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Sivamalar S, Gomathi S, Boobalan J, Balakrishnan P, Pradeep A, Devaraj CA, Solomonl SS, Nallusamy D, Nalini D, Sureka V, Saravanan S. Delayed identification of treatment failure causes high levels of acquired drug resistance and less future drug options among HIV-1-infected South Indians. Indian J Med Microbiol 2024; 47:100520. [PMID: 38052366 DOI: 10.1016/j.ijmmb.2023.100520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 06/21/2023] [Accepted: 11/28/2023] [Indexed: 12/07/2023]
Abstract
PURPOSE HIV-1 Drug Resistance Mutations (DRMs) among Immunological failure (IF) on NRTI based first-line regimens, Thymidine analogue (TA) - AZT & D4T and Non-Thymidine Analogue (NTA) -TDF; and predict viral drug susceptibility to gain vision about optimal treatment strategies for second-line. METHODS Cross-sectionally, 300 HIV-1 infected patients, failing first-line HAART were included. HIV-1 pol gene spanning 20-240 codons of RT was genotyped and mutation pattern was examined, (IAS-USA 2014 and Stanford HIV drug resistance database v7.0). RESULTS The median age of the participants was 35 years (IQR 29-40), CD4 T cell count of TDF failures was low at 172 cells/μL (IQR 80-252), and treatment duration was low among TDF failures (24 months vs. 61 months) (p < 0.0001). Majority of the TDF failures were on EFV based first-line (89 % vs 45 %) (p < 0.0001). Level of resistance for TDF and AZT shows, that resistance to TDF was about one-third (37 %) of TDF participants and onefourth (23 %) of AZT participants; resistance to AZT was 17 % among TDF participants and 47 % among AZT participants; resistance to both AZT and TDF was significantly high among AZT participants [21 % vs. 8 %, OR 3.057 (95 % CI 1.4-6.8), p < 0.0001]. CONCLUSION Although delayed identification of treatment failure caused high levels of acquired drug resistance in our study. Thus, we must include measures to regularize virological monitoring with integrated resistance testing in LMIC (Low and Middle Income Countries) like in India; this will help to preserve the effectiveness of ARV and ensure the success of ending AIDS as public health by 2030.
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Affiliation(s)
- Sathasivam Sivamalar
- Meenakshi Academy of Higher Education and Research (Deemed to be University), West K. K. Nagar, Chennai, 600 078, India; YR Gaitonde Centre for AIDS Research and Education, Voluntary Health Services, Hospital Campus, Taramani, Chennai, 600 113, India
| | - Selvamurthi Gomathi
- YR Gaitonde Centre for AIDS Research and Education, Voluntary Health Services, Hospital Campus, Taramani, Chennai, 600 113, India
| | - Jayaseelan Boobalan
- YR Gaitonde Centre for AIDS Research and Education, Voluntary Health Services, Hospital Campus, Taramani, Chennai, 600 113, India
| | - Pachamuthu Balakrishnan
- Centre for Infectious Diseases Saveetha Medical College & Hospitals [SMCH], Saveetha Institute of Medical and Technical Sciences [SIMATS], Saveetha University, Thandalam, Chennai, 602105, India
| | - Amrose Pradeep
- YR Gaitonde Centre for AIDS Research and Education, Voluntary Health Services, Hospital Campus, Taramani, Chennai, 600 113, India
| | - Chithra A Devaraj
- YR Gaitonde Centre for AIDS Research and Education, Voluntary Health Services, Hospital Campus, Taramani, Chennai, 600 113, India
| | - Sunil Suhas Solomonl
- YR Gaitonde Centre for AIDS Research and Education, Voluntary Health Services, Hospital Campus, Taramani, Chennai, 600 113, India; Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Duraisamy Nallusamy
- Meenakshi Academy of Higher Education and Research (Deemed to be University), West K. K. Nagar, Chennai, 600 078, India
| | - Devarajan Nalini
- Meenakshi Academy of Higher Education and Research (Deemed to be University), West K. K. Nagar, Chennai, 600 078, India
| | - Varalakshmi Sureka
- Meenakshi Academy of Higher Education and Research (Deemed to be University), West K. K. Nagar, Chennai, 600 078, India
| | - Shanmugam Saravanan
- Centre for Infectious Diseases Saveetha Medical College & Hospitals [SMCH], Saveetha Institute of Medical and Technical Sciences [SIMATS], Saveetha University, Thandalam, Chennai, 602105, India.
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Spectrum of Atazanavir-Selected Protease Inhibitor-Resistance Mutations. Pathogens 2022; 11:pathogens11050546. [PMID: 35631067 PMCID: PMC9148044 DOI: 10.3390/pathogens11050546] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 04/26/2022] [Accepted: 05/03/2022] [Indexed: 12/04/2022] Open
Abstract
Ritonavir-boosted atazanavir is an option for second-line therapy in low- and middle-income countries (LMICs). We analyzed publicly available HIV-1 protease sequences from previously PI-naïve patients with virological failure (VF) following treatment with atazanavir. Overall, 1497 patient sequences were identified, including 740 reported in 27 published studies and 757 from datasets assembled for this analysis. A total of 63% of patients received boosted atazanavir. A total of 38% had non-subtype B viruses. A total of 264 (18%) sequences had a PI drug-resistance mutation (DRM) defined as having a Stanford HIV Drug Resistance Database mutation penalty score. Among sequences with a DRM, nine major DRMs had a prevalence >5%: I50L (34%), M46I (33%), V82A (22%), L90M (19%), I54V (16%), N88S (10%), M46L (8%), V32I (6%), and I84V (6%). Common accessory DRMs were L33F (21%), Q58E (16%), K20T (14%), G73S (12%), L10F (10%), F53L (10%), K43T (9%), and L24I (6%). A novel nonpolymorphic mutation, L89T occurred in 8.4% of non-subtype B, but in only 0.4% of subtype B sequences. The 264 sequences included 3 (1.1%) interpreted as causing high-level, 14 (5.3%) as causing intermediate, and 27 (10.2%) as causing low-level darunavir resistance. Atazanavir selects for nine major and eight accessory DRMs, and one novel nonpolymorphic mutation occurring primarily in non-B sequences. Atazanavir-selected mutations confer low-levels of darunavir cross resistance. Clinical studies, however, are required to determine the optimal boosted PI to use for second-line and potentially later line therapy in LMICs.
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Acquired HIV drug resistance mutations on first-line antiretroviral therapy in Southern Africa: Systematic review and Bayesian evidence synthesis. J Clin Epidemiol 2022; 148:135-145. [PMID: 35192922 PMCID: PMC9388696 DOI: 10.1016/j.jclinepi.2022.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 01/11/2022] [Accepted: 02/16/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To estimate the prevalence of NRTI and NNRTI drug resistance mutations in patients failing NNRTI-based ART in Southern Africa. STUDY DESIGN We conducted a systematic review to identify studies reporting drug resistance mutations among adult people living with HIV (PLWH) who experienced virological failure on first-line NNRTI-based ART in Southern Africa. We used a Bayesian hierarchical meta-regression model to synthesize the evidence on the frequency of eight NRTI- and seven NNRTI-DRMs across different ART regimens, accounting for ART duration and study characteristics. RESULTS We included 19 study populations, including 2,690 PLWH. Patients failing first-line ART including emtricitabine or lamivudine showed high levels of the M184V/I mutation after 2 years: 75.7% (95% Credibility Interval [CrI] 61.9%-88.9%) if combined with tenofovir, and 72.1% (95% CrI 56.8%-85.9%) with zidovudine. With tenofovir disoproxil fumarate, the prevalence of the K65R mutation was 52.0% (95% CrI 32.5%-76.8%) at 2 years. On efavirenz, K103 was the most prevalent NNRTI resistance mutation (57.2%, 95% CrI 40.9%-80.1%), followed by V106 (46.8%, 95% CrI 31.3%-70.4%). CONCLUSIONS NRTI/NNRTI drug resistance mutations are common in patients failing first-line ART in Southern Africa. These patients might switch to dolutegravir-based regimen with compromised NRTIs, which could impair the long-term efficacy of ART.
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Gregson J, Rhee SY, Datir R, Pillay D, Perno CF, Derache A, Shafer RS, Gupta RK. Human Immunodeficiency Virus-1 Viral Load Is Elevated in Individuals With Reverse-Transcriptase Mutation M184V/I During Virological Failure of First-Line Antiretroviral Therapy and Is Associated With Compensatory Mutation L74I. J Infect Dis 2020; 222:1108-1116. [PMID: 31774913 PMCID: PMC7459140 DOI: 10.1093/infdis/jiz631] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 11/26/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND M184V/I cause high-level lamivudine (3TC) and emtricitabine (FTC) resistance and increased tenofovir disoproxil fumarate (TDF) susceptibility. Nonetheless, 3TC and FTC (collectively referred to as XTC) appear to retain modest activity against human immunodeficiency virus-1 with these mutations possibly as a result of reduced replication capacity. In this study, we determined how M184V/I impacts virus load (VL) in patients failing therapy on a TDF/XTC plus nonnucleoside reverse-transcriptase inhibitor (NNRTI)-containing regimen. METHODS We compared VL in the absence and presence of M184V/I across studies using random effects meta-analysis. The effect of mutations on virus reverse-transcriptase activity and infectiousness was analyzed in vitro. RESULTS M184I/V was present in 817 (56.5%) of 1445 individuals with virologic failure (VF). Virus load was similar in individuals with or without M184I/V (difference in log10 VL, 0.18; 95% confidence interval, .05-.31). CD4 count was lower both at initiation of antiretroviral therapy and at VF in participants who went on to develop M184V/I. L74I was present in 10.2% of persons with M184V/I but absent in persons without M184V/I (P < .0001). In vitro, L74I compensated for defective replication of M184V-mutated virus. CONCLUSIONS Virus loads were similar in persons with and without M184V/I during VF on a TDF/XTC/NNRTI-containing regimen. Therefore, we did not find evidence for a benefit of XTC in the context of first-line failure on this combination.
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Affiliation(s)
- J Gregson
- Department of Biostatistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - S Y Rhee
- Department of Medicine, Stanford University, Stanford, California, USA
| | - R Datir
- Division of Infection and Immunity, UCL, London, United Kingdom
| | - D Pillay
- Division of Infection and Immunity, UCL, London, United Kingdom
- Africa Health Research Institute, Durban, South Africa
| | - C F Perno
- Department of Oncology and Haematoncology, University of Milan, Milan, Italy
| | - A Derache
- Africa Health Research Institute, Durban, South Africa
| | - R S Shafer
- Department of Medicine, Stanford University, Stanford, California, USA
| | - R K Gupta
- Africa Health Research Institute, Durban, South Africa
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom
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Ledwaba J, Sayed Y, Pillay V, Morris L, Hunt G. Low Frequency of Protease Inhibitor Resistance Mutations and Insertions in HIV-1 Subtype C Protease Inhibitor-Naïve Sequences. AIDS Res Hum Retroviruses 2019; 35:673-678. [PMID: 30793914 DOI: 10.1089/aid.2019.0012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Human immunodeficiency virus-1 (HIV-1) protease sequences from 2,225 protease inhibitor (PI)-naïve HIV-1 subtype C-infected individuals collected over a 14-year period were analyzed for polymorphisms. Over 50% of sequences differed from an HIV-1 subtype B consensus sequence at 8 of the 99 amino acids at residues 12, 15, 19, 36, 41, 69, 89, and 93, but not in the functionally important regions. The frequency of primary resistance and accessory mutations occurred in <1% of the sequences. Of note, 11 sequences (0.5%) harbored amino acid insertions between residues 36 and 39, located in the elbow of the flap region. The insertions were found throughout the 13-year period. Occurrence of insertions in subtype C viruses is rare and viruses remain sensitive to currently used PIs (lopinavir/r, atazanavir/r, and darunavir/r). However, ongoing characterization of isolates is required to identify changes that may impact PI treatment since PIs are part of standard SA regimens.
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Affiliation(s)
- Johanna Ledwaba
- Centre for HIV and STIs, National Institute for Communicable Diseases, Johannesburg, South Africa
| | - Yasien Sayed
- Protein Structure-Function Research Unit, School of Molecular and Cell Biology, University of the Witwatersrand, Johannesburg, South Africa
| | - Visva Pillay
- Centre for HIV and STIs, National Institute for Communicable Diseases, Johannesburg, South Africa
| | - Lynn Morris
- Centre for HIV and STIs, National Institute for Communicable Diseases, Johannesburg, South Africa
- Department of Virology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Gillian Hunt
- Centre for HIV and STIs, National Institute for Communicable Diseases, Johannesburg, South Africa
- Department of Virology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Smit E, White E, Clark D, Churchill D, Zhang H, Collins S, Pillay D, Sabin C, Nelson M, Winston A, Jose S, Tostevin A, Dunn DT. An association between K65R and HIV-1 subtype C viruses in patients treated with multiple NRTIs. J Antimicrob Chemother 2018; 72:2075-2082. [PMID: 28379449 PMCID: PMC5890671 DOI: 10.1093/jac/dkx091] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Accepted: 02/28/2017] [Indexed: 11/13/2022] Open
Abstract
Objectives: HIV-1 subtype C might have a greater propensity to develop K65R mutations in patients with virological failure compared with other subtypes. However, the strong association between viral subtype and confounding factors such as exposure groups and ethnicity affects the calculation of this propensity. We exploited the diversity of viral subtypes within the UK to undertake a direct comparative analysis. Patients and methods: We analysed only sequences with major IAS-defined mutations from patients with virological failure. Prevalence of K65R was related to subtype and exposure to the NRTIs that primarily select for this mutation (tenofovir, abacavir, didanosine and stavudine). A multivariate logistic regression model quantified the effect of subtype on the prevalence of K65R, adjusting for previous and current exposure to all four specified drugs. Results: Subtype B patients (n = 3410) were mostly MSM (78%) and those with subtype C (n = 810) were mostly heterosexual (82%). K65R was detected in 7.8% of subtype B patients compared with 14.2% of subtype C patients. The subtype difference in K65R prevalence was observed irrespective of NRTI exposure and K65R was frequently selected by abacavir, didanosine and stavudine in patients with no previous exposure to tenofovir. Multivariate logistic regression confirmed that K65R was significantly more common in subtype C viruses (adjusted OR = 2.02, 95% CI = 1.55–2.62, P < 0.001). Conclusions: Patients with subtype C HIV-1 have approximately double the frequency of K65R in our database compared with other subtypes. The exact clinical implications of this finding need to be further elucidated.
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Affiliation(s)
- Erasmus Smit
- Public Health Laboratory Birmingham, Public Health England, Heartlands Hospital, Birmingham, UK
| | - Ellen White
- MRC CTU at UCL, University College London, London, UK
| | | | - Duncan Churchill
- Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Hongyi Zhang
- Public Health Laboratory Cambridge, Public Health England, Addenbrooke's Hospital, Cambridge, UK
| | | | - Deenan Pillay
- Research Department of Infection, Division of Infection and Immunity, University College London, London, UK.,Wellcome Trust Africa Centre for Health and Population Sciences, University of KwaZulu Natal, Mtubatuba, South Africa
| | - Caroline Sabin
- Research Department of Infection and Population Health London, University College London, London, UK
| | - Mark Nelson
- Chelsea and Westminster Hospital, London, UK
| | - Alan Winston
- Section of Infectious Diseases, Department of Medicine, Imperial College London, London, UK
| | - Sophie Jose
- Research Department of Infection and Population Health London, University College London, London, UK
| | - Anna Tostevin
- Research Department of Infection and Population Health London, University College London, London, UK
| | - David T Dunn
- Research Department of Infection and Population Health London, University College London, London, UK
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Sivamalar S, Dinesha TR, Gomathi S, Pradeep A, Boobalan J, Solomon SS, Poongulali S, Solomon S, Balakrishnan P, Saravanan S. Accumulation of HIV-1 Drug Resistance Mutations After First-Line Immunological Failure to Evaluate the Options of Recycling NRTI Drugs in Second-Line Treatment: A Study from South India. AIDS Res Hum Retroviruses 2017; 33:271-274. [PMID: 27460519 DOI: 10.1089/aid.2016.0070] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
Lack of HIV-1 viral load monitoring in resource-limited settings leads to the development of HIV drug resistance mutations, although WHO recommends viral load testing for monitoring as this helps in preserving future treatment options and also avoid unnecessary switching to more expensive drugs. A total of 101 patients attaining first-line treatment failure (FTF) were followed until second-line treatment failure (STF) to study the rate of accumulation of thymidine analogue mutations (TAMs), their future drug options, and genetic evolution. The result shows that predominant nucleos(t)ide reverse transcriptase inhibitor (NRTI) mutations were M184V/I (87.3% in FTF and 79% in STF) followed by TAMs (53.4% in FTF and 54.5% in STF). The rate of accumulation of TAMs was higher for a patient with TAMI [0.015 TAM per person-month (TPPM)], TAMII (0.042 TPPM), and 1 (0.005 TPPM) or 2 TAMs (0.008 TPPM) compared with a patient with both TAMs and 3 or >3 TAMs. Future ART options show that >50% of the patients can be considered for choices to recycle NRTIs in the second-line, and third-line therapy. We conclude that the patients who initiated thymidine analogue-based first-line before 2010 can be very well opted for AZT- and TDF-based second-line regimen in the future.
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Affiliation(s)
- Sathasivam Sivamalar
- Y.R. Gaitonde Center for AIDS Research and Education, Voluntary Health Services Hospital, Chennai, India
| | - Thongadi Ramesh Dinesha
- Y.R. Gaitonde Center for AIDS Research and Education, Voluntary Health Services Hospital, Chennai, India
| | - Selvamurthi Gomathi
- Y.R. Gaitonde Center for AIDS Research and Education, Voluntary Health Services Hospital, Chennai, India
| | - Ambrose Pradeep
- Y.R. Gaitonde Center for AIDS Research and Education, Voluntary Health Services Hospital, Chennai, India
| | - Jayaseelan Boobalan
- Y.R. Gaitonde Center for AIDS Research and Education, Voluntary Health Services Hospital, Chennai, India
| | - Sunil S. Solomon
- Y.R. Gaitonde Center for AIDS Research and Education, Voluntary Health Services Hospital, Chennai, India
- Johns Hopkins University School of Medicine, Department of Medicine, Baltimore, Maryland
| | - Selvamuthu Poongulali
- Y.R. Gaitonde Center for AIDS Research and Education, Voluntary Health Services Hospital, Chennai, India
| | - Suniti Solomon
- Y.R. Gaitonde Center for AIDS Research and Education, Voluntary Health Services Hospital, Chennai, India
| | - Pachamuthu Balakrishnan
- Y.R. Gaitonde Center for AIDS Research and Education, Voluntary Health Services Hospital, Chennai, India
| | - Shanmugam Saravanan
- Y.R. Gaitonde Center for AIDS Research and Education, Voluntary Health Services Hospital, Chennai, India
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Abstract
PURPOSE OF REVIEW To review current data on HIV-1 resistance arising from the use of fixed dose combination tenofovir disoproxil fumarate/emtricitabine (TDF/FTC) for preexposure prophylaxis (PrEP) to prevent HIV-1 infection. RECENT FINDINGS Resistance to tenofovir (TNV) or FTC is infrequently selected by TDF/FTC PrEP if started before HIV-1 infection has occurred, but is much more common when inadvertently started during undiagnosed acute infection. Mathematical modeling predicts that the number of HIV-1 infections averted by the use of PrEP far exceeds the increase in drug-resistant infections that could occur from PrEP. Studies in macaques show that TNV-resistant virus but not FTC-resistant virus can cause breakthrough infection despite TDF/FTC PrEP. FTC resistance with M184 V/I occurs more frequently than TFV resistance with K65R in seroconverters from clinical trials of TDF/FTC PrEP. SUMMARY The benefit of preventing HIV-1 infections with TDF/FTC PrEP far outweighs the risk of drug-resistant infection, provided PrEP is not started in persons with undiagnosed HIV-1 infection. We should respect but not fear HIV-1 resistance from TDF/FTC PrEP and recognize that most TNV or FTC resistance will arise from its use for antiretroviral therapy (ART). Preventing ART failure or detecting it early is most important for preventing the spread of HIV-1 resistance to TDF/FTC and preserving its effectiveness for both PrEP and ART.
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Steegen K, Bronze M, Papathanasopoulos MA, van Zyl G, Goedhals D, Variava E, MacLeod W, Sanne I, Stevens WS, Carmona S. HIV-1 antiretroviral drug resistance patterns in patients failing NNRTI-based treatment: results from a national survey in South Africa. J Antimicrob Chemother 2016; 72:210-219. [PMID: 27659733 DOI: 10.1093/jac/dkw358] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Revised: 07/29/2016] [Accepted: 07/31/2016] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Routine HIV-1 antiretroviral drug resistance testing for patients failing NNRTI-based regimens is not recommended in resource-limited settings. Therefore, surveys are required to monitor resistance profiles in patients failing ART. METHODS A cross-sectional survey was conducted amongst patients failing NNRTI-based regimens in the public sector throughout South Africa. Virological failure was defined as two consecutive HIV-1 viral load results >1000 RNA copies/mL. Pol sequences were obtained using RT-PCR and Sanger sequencing and submitted to Stanford HIVdb v7.0.1. RESULTS A total of 788 sequences were available for analysis. Most patients failed a tenofovir-based NRTI backbone (74.4%) in combination with efavirenz (82.1%) after median treatment duration of 36 months. K103N (48.9%) and V106M (34.9%) were the most common NNRTI mutations. Only one-third of patients retained full susceptibility to second-generation NNRTIs such as etravirine (36.5%) and rilpivirine (27.3%). After M184V/I (82.7%), K65R was the most common NRTI mutation (45.8%). The prevalence of K65R increased to 57.5% in patients failing a tenofovir regimen without prior stavudine exposure. Cross-resistance to NRTIs was often observed, but did not seem to affect the predicted activity of zidovudine as 82.9% of patients remained fully susceptible to this drug. CONCLUSIONS The introduction of tenofovir-based first-line regimens has dramatically increased the prevalence of K65R mutations in the HIV-1-infected South African population. However, most patients failing tenofovir-based regimens remained fully susceptible to zidovudine. Based on these data, there is currently no need to change either the recommended first- or second-line ART regimens in South Africa.
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Affiliation(s)
- K Steegen
- Department of Molecular Medicine and Haematology, University of the Witwatersrand, Johannesburg, South Africa
| | - M Bronze
- National Health Laboratory Service, Johannesburg, South Africa
| | - M A Papathanasopoulos
- Department of Molecular Medicine and Haematology, University of the Witwatersrand, Johannesburg, South Africa
| | - G van Zyl
- National Health Laboratory Service, Johannesburg, South Africa.,Division of Medical Virology, Stellenbosch University, Stellenbosch, South Africa
| | - D Goedhals
- National Health Laboratory Service, Johannesburg, South Africa.,Department of Medical Microbiology and Virology, University of the Free State, Bloemfontein, South Africa
| | - E Variava
- Department of Internal Medicine, Klerksdorp Tshepong Hospital Complex, Klerksdorp, South Africa.,Department of Internal Medicine, University of the Witwatersrand, Johannesburg, South Africa.,Perinatal HIV Research Unit, Johannesburg, South Africa
| | - W MacLeod
- Center for Global Health and Development, Boston University School of Public Health, Boston, MA, USA.,Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - I Sanne
- Right to Care, Johannesburg, South Africa
| | - W S Stevens
- Department of Molecular Medicine and Haematology, University of the Witwatersrand, Johannesburg, South Africa.,National Health Laboratory Service, Johannesburg, South Africa
| | - S Carmona
- Department of Molecular Medicine and Haematology, University of the Witwatersrand, Johannesburg, South Africa.,National Health Laboratory Service, Johannesburg, South Africa
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10
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Treatment failure and drug resistance in HIV-positive patients on tenofovir-based first-line antiretroviral therapy in western Kenya. J Int AIDS Soc 2016; 19:20798. [PMID: 27231099 PMCID: PMC4882399 DOI: 10.7448/ias.19.1.20798] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2015] [Revised: 03/31/2016] [Accepted: 04/26/2016] [Indexed: 12/03/2022] Open
Abstract
Introduction Tenofovir-based first-line antiretroviral therapy (ART) is recommended globally. To evaluate the impact of its incorporation into the World Health Organization (WHO) guidelines, we examined treatment failure and drug resistance among a cohort of patients on tenofovir-based first-line ART at the Academic Model Providing Access to Healthcare, a large HIV treatment programme in western Kenya. Methods We determined viral load (VL), drug resistance and their correlates in patients on ≥six months of tenofovir-based first-line ART. Based on enrolled patients’ characteristics, we described these measures in those with (prior ART group) and without (tenofovir-only group) prior non-tenofovir-based first-line ART using Wilcoxon rank sum and Fisher's exact tests. Results Among 333 participants (55% female; median age 41 years; median CD4 336 cells/µL), detectable (>40 copies/mL) VL was found in 18%, and VL>1000 copies/mL (WHO threshold) in 10%. Virologic failure at both thresholds was significantly higher in 217 participants in the tenofovir-only group compared with 116 in the prior ART group using both cut-offs (24% vs. 7% with VL>40 copies/mL; 15% vs. 1% with VL>1000 copies/mL). Failure in the tenofovir-only group was associated with lower CD4 values and advanced WHO stage. In 35 available genotypes from 51 participants in the tenofovir-only group with VL>40 copies/mL (69% subtype A), any resistance was found in 89% and dual-class resistance in 83%. Tenofovir signature mutation K65R occurred in 71% (17/24) of the patients infected with subtype A. Patients with K65R had significantly lower CD4 values, higher WHO stage and more resistance mutations. Conclusions In this Kenyan cohort, tenofovir-based first-line ART resulted in good (90%) virologic suppression including high suppression (99%) after switch from non-tenofovir-based ART. Lower virologic suppression (85%) and high observed resistance levels (89%) in the tenofovir-only group impact future treatment options, support recommendations for widespread VL monitoring in such resource limited settings to identify early treatment failure and suggest consideration of individualized resistance testing to design effective subsequent regimens.
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11
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Treatment options after virological failure of first-line tenofovir-based regimens in South Africa: an analysis by deep sequencing. AIDS 2016; 30:1137-40. [PMID: 26807968 DOI: 10.1097/qad.0000000000001033] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
In a South African cohort of participants living with HIV developing virological failure on first-line tenofovir disoproxyl fumarate (TDF)-based regimens, at least 70% of participants demonstrated TDF resistance according to combined Sanger and MiSeq genotyping. Sanger sequencing missed the K65R mutation in 30% of samples. Unless HIV genotyping is available to closely monitor epidemiological HIV resistance to TDF, its efficacy as second-line therapy will be greatly compromised.
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Palombi L, Pirillo MF, Marchei E, Jere H, Sagno JB, Luhanga R, Floridia M, Andreotti M, Galluzzo CM, Pichini S, Mwenda R, Mancinelli S, Marazzi MC, Vella S, Liotta G, Giuliano M. Concentrations of tenofovir, lamivudine and efavirenz in mothers and children enrolled under the Option B-Plus approach in Malawi. J Antimicrob Chemother 2015; 71:1027-30. [PMID: 26679247 DOI: 10.1093/jac/dkv435] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Accepted: 11/13/2015] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES To evaluate antiretroviral drug concentrations in mothers and infants enrolled under the Option B-Plus approach for the prevention of HIV mother-to-child transmission in Malawi and to assess the maternal virological response after 1 year of treatment. PATIENTS AND METHODS Forty-seven women and 25 children were studied. Mothers were administered during pregnancy a combination of tenofovir, lamivudine and efavirenz and continued it during breastfeeding (up to 2 years) and thereafter. Drug concentrations were evaluated in mothers (plasma and breast milk) at 1 and 12 months post-partum and in infants (plasma) at 6 and 12 months of age. Drug concentrations were determined using an LC-MS/MS validated methodology. RESULTS In breast milk, tenofovir concentrations were very low (breast milk/maternal plasma ratio = 0.08), while lamivudine was concentrated (breast milk/plasma ratio = 3) and efavirenz levels were 80% of those found in plasma. In infants, median levels at 6 months were 24 ng/mL tenofovir, 2.5 ng/mL lamivudine and 86.4 ng/mL efavirenz. At month 12, median levels were below the limit of quantification for the three drugs. No correlation was found between drug concentrations and laboratory parameters or indices of growth. HIV-RNA >1000 copies/mL was seen at month 1 in 15% of the women and at month 12 in 8.5%. Resistance was found in half of the women with detectable viral load. CONCLUSIONS Breastfeeding infants under Option B-Plus are exposed to low concentrations of antiretroviral drugs. With this strategy, mothers had a good virological response 1 year after delivery.
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Affiliation(s)
- Leonardo Palombi
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Via Montpellier 1, 00133 Rome, Italy
| | - Maria F Pirillo
- Department of Therapeutic Research and Medicines Evaluation, Istituto Superiore di Sanità, Viale Regina Elena 299, 00161 Rome, Italy
| | - Emilia Marchei
- Department of Therapeutic Research and Medicines Evaluation, Istituto Superiore di Sanità, Viale Regina Elena 299, 00161 Rome, Italy
| | - Haswell Jere
- DREAM Program, Community of S. Egidio, PO Box 30355, Blantyre, Malawi
| | | | - Richard Luhanga
- DREAM Program, Community of S. Egidio, PO Box 30355, Blantyre, Malawi
| | - Marco Floridia
- Department of Therapeutic Research and Medicines Evaluation, Istituto Superiore di Sanità, Viale Regina Elena 299, 00161 Rome, Italy
| | - Mauro Andreotti
- Department of Therapeutic Research and Medicines Evaluation, Istituto Superiore di Sanità, Viale Regina Elena 299, 00161 Rome, Italy
| | - Clementina Maria Galluzzo
- Department of Therapeutic Research and Medicines Evaluation, Istituto Superiore di Sanità, Viale Regina Elena 299, 00161 Rome, Italy
| | - Simona Pichini
- Department of Therapeutic Research and Medicines Evaluation, Istituto Superiore di Sanità, Viale Regina Elena 299, 00161 Rome, Italy
| | - Ruben Mwenda
- Diagnostics Department, Ministry of Health, PO Box 30377, Lilongwe 3, Malawi
| | - Sandro Mancinelli
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Via Montpellier 1, 00133 Rome, Italy
| | | | - Stefano Vella
- Department of Therapeutic Research and Medicines Evaluation, Istituto Superiore di Sanità, Viale Regina Elena 299, 00161 Rome, Italy
| | - Giuseppe Liotta
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Via Montpellier 1, 00133 Rome, Italy
| | - Marina Giuliano
- Department of Therapeutic Research and Medicines Evaluation, Istituto Superiore di Sanità, Viale Regina Elena 299, 00161 Rome, Italy
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Hoffmann CJ, Maritz J, van Zyl GU. CD4 count-based failure criteria combined with viral load monitoring may trigger worse switch decisions than viral load monitoring alone. Trop Med Int Health 2015; 21:219-23. [PMID: 26584666 DOI: 10.1111/tmi.12639] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE CD4 count decline often triggers antiretroviral regimen switches in resource-limited settings, even when viral load testing is available. We therefore compared CD4 failure and CD4 trends in patients with viraemia with or without antiretroviral resistance. METHODS Retrospective cohort study investigating the association of HIV drug resistance with CD4 failure or CD4 trends in patients on first-line antiretroviral regimens during viraemia. Patients with viraemia (HIV RNA >1000 copies/ml) from two HIV treatment programmes in South Africa (n = 350) were included. We investigated the association of M184V and NNRTI resistance with WHO immunological failure criteria and CD4 count trends, using chi-square tests and linear mixed models. RESULTS Fewer patients with the M184V mutation reached immunologic failure criteria than those without: 51 of 151(34%) vs. 90 of 199 (45%) (P = 0.03). Similarly, 79 of 220 (36%) patients, who had major NNRTI resistance, had immunological failure, whereas 62 of 130 (48%) without (chi-square P = 0.03) did. The CD4 count decline among patients with the M184V mutation was 2.5 cells/mm(3) /year, whereas in those without M184V it was 14 cells/mm(3) /year (P = 0.1), but the difference in CD4 count decline with and without NNRTI resistance was marginal. CONCLUSION Our data suggest that CD4 count monitoring may lead to inappropriate delayed therapy switches for patients with HIV drug resistance. Conversely, patients with viraemia but no drug resistance are more likely to have a CD4 count decline and thus may be more likely to be switched to a second-line regimen.
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Affiliation(s)
- Christopher J Hoffmann
- Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Aurum Institute, Johannesburg, South Africa
| | - Jean Maritz
- National Health Laboratory Service, Tygerberg, Cape Town, South Africa.,Division of Medical Virology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Gert U van Zyl
- National Health Laboratory Service, Tygerberg, Cape Town, South Africa.,Division of Medical Virology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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Derache A, Wallis CL, Vardhanabhuti S, Bartlett J, Kumarasamy N, Katzenstein D. Phenotype, Genotype, and Drug Resistance in Subtype C HIV-1 Infection. J Infect Dis 2015; 213:250-6. [PMID: 26175454 DOI: 10.1093/infdis/jiv383] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Accepted: 07/06/2015] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Virologic failure in subtype C is characterized by high resistance to first-line antiretroviral (ARV) drugs, including efavirenz, nevirapine, and lamivudine, with nucleoside resistance including type 2 thymidine analog mutations, K65R, a T69del, and M184V. However, genotypic algorithms predicting resistance are mainly based on subtype B viruses and may under- or overestimate drug resistance in non-B subtypes. To explore potential treatment strategies after first-line failure, we compared genotypic and phenotypic susceptibility of subtype C human immunodeficiency virus 1 (HIV-1) following first-line ARV failure. METHODS AIDS Clinical Trials Group 5230 evaluated patients failing an initial nonnucleoside reverse-transcriptase inhibitor (NNRTI) regimen in Africa and Asia, comparing the genotypic drug resistance and phenotypic profile from the PhenoSense (Monogram). Site-directed mutagenesis studies of K65R and T69del assessed the phenotypic impact of these mutations. RESULTS Genotypic algorithms overestimated resistance to etravirine and rilpivirine, misclassifying 28% and 32%, respectively. Despite K65R with the T69del in 9 samples, tenofovir retained activity in >60%. Reversion of the K65R increased susceptibility to tenofovir and other nucleosides, while reversion of the T69del showed increased resistance to zidovudine, with little impact on other NRTI. CONCLUSIONS Although genotype and phenotype were largely concordant for first-line drugs, estimates of genotypic resistance to etravirine and rilpivirine may misclassify subtype C isolates compared to phenotype.
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Affiliation(s)
- Anne Derache
- Division of Infectious Diseases, Stanford University, California
| | - Carole L Wallis
- Department of Molecular Pathology, Lancet Laboratories and BARC-SA, Johannesburg, South Africa
| | | | - John Bartlett
- Duke University Medical Center, Durham, North Carolina
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Skhosana L, Steegen K, Bronze M, Lukhwareni A, Letsoalo E, Papathanasopoulos MA, Carmona SC, Stevens WS. High prevalence of the K65R mutation in HIV-1 subtype C infected patients failing tenofovir-based first-line regimens in South Africa. PLoS One 2015; 10:e0118145. [PMID: 25659108 PMCID: PMC4320083 DOI: 10.1371/journal.pone.0118145] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Accepted: 01/05/2015] [Indexed: 12/04/2022] Open
Abstract
Background Tenofovir (TDF) has replaced stavudine (d4T) as the preferred nucleoside reverse transcriptase inhibitor (NRTI) in first-line regimens in South Africa, but limited information is available on the resistance patterns that develop after the introduction of TDF. This study investigated the antiretroviral drug resistance patterns in South African HIV-1 subtype C-infected patients failing stavudine- (d4T) and tenofovir- (TDF) based first-line regimens and assess the suitability of TDF as the preferred first-line nucleotide reverse transcriptase inhibitor (NRTI). Methods Resistance patterns of HIV-1 from 160 adult patients virologically failing TDF- (n = 80) and d4T- (n = 80) based first-line regimens were retrospectively analyzed. The pol gene was sequenced using an in-house protocol and mutations were analysed using the IAS-USA 2014 Drug Resistance Mutation list. Results Compared to d4T-exposed patients (n = 7), patients failing on a TDF-containing regimen (n = 43) were almost 5 times more likely to present with a K65R mutation (aRR 4.86 95% CI 2.29 – 10.34). Y115F was absent in the d4T group, and detected in 13.8% (n = 11) of TDF-exposed patients, p = 0.0007. Virus from 9 of the 11 patients (82.0%) who developed the Y115F mutation also developed K65R. Intermediate or high-level resistance to most NRTIs was common in the TDF-treatment group, but these patients twice more likely to remain susceptible to AZT as compared to those exposed to d4T (aRR 2.09 95% CI 1.13 – 3.90). Conclusion The frequency of the TDF induced K65R mutation was higher in our setting compared to non-subtype C dominated countries. However, despite the higher frequency of cross-resistance to NRTIs, most patients remained susceptible to AZT, which is reflected in the South African treatment guidelines that recommend AZT as an essential component of second-line regimens.
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Affiliation(s)
- Lindiwe Skhosana
- Department of Haematology and Molecular Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Kim Steegen
- Department of Haematology and Molecular Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- * E-mail:
| | - Michelle Bronze
- Department of Haematology and Molecular Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Azwidowi Lukhwareni
- National Health Laboratory Services, Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa
| | - Esrom Letsoalo
- Department of Haematology and Molecular Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Maria A. Papathanasopoulos
- Department of Haematology and Molecular Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Sergio C. Carmona
- Department of Haematology and Molecular Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- National Health Laboratory Services, Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa
| | - Wendy S. Stevens
- Department of Haematology and Molecular Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- National Health Laboratory Services, Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa
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Emerging antiretroviral drug resistance in sub-Saharan Africa: novel affordable technologies are needed to provide resistance testing for individual and public health benefits. AIDS 2014; 28:2643-8. [PMID: 25493592 DOI: 10.1097/qad.0000000000000502] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Abstract
PURPOSE OF REVIEW This review focuses on the chemical and pharmacological rationale behind the development of nucleoside antiviral prodrugs (NAPs). RECENT FINDINGS Highly efficacious NAPs have been developed that extend and improve the quality of lives of individuals infected with HIV and hepatitis B virus (HBV), herpes viruses, and adenovirus infection in immunocompromised individuals. A very high rate of hepatitis C virus (HCV) cure is now possible using NAPs combined with other direct acting antiviral agents (DAAs). SUMMARY Prodrug strategies can address the issues of poor oral bioavailability and delivery of active metabolites to the targeted cells. Additionally, NAPs demonstrate potential for improving deficiencies in oral absorption, metabolism, tissue distribution, cellular accumulation, phosphorylation, and overall potency, in addition to diminishing potential for in-vivo selection of resistant viruses. NAPs continue to be the backbone for the treatment of HIV and HBV, herpesviruses, and adenovirus infections because their active forms are potent, have long intracellular half-lives and are relatively safe with high barrier to resistance.
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Ketseoglou I, Lukhwareni A, Steegen K, Carmona S, Stevens WS, Papathanasopoulos MA. Viral tropism and antiretroviral drug resistance in HIV-1 subtype C-infected patients failing highly active antiretroviral therapy in Johannesburg, South Africa. AIDS Res Hum Retroviruses 2014; 30:289-93. [PMID: 24224886 DOI: 10.1089/aid.2013.0267] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Reports show that up to 30% of antiretroviral drug-naive patients in Johannesburg have CXCR4-utilizing HIV-1 subtype C. We assessed whether HIV-1 subtype C-infected individuals failing highly active antiretroviral therapy (HAART) have a higher proportion of CXCR4-utilizing viruses compared to antiretroviral drug-naive patients. The V3 loop was sequenced from plasma from 100 randomly selected HAART-failing patients, and tropism was established using predictive algorithms. All patients harbored HIV-1 subtype C with at least one antiretroviral drug resistance mutation. Viral tropism prediction in individuals failing HAART revealed similar proportions (29%) of X4-utilizing viruses compared to antiretroviral drug-naive patients (30%). Findings are in contrast to reports from Durban in which 60% of HAART-failing subjects harbored X4/dual/mixed-tropic viruses. Despite differences in proportions of X4-tropism within South Africa, the high proportion of thymidine analogue mutations (TAMs) and CXCR4-utilizing HIV-1 highlights the need for intensified monitoring of HAART patients and the predicament of diminishing drug options, including CCR5 antagonists, for patients failing therapy.
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Affiliation(s)
- Irene Ketseoglou
- 1 Faculty of Health Sciences, University of the Witwatersrand Medical School , Johannesburg, South Africa
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Lessells RJ, Avalos A, de Oliveira T. Implementing HIV-1 genotypic resistance testing in antiretroviral therapy programs in Africa: needs, opportunities, and challenges. AIDS Rev 2013; 15:221-9. [PMID: 24322382 PMCID: PMC3951902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Tremendous progress has been made with the scale-up of antiretroviral therapy in Africa, with an estimated seven million people now receiving antiretroviral therapy in the region. The long-term success of antiretroviral therapy programs depends on appropriate strategies to deal with potential threats, one of which is the emergence and spread of antiretroviral drug resistance. Whilst public health surveillance forms the mainstay of the World Health Organization approach to antiretroviral drug resistance, there is likely to be increasing demand for access to drug resistance testing as programs mature and as HIV clinical management becomes more complex. African-owned research initiatives have helped to develop affordable resistance testing appropriate for use in the region, and have developed delivery models for resistance testing at different levels of the public health system. Some upper-middle-income countries such as Botswana and South Africa have introduced drug resistance testing for selected patient groups to guide clinical management. The scale-up of resistance testing will require substantial expansion of clinical and laboratory capacity in the region, but the expertise and resources exist in Africa to support this. The long-term population health impact and cost-effectiveness of resistance testing in the region will also require further investigation.
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Affiliation(s)
- Richard J. Lessells
- Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Mtubatuba, South Africa
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
| | - Ava Avalos
- Ministry of Health (MOH), Republic of Botswana, Gaborone, Botswana
| | - Tulio de Oliveira
- Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Mtubatuba, South Africa
- Research Department of Infection, University College London, London, UK
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