ART resistance increasing in sub-Saharan Africa

By MedWire Reporters

The prevalence of antiretroviral drug resistance is on the rise in sub-Saharan Africa, an increase driven by resistance to non-nucleoside reverse transcriptase inhibitors (NNRTI) in east and southern Africa, research shows.

"The findings are of concern and draw attention to the need for enhanced surveillance and drug-resistance prevention efforts by national HIV programmes," write Silvia Bertagnolio (World Health Organization, Geneva, Switzerland) and colleagues in TheLancet.

At the end of 2011, more than 8 million people infected with HIV in low- and middle-income countries were treated with antiretroviral therapy (ART). The increased use of ART in resource-limited countries was in response to a World Health Organization (WHO)-recommended public health approach to treat the global HIV epidemic.

But one consequence of the widespread availability of ART is treatment failure, which can result in the spread of resistant strains of HIV and the need to start more expensive second-line treatments.

Using data from 162 individual reports spanning sub-Saharan Africa, Asia, and Latin America, Bertagnolio and colleagues assessed the prevalence of drug-resistant mutations in 26,102 treatment-naïve patients.

Since the WHO rollout in 2003, East Africa had the highest average increase in the prevalence of drug-resistant mutations, at 29% per year. At the time of the rollout, the prevalence of HIV drug resistance was 1.0% and this increased to 7.4% 8 years later.

The estimated annual rate of increase in the prevalence of any drug resistance in southern African was 14% and 3% in west and central Africa. In southern or west and central Africa, ART coverage did not appear to be associated with an increase in drug resistance.

With respect to specific drug classes, there was a significant 36% annual increase in NNRTI resistance since the ART rollout in east Africa and a 23% annual increase in southern Africa. In east Africa, the estimated prevalence of NNRTI resistance was 5.1% 8 years after the rollout.

"Although still within expected levels, further increases in the prevalence of HIV drug resistance might jeopardize the global HIV response," write Bertagnolio and colleagues. Further increases would halt the decade-long trend of decreasing HIV-related morbidity and mortality in low-income countries, they add.

In an editorial, Douglas Richman (University of California, San Diego, USA) points out that the cost and restricted use of second-line treatment regimens in resource-limited countries would diminish the ability to manage acquired and transmitted drug resistance.

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