatment with either a three-drug regimen containing dolutegravir (n=703) or bictegravir (n=1,826).
Patients initiating dolutegravir or bictegravir had a similar profile: median age was 38 years, 80 percent were male, and 40 percent were born outside France. The timing of HIV-RNA measurements did not differ between groups.
Viral load at treatment initiation was slightly higher in the dolutegravir group. Additionally, patients were more likely to start dolutegravir than bictegravir during acute HIV infection (27 percent vs 17 percent). Among patients initiating treatment during the acute phase, viral load did not differ between groups.
Implications for practice
Chéret said the findings are particularly important for clinical decision-making in patients presenting with high baseline viraemia. “Rapid viral suppression not only helps preserve immune function but also curtails the latent HIV reservoir and prevents transmission.”