HIV-1 drug resistance before initiation or re-initiation of first-line ART in eight regions of Mexico: a sub-nationally representative survey
Authors: Ávila-Ríos Santiago , García-Morales Claudia , Valenzuela-Lara Marisol , Chaillon Antoine , Tapia-Trejo Daniela , Pérez-García Marissa , López-Sánchez Dulce M , Maza-Sánchez Liliana , del Arenal-Sánchez Silvia J , Paz-Juárez Héctor E , Quiroz-Morales Verónica S , Mehta Sanjay R , Smith David M , León-Juárez Eddie A , Magis-Rodríguez Carlos , Reyes-Terán Gustavo ,   HIVDR MexNet Group, Gamboa-Marroquín Jorge A , Espinoza-Fernández Alan F , Lam-Enríquez Mario , Castillo-Soria Oscar A , Navarro-Álvarez Samuel , Varela-Lara Noemí , Ortiz-Batanero Rogelio , Flores-Gómez Andrés , Velasco-Robledo Luis , Alatorre-Manjarrez Arturo , Gutiérrez-Zúñiga Rita E , Peña-Gutiérrez Jesús , Rivera-Marroquín Alejandro , Robles Berenice , Gálvez-Martínez Maribel , Hernández-Gutiérrez Raúl , Solís-Grajales David , Mora-Castellanos María G , Vidal-López Manuel , González-Pacheco Maribel A , Salazar-Pérez Carmen , Padilla-Acosta Juan C A , González-Rodríguez Andrea , Badial-Hernández Florentino , Tecalero-Hernández José C , García-Martínez Patricia G , Cendejas-Hernández Arturo , Mosqueda-Gómez Juan L , Benítez-Carrasco José M , Sánchez Bello José L , Fierro-Teliz Benjamín , Arellano-Torreblanca Jazmín , Manríquez-Gómez Ramiro , Zaragoza-Zapata Elizabeth , Ruiz-Torrez Saúl O , González-Hernández Luz A , Soria-Rodríguez Raúl , Quintero-Pérez Nora P , Amaya-Tapia Gerardo , Arredondo-Fuentes Juana , Santiesteban-Garay Javier , Mendoza-García María S , Durán-Arias Gustavo , Rosas-Dossetti Margarita M , Chacón-Sánchez Juana C , Uribe-Iturbide Angélica , Castro-Melchor Pedro , Castillo-Reyna Luis G , Rivera-Abarca Lesvia M , de la Cruz-Castillo Jorge E , Papaqui-Limón Elizabeth , Velázquez-Esqueda María P , Domínguez-Sánchez Alexandra S , Magdaleno-Sandoval Zoila , Silva-Herrera Jorge , Esparza-Pérez Mario A , Muñoz-Doana Alejandro , Aldapa Gabriela , Arrollo-Romero Fernando , Salazar-Arriola Sergio A , Vásquez-Bañuelos Elva C , Hernández-Morales Mario J , Prado-Rosas Daniel , Santos-Villegas Mercedes , Sánchez-Hernández Esteban , Jiménez-Jiménez Adonay , Cárdenas-Anzures Alejandro , Ortiz-Brisuela Juan F , Díaz-García Juana , Carrillo-Garza Carlos A , Beltrán-Saldaña Juan , Sánchez-Rivas Santos , Domínguez-Ramírez Lizbeth , de la Roca-Chiapas Jorge M , Basilio-Badillo Hilda , Torruco-García Uri , Pérez-Alonso Juan A , Arias-Tlacuilo Luis E , Palacios-Lara Omar 
Published: November 2018

Abstract

Background
HIV pretreatment drug resistance (PDR) to NNRTIs in persons initiating ART is increasing in Mexico.

Objectives
To compare HIV PDR in eight sub-regions of Mexico.

Patients and methods
A large PDR survey was implemented in Mexico (September 2017–March 2018) across eight sub-regions. All larger clinics (which provide ART to 90% of all initiators) were included, allocating sample size using the probability-proportional-to-size method. Both antiretroviral-naive and prior antiretroviral-exposed persons were included. HIV PDR levels were estimated from pol Sanger sequences obtained at a WHO-designated laboratory.

Results
A total of 2006 participants were enrolled from 74 clinics. PDR to NNRTIs was higher than to other drug classes (P &lt; 0.0001), crossing the 10% threshold in the North-East, East, South-West and South-East. NNRTI PDR was higher in the South-West (P = 0.02), coinciding with the highest proportion of restarters in this sub-region (14%). We observed higher PDR prevalence to any drug in women compared with men (16.5% versus 12.2%, P = 0.04). After multivariable adjustment, higher NNRTI PDR remained significantly associated with previous antiretroviral exposure in the Centre-North, North-West, South-West and South-East [adjusted OR (aOR): 21, 5, 8 and 25, respectively; P &lt; 0.05]. Genetic network analyses showed high assortativity by sub-region (P &lt; 0.0001), with evidence of drug resistance mutation transmission within local clusters.

Conclusions
Diversification of the public health response to HIV drug resistance based on sub-regional characteristics could be considered in Mexico. Higher NNRTI PDR levels were associated with poorer regions, suggesting opportunities to strengthen local HIV programmes. Price and licensing negotiations of drug regimens containing integrase inhibitors are warranted.