Advancing HIV Drug Resistance Technologies and Strategies: Insights from South Africa’s Experience and Future Directions for Resource-Limited Settings

Abstract

Monitoring of HIV drug resistance (HIVDR) remains critical for ensuring countries attain and sustain the global goals for ending HIV as a public health threat by 2030. On an individual patient level, drug resistance results assist in ensuring unnecessary treatment switches are avoided and subsequent regimens are tailored on a case-by-case basis, should resistance be detected. Although there is a disparity in access to HIVDR testing in high-income countries compared to low- and middle-income countries (LMICS), more LMICs have now included HIVDR testing for individual patient management in some groups of patients. In this review, we describe different strategies for surveillance as well as where HIVDR testing can be implemented for individual patient management. In addition, we briefly review available technologies for HIVDR testing in LMICs, including Sanger sequencing, next-generation sequencing, and some point-of-care options. Finally, we describe how South Africa has implemented HIVDR testing in the public sector.

Strengthening and enhancing national antiretroviral drug resistance surveillance in Zimbabwe—A country that has reached UNAIDS 95-95-95 amongst adults

“…When the anchor drugs are susceptible, HIVDR surveillance for individual patient monitoring may reduce the number of unnecessary therapy switches. It should be highlighted that the implementation of HIVDR surveillance at the patient level in LMICs like Zimbabwe only adds value when viral load testing is available on a large scale, resources, and laboratory capacity are available, and the country has access to clinical experts and virologists who can interpret the resistance results ( 20 ). When routine HIVDR is not possible because of several factors, including technological and financial limitations, as is the case in Zimbabwe, it is especially recommended that regular HIVDR surveys be conducted.…”

“…There will be certain patient groups that require monitoring in these circumstances. Such groups include adults initiating or re-initiating first-line ART, infants newly diagnosed with HIV, anyone with virological failure, and HIV-diagnosed PrEP recipients ( 20 ). It is also important to note that, without surveillance, patients may be maintained on failing regimes, which leads to the accumulation of resistance mutations that jeopardize the effectiveness of ensuing regimens ( 8 ).…”

“…The best salvage therapy can be informed by genotypic resistance testing ( 20 ). Genotypic resistance testing helps in predicting antiretroviral drug susceptibility and subsequent effective treatment for patients in the future ( 27 ).…”

“…With DTG being given as the first-line ART, there are limited ART options for third-line regimens in LMICs such as Zimbabwe. HIVDR testing and surveillance are necessary for patients who are not responding to protease inhibitor-based ART ( 20 ). In addition to benefiting patients, HIVDR surveillance offers vital data that are needed to evaluate how well ART programs are doing at achieving viral suppression targets ( 20 ).…”

“…Multiple factors contribute to HIVDR emergence, including viral, drug-related, programmatic, and patient-related factors. Increased pretreatment HIVDR prevalence is linked to ART failure, potentially leading to further resistance ( 19 , 20 ). Previous Zimbabwe studies show high pretreatment and acquired HIVDR against non-nucleoside reverse transcriptase inhibitors.…”