Pretreatment HIV-1 drug resistance testing in sub-Saharan Africa
Authors: Lutgarde Lynen, Katrien Fransen, Johan Van Griensven, Robert Colebunders
Journal: The Lancet Infectious Diseases (2012)

We welcome the analysis of Raph Hamers and colleagues1Hamers RL Schuurman R Sigaloff KC et al.Effect of pretreatment HIV-1 drug resistance on immunological, virological, and drug-resistance outcomes of first-line antiretroviral treatment in sub-Saharan Africa: a multicentre cohort study.Lancet Infect Dis. 2012; 12: 307-317Summary Full Text Full Text PDF PubMed Scopus (159) Google Scholar on the effect of pretreatment HIV-1 drug resistance on first-line treatment outcomes, calling for investment in testing for pretreatment drug resistance in Africa. It is clear that the risk of pretreatment drug resistance will increase as the rollout of antiretroviral treatment continues in Africa.2Hamers RL Wallis CL Kityo C et al.HIV-1 drug resistance in antiretroviral-naive individuals in sub-Saharan Africa after rollout of antiretroviral therapy: a multicentre observational study.Lancet Infect Dis. 2011; 11: 750-759Summary Full Text Full Text PDF PubMed Scopus (247) Google Scholar However, because of cost, and scarcity of human resources and laboratory infrastructure, it will not be possible in the near future to routinely test for drug resistance in Africa before the start of first-line antiretroviral treatment. Andrew Kambugu in his Comment3Kambugu A Pre-ART HIV resistance testing in Africa: are we there yet?.Lancet Infect Dis. 2012; 12: 261Summary Full Text Full Text PDF PubMed Scopus (5) Google Scholar proposes a more pragmatic approach, in which patients with a history of previous exposure to antiretroviral treatment should be offered an alternative first-line regimen. However, in the study of Hamers and colleagues1Hamers RL Schuurman R Sigaloff KC et al.Effect of pretreatment HIV-1 drug resistance on immunological, virological, and drug-resistance outcomes of first-line antiretroviral treatment in sub-Saharan Africa: a multicentre cohort study.Lancet Infect Dis. 2012; 12: 307-317Summary Full Text Full Text PDF PubMed Scopus (159) Google Scholar only 15 (13%) of the 115 patients with previous exposure to antiretroviral treatment developed treatment failure at 12 months. Therefore, rather than giving a different antiretroviral treatment regimen, we propose that these patients should have a viral load test done 6 months after the start of treatment. The problem of monitoring patients on antiretroviral therapy needs to be solved before introducing large-scale testing for pretreatment drug resistance. The use of targeted viral load testing before switching to second-line antiretroviral treatment has major cost-saving potential by avoiding unnecessary switches.4Lynen L An S Koole O et al.An algorithm to optimize viral load testing in HIV-positive patients with suspected first-line antiretroviral therapy failure in Cambodia.J Acquir Immune Defic Syndr. 2009; 52: 40-48Crossref PubMed Scopus (46) Google Scholar The availability of a point-of-care viral load test is the priority in low-resource settings.5Calmy A Ford N Hirschel B et al.HIV viral load monitoring in resource-limited regions: optional or necessary?.Clin Infect Dis. 2007; 44: 128-134Crossref PubMed Scopus (210) Google Scholar Subsequently, such an approach could integrate the detection of key drug-resistant mutations. We declare that we have no conflicts of interest. Effect of pretreatment HIV-1 drug resistance on immunological, virological, and drug-resistance outcomes of first-line antiretroviral treatment in sub-Saharan Africa: a multicentre cohort studyAt least three fully active antiretroviral drugs are needed to ensure an optimum response to first-line regimens and to prevent acquisition of drug resistance. Improved access to alternative combinations of antiretroviral drugs in sub-Saharan Africa is warranted. Full-Text PDF Pre-ART HIV resistance testing in Africa: are we there yet?In The Lancet Infectious Diseases, Raph Hamers and colleagues1 report an increased likelihood of virological failure after the first year of standard first-line non-nucleoside transcriptase inhibitor-based antiretroviral therapy (ART) in patients who have a drug resistance mutation for at least one drug in the regimen. Moreover, they show that the risk of acquired HIV drug resistance is higher in people with pretreatment drug resistance than in those without. Although not entirely surprising, this study provides the first documentation of this finding in an African setting. Full-Text PDF Pretreatment HIV-1 drug resistance in AfricaWe recently showed that pretreatment antiretroviral resistance more than doubled the risk of virological failure and further acquisition of drug-resistance mutations in patients receiving standard first-line antiretroviral therapy (ART) from a large sub-Saharan African cohort of people infected with HIV.1 Debate about what the public health response should be to high levels of pretreatment resistance in any given setting is ongoing, and a level at which a policy change would be appropriate has not yet been defined. Full-Text PDF