Key Factors Influencing the Emergence of Human Immunodeficiency Virus Drug Resistance in Low- and Middle-Income Countries

Wallis, Carole L.; Godfrey, Catherine; Fitzgibbon, Joseph E.; Mellors, John W.

doi:10.1093/infdis/jix409

Cited by 25 publications

(21 citation statements)

References 59 publications

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“…KEYWORDS HIV, SIV, animal models, dolutegravir, resistance D espite the increasing arsenal of potent antiretroviral drugs (ARV) and combinations to combat human immunodeficiency virus (HIV) infection, the emergence of viral mutants with reduced susceptibility (drug resistance) remains a major concern. This is especially the case for middle-and low-income countries, where factors such as late presentation, an inconsistent supply chain, poor adherence, suboptimal drug regimens, and a lack of routine viral load monitoring contribute to ongoing virus replication, which promotes the emergence and persistence of such drug-resistant mutants (1).…”

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confidence: 99%

Dolutegravir Monotherapy of Simian Immunodeficiency Virus-Infected Macaques Selects for Several Patterns of Resistance Mutations with Variable Virological Outcomes

Rompay

Hassounah

Keele

et al. 2019

J Virol

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Drug resistance remains a major concern for human immunodeficiency virus (HIV) treatment. To date, very few resistance mutations have emerged in first-line combination therapy that includes the integrase strand transfer inhibitor (INSTI) dolutegravir (DTG). In vitro, DTG selects for several primary mutations that induce low-level DTG resistance; secondary mutations, while increasing the level of resistance, however, further impair replication fitness, which raised the idea that DTG monotherapy may be feasible. The simian immunodeficiency virus (SIV) rhesus macaque model of HIV infection can be useful to explore this concept. Nine macaques were infected with virulent SIVmac251 and started on DTG monotherapy during either acute (n = 2) or chronic infection (n = 7). Within 4 weeks of treatment, all animals demonstrated a reduction in viremia of 0.8 to 3.5 log RNA copies/ml plasma. Continued treatment led to overall sustained benefits, but the outcome after 10 to 50 weeks of treatment was highly variable and ranged from viral rebound to near pretreatment levels to sustained suppression, with viremia being 0.5 to 5 logs lower than expected based on pretreatment viremia. A variety of mutations previously described to confer low-level resistance of HIV-1 to DTG or other INSTI were detected, and these were sometimes followed by mutations believed to be compensatory. Some mutations, such as G118R, previously shown to severely impair the replication capacity in vitro, were associated with more sustained virological and immunological benefits of continued DTG therapy, while other mutations, such as E92Q and G140A/Q148K, were associated with more variable outcomes. The observed variability of the outcomes in macaques warrants avoidance of DTG monotherapy in HIV-infected people. IMPORTANCE A growing number of anti-HIV drug combinations are effective in suppressing virus replication in HIV-infected persons. However, to reduce their cost and risk for toxicity, there is considerable interest in simplifying drug regimens. A major concern with single-drug regimens is the emergence of drug-resistant viral mutants. It has been speculated that DTG monotherapy may be a feasible option, because DTG may have a higher genetic barrier for the development of drug resistance than other commonly used antiretrovirals. To explore treatment initiation with DTG monotherapy, we started SIV-infected macaques on DTG during either acute or chronic infection. Although DTG initially reduced virus replication, continued treatment led to the emergence of a variety of viral mutations previously described to confer low-level resistance of HIV-1 to DTG, and this was associated with variable clinical outcomes. This unpredictability of mutational pathways and outcomes warns against using DTG monotherapy as initial treatment for HIV-infected people.

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confidence: 99%

Dolutegravir Monotherapy of Simian Immunodeficiency Virus-Infected Macaques Selects for Several Patterns of Resistance Mutations with Variable Virological Outcomes

Rompay

Hassounah

Keele

et al. 2019

J Virol

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“…In contrast, other studies have found no association with treatment outcomes when low-frequency resistance mutations are detected that confer resistance to an ARV drug used in the regimen (12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25)(26)(27)(28)(29). These conflicting results make interpretation of resistance results from newer, more sensitive resistance assays difficult (30).…”

Section: Introductionmentioning

confidence: 93%

Linked dual-class HIV resistance mutations are associated with treatment failure

et al. 2019

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“…Drug resistance is when the response to a drug in a susceptible parasite population decreases significantly [46]. According to studies by the WHO, it was found that in 2010 the prevalence of HIV drug resistance for patients starting treatment was 6.8% for any drug, and that the treatment of these patients was more likely to fail [47], [48]. Drug resistance leads to further challenges relating not only to the patient's own future treatment, but also to the whole community [25].…”

Section: Drug Resistancementioning

confidence: 99%

Developing a Challenges Landscape Relating to Drug Safety, Provision, and Distribution in Resource-Limited Settings for the Case of Hiv/Aids

Huysamen

Kock

Bam

2018

SAJIE

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Key Factors Influencing the Emergence of Human Immunodeficiency Virus Drug Resistance in Low- and Middle-Income Countries

Cited by 25 publications

References 59 publications

Dolutegravir Monotherapy of Simian Immunodeficiency Virus-Infected Macaques Selects for Several Patterns of Resistance Mutations with Variable Virological Outcomes

Dolutegravir Monotherapy of Simian Immunodeficiency Virus-Infected Macaques Selects for Several Patterns of Resistance Mutations with Variable Virological Outcomes

Linked dual-class HIV resistance mutations are associated with treatment failure

Developing a Challenges Landscape Relating to Drug Safety, Provision, and Distribution in Resource-Limited Settings for the Case of Hiv/Aids

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