Abstract:Introduction
HIV-1 transmitted drug resistance (TDR) in treatment-naïve individuals is a well-described phenomenon. Baseline genotypic resistance testing is considered standard of care in most developed areas of the world.
Methods
In the Strategic Timing of AntiRetroviral Treatment (START) trial, baseline genotypic resistance testing results were collected at study entry and analysed centrally to determine the prevalence of TDR in the study population. Resistance was based on a modified 2009 World Health Org… Show more
“…120–122 Nonnucleoside reverse transcriptase inhibitor mutations are the most common transmitted resistance mutations (4.5%-10%); NRTI (4.0%-4.5%) and PI mutations are less common (2.8%-3.4%). 107,123 Virologic failure with an InSTI-containing regimen requires integrase resistance testing, as integrase resistance has been described in up to 6.8% of patients. 124 Resistance testing is less reliable if a patient has stopped ART for longer than 1 month when the sample is collected.…”
“…120–122 Nonnucleoside reverse transcriptase inhibitor mutations are the most common transmitted resistance mutations (4.5%-10%); NRTI (4.0%-4.5%) and PI mutations are less common (2.8%-3.4%). 107,123 Virologic failure with an InSTI-containing regimen requires integrase resistance testing, as integrase resistance has been described in up to 6.8% of patients. 124 Resistance testing is less reliable if a patient has stopped ART for longer than 1 month when the sample is collected.…”
“…This has not been seen at scale, despite over a decade of non-nucleoside reverse transcriptase inhibitor (NNRTI)-based regimens, which have a very low resistance barrier, being used in developing countries. Resistance occurs, and can have severe consequences for individuals, but is not yet a major public health issue, and transmitted resistance appears relatively unusual [24,25]. In South Africa, where viral load monitoring has been done since inception of the programme, and where over 3 million people (20% of the world total) are on ART (almost all on), only 200 000 are on second line, and just over 300 on third line, with surveillance programmes suggesting community resistance remains unusual, especially resistance to the drugs used for PrEP [26].…”
This article discusses the intersection of the two interventions, some programmatic misconceptions and complexities, and argues that PrEP is a nuanced and useful adjunct to HIV programmes. PrEP can be rolled out in a way that complements treatment, possibly even within primary health clinics, and may be required for the many people in whom TaP currently fails. PrEP will need constant adaptation so as to maintain programmatic and cost-effectiveness, as the epidemiology of HIV changes with TaP rollout and expansion as CD4 restrictions are lifted. Finally, the article also argues that so-called ethical concerns around competing resources are relatively easily resolved.
“…Use of standard packages to optimize differentiated care must be field-tested for feasibility and impact on the achievement of TfA. Successful implementation of these packages will also be dependent on 1) the placement of policies that enable task shifting; 2) the development of metrics that reflect progress towards the 90Á90Á90 and assess the impact of the differentiated package of care; 3) the existence of sufficient programmatic infrastructure, including procurement and supply chains; and 4) support of sentinel sites to monitor transmitted and acquired drug resistance and to inform future first-line ART [34] Á especially in light of growing nonnucleoside reverse-transcriptase inhibitors [35] resistance and higher-than-expected tenofovir disoproxil fumarate [36] resistance.…”
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