Pretreatment HIV drug resistance increases regimen switches in sub-Saharan Africa

T. Sonia Boender, Bernice M. Hoenderboom, Kim C. E. Sigaloff, Raph L. Hamers, Maureen Wellington, Tinei Shamu, Margaret Siwale, Eman E. F. Labib Maksimos, Immaculate Nankya, Cissy M. Kityo, Titilope A. Adeyemo, Alani Sulaimon Akanmu, Kishor Mandaliya, Mariette E. Botes, Pascale Ondoa, Tobias F. Rinke de Wit

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After the scale-up of antiretroviral therapy (ART) for human immunodeficiency virus (HIV) infection in Africa, increasing numbers of patients have pretreatment drug resistance. In a large multicountry cohort of patients starting standard first-line ART in six African countries, pol genotyping was retrospectively performed if viral load (VL) ≥1000 cps/mL. Pretreatment drug resistance was defined as a decreased susceptibility to ≥1 prescribed drug. We assessed the effect of pretreatment drug resistance on all-cause mortality, new AIDS events and switch to second-line ART due to presumed treatment failure, using Cox models. Among 2579 participants for whom a pretreatment genotype was available, 5.5% had pretreatment drug resistance. Pretreatment drug resistance was associated with an increased risk of regimen switch (adjusted hazard ratio [aHR] 3.80; 95% confidence interval [CI], 1.49-9.68; P = .005) but was not associated with mortality (aHR 0.75, 95% CI, .24-2.35; P = .617) or new AIDS events (aHR 1.06, 95% CI, .68-1.64; P = .807). During three years of follow up, 106 (4.1%) participants switched to second-line, of whom 18 (17.0%) switched with VL < 1000 cps/mL, 7 (6.6%) with VL ≥ 1000 cps/mL and no drug resistance mutations (DRMs), 46 (43.4%) with VL ≥ 1000 cps/mL and ≥1 DRMs; no HIV RNA data was available for 32 (30.2%) participants. Given rising pretreatment HIV drug resistance levels in sub-Saharan Africa, these findings underscore the need for expanded access to second-line ART. VL monitoring can improve the accuracy of failure detection and efficiency of switching practices
Original languageEnglish
Pages (from-to)1749-1758
Number of pages10
JournalClinical Infectious Diseases
Issue number11
Publication statusPublished - 1 Dec 2015


  • HIV-1 drug resistance
  • antiretroviral therapy
  • mortality
  • regimen switch
  • sub-Saharan Africa

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