Phillips AN, Bansi-Matharu L, Venter F, et al. - In response to the request from WHO for updating modeling results for its 2019 Antiretroviral antiretroviral therapy (ART) update, which was restricted to the choice of dolutegravir or efavirenz in new ART initiators, researchers here modelled the risks and benefits of alternative policies for initial first-line ART regimens. An existing individual-based model of HIV transmission and progression in adults was updated to acknowledge the data on the risk of neural tube defects in women receiving dolutegravir at the time of conception, as well as the impacts of dolutegravir on weight gain. The model considered drug resistance in defining viral suppression, with results for clinical outcomes and mother-to-child transmission. Various epidemic setting scenarios were developed via sampling distributions of parameters, which reflected the heterogeneity of epidemic and programmatic situations in sub-Saharan Africa. For each setting scenario, the situation in 2018 was considered and comparison was performed of ART initiation policies of an efavirenz-based regimen in women intending pregnancy, and a dolutegravir-based regimen in others, and a dolutegravir-based regimen, including in women intending pregnancy. Predicted outcomes over a 20-year period from 2019 to 2039 were considered, a 3% discount rate was used, and aversion of a cost-effectiveness threshold of US$500 per disability-adjusted life-year averted. Outcomes suggest that a policy of ART introduction with a dolutegravir-based regimen, including in women planning a pregnancy, was prophesied to bring population health benefits and be cost-effective, strengthening WHO's strong recommendation for dolutegravir as a preferred drug for ART initiators.