DISCUSSION
virologic failure, TLD, insomnia
DRUG INTERACTION
In our study, second-line TLD produced acceptable rates of virologic suppression at 24 weeks in adults with virologic failure on first-line TEE, with and without a lead-in supplementary dolutegravir dose. No emergent dolutegravir resistance occurred over 24 weeks among our cohort of patients who switched with unsuppressed HIV-1 RNA levels, despite the majority having resistance to both tenofovir and lamivudine at baseline. Our findings strengthen the evidence base for recycling tenofovir and lamivudine with dolutegravir in second-line ART in resource-limited settings.Our results are consistent with those from previous randomized controlled trials assessing the efficacy of dolutegravir in second-line ART [A previous study conducted among healthy, HIV-negative volunteers showed that efavirenz reduced dolutegravir trough concentrations by 75% when coadministered, but that doubling the dolutegravir dose mitigated the drug–drug interaction [Emergent dolutegravir resistance has been documented infrequently in second-line ART (4% at 96 weeks in NADIA, and 2% at 159 weeks in DAWNING) [In ARTIST, we observed a substantial incidence of insomnia (13%) reported by participants at week 2 with no discernible difference in the proportion between arms; the majority of insomnia complaints were mild and did not reach clinical significance based on ISI scores, and 76% resolved by week 4. The incidence of insomnia we found is twice that reported in a meta-analysis of trial participants randomized to dolutegravir [Our study has limitations. First, our study was not powered to formally assess differences between arms. Although the sample size did not allow for a statistically powered comparison, our study was designed to rapidly generate data to supplement the findings from NADIA [