HIV Drug Resistance — An Emerging Threat to Epidemic Control

New England Journal of Medicine
October 26, 2017  Vol. 377 No. 17
http://www.nejm.org/toc/nejm/medical-journal

HIV Drug Resistance — An Emerging Threat to Epidemic Control
Beyrer and A. Poznia
… A recent report from the WHO, the Global Fund to Fight AIDS, Tuberculosis, and Malaria, and the Centers for Disease Control and Prevention (CDC) showed that the prevalence of HIV drug resistance has increased from 11% to 29% since the global rollout of ART in 2001.1 The report was based on findings from 16 surveys in 14 countries that used the WHO’s recommended approach to population-based sampling for HIV drug resistance among patients in public ART programs, supplemented by data from two population-based HIV impact assessments conducted through the President’s Emergency Plan for AIDS Relief (PEPFAR) in Malawi and Zimbabwe.
It is worrisome that in 6 of 11 countries surveyed — Argentina, Guatemala, Namibia, Nicaragua, Uganda, and Zimbabwe — the rate of pretreatment drug resistance surpassed 10% among people receiving ART for the first time (see graph– Pretreatment HIV Drug Resistance to Nonnucleoside Reverse Transcriptase Inhibitors in 11 Countries.). Here HIV drug resistance was defined as resistance to nonnucleoside reverse transcriptase inhibitors (NNRTIs), core drugs in most low- and middle-income countries’ first-line regimens for HIV. Among people with past exposure to ART (those restarting treatment or women with past perinatal exposure) the rate of NNRTI resistance is even higher: 21.6% (95% confidence interval [CI], 13.8 to 32.2).1 A recent report from South Africa revealed that among children 18 months old or younger identified through early infant diagnoses, NNRTI resistance was found in 63.7% (95% CI, 59.0 to 68.4).1
How significant is the increase in resistance to HIV treatment? And what can be done to mitigate it?