Background: Pre-treatment HIV-drug-resistance (PDR) to WHO-recommended 1st-line non-nucleoside reverse transcriptase inhibitors (NNRTI)-based antiretroviral treatment (ART) is increasing in low-resource communities. We evaluated the risk of PDR on treatment failure if detected at single or multiple codons, at minority (2À9%) or higher (10%) frequencies during efavirenz-vs. nevirapine-ART. Methods: We conducted a pooled analysis across three cohorts of Kenyans initiating 1st-line NNRTI-ART between 2006 and 2014. Mutations K103N, Y181C, G190A, M184V and K65R were detected by an oligonucleotide ligation assay (OLA) and confirmed by Sanger and next-generation sequencing (NGS). PDR was defined as detection of any mutation by OLA when confirmed by NGS. Treatment failure, defined as plasma HIV RNA 400 copies/mL at month-12 of ART, was compared by PDR genotypes. Findings: PDR was detected in 59/1231 (4¢8%) participants. Compared to wild-type genotypes, PDR in participants prescribed nevirapine-ART was associated with increased treatment failure [PDR 69¢2% (27/39) vs. wild-type 10¢4% (70/674); p = 0¢0001], whether detected as minority [66¢7% (4/6)] or higher [69¢7% (23/33)] frequencies in an individual's HIV quasispecies (p = 0¢002 and p < 0¢0001, respectively), or mutations at single [50¢0% (12/24)] or multiple [100¢0% (15/15)] codons (p < 0¢0001). During efavirenz-ART, PDR was also associated with increased virologic failure [PDR 25¢0% (5/20) vs. wild-type 5¢0% (25/498); p = 0¢005], but only if detected at multiple drugresistant codons [50¢0% (3/6); p = 0¢003] or high frequencies PDR [33¢3% (5/15); p = 0¢001]. Interpretation: The risk that PDR confers for treatment failure varies by number of mutant codons and their frequency in the quasispecies, with a lower risk for efavirenz-compared to nevirapine-based regimens. PDR detection and management could extend the effective use of efavirenz-ART in low-resource settings.
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