Overview HIV
Antiretroviral therapy (ART), which has helped tens of millions of individuals living with HIV/AIDS, has seen an unparalleled rise in use over the past ten years. Out of an estimated 37.7 million persons living with HIV, 27.5 million were receiving ART globally as of the end of 2020.
The evolution of HIV treatment resistance, whose levels have gradually risen in recent years, has coincided with growing usage of HIV medications.
HIV genetic mutations that affect a treatment's capacity to stop the virus from replicating are what lead to HIV drug resistance. Due to the advent of drug-resistant viruses, all antiretroviral medications, even those from more recent pharmacological classes, run the danger of going partially or completely inactive. HIV drug resistance puts the effectiveness of HIV medications in jeopardy if it is not prevented, leading to a rise in HIV infections and HIV-related morbidity and mortality.
Size of the issue
HIV medication resistance monitoring gives nations data they can utilize to improve patient and population-level treatment outcomes. WHO recommends that nations regularly carry out surveys on HIV drug resistance in various populations, including adults, kids, and teenagers.
The implementation of nationally representative surveys in low- and middle-income countries, as well as the formulation of national action plans to prevent, monitor, and address HIV drug resistance, have advanced significantly, according to the WHO's Report on HIV Drug Resistance 2021. As of 2021, national action plans had been created in 64% of the nations with a high prevalence of HIV. 34 nations intend to carry out HIV drug resistance surveys during the next two years. Between 2004 and 2021, 66 countries implemented surveys of HIV drug resistance using WHO-recommended standard procedures.
HIV medication resistance during pretreatment
Some individuals already exhibit drug resistance before starting treatment. This resistance may be developed during prior treatments or transmitted at the time of infection, as in the case of women who use antiretroviral medication to stop HIV from being passed from mother to child.
In order to make the best choice of first-line regimens, WHO advises monitoring HIV medication resistance in adults starting or restarting ART as well as in treatment-naive newborns starting ART.
When initiating HIV treatment, up to 10% of individuals may have medication resistance to the NNRTI drug class. People who have previously taken antiretroviral medications are up to three times more likely to develop pretreatment NNRTI resistance. Children under the age of 18 months who have just been diagnosed with HIV have a high prevalence of drug-resistant HIV. According to surveys done in ten sub-Saharan African nations between 2012 and 2020, over half of babies with newly discovered HIV already had NNRTI-resistant virus.
The urgency of accelerating the switch to the dolutegravir-based treatments advised by the WHO is highlighted by the global incidence of NNRTI resistance in both adults and newborns.
acquired medication resistance to HIV
The purpose of HIV treatment, viral load suppression, is to avoid the development of HIV medication resistance. HIV that has developed treatment resistance is less likely to spread when viral load reduction is attained and maintained. Adults using ART generally had high levels of viral load suppression in 14 nationally representative studies conducted between 2015 and 2020. For people taking first-line ART, the combined outcomes for viral load suppression in Africa were 94% (95% CI 92-96%), and for those receiving second-line ART, they were 84% (95% CI 79-88%). For individuals getting first-line ART in the Americas, the pooled results for viral load suppression were 81% (95% CI 75-87%) and for those receiving second-line ART, they were 70% (95% CI 67-72%).
Some HIV drug resistance is anticipated to develop despite therapy with powerful medications and even when adherence to treatment is encouraged. For the best choice and management of ART regimens, surveillance of acquired HIV drug resistance in people undergoing ART offers valuable information. Resistance to routinely used NNRTIs varied from 50% to 97% among populations that failed NNRTI-based ART.
The high rates of HIV medication resistance to NNRTIs among those who experience treatment failure highlight the need for expanded viral load testing, improved adherence counseling, and rapid therapy switching.
Fortunately, nations are implementing dolutegravir-containing regimens for both adults and children very quickly. It has been demonstrated that dolutegravir-based ART is associated with very high levels of viral load suppression and that patients who fail it do not develop as much acquired resistance. Global statistics on the establishment of HIV resistance to dolutegravir are currently scarce.
According to WHO, nations should regularly monitor the development of HIV medication resistance in adults, kids, and teenagers using ART using either a viral load laboratory-based method or an ART clinic-based method. Depending on the availability of deidentified demographic data and the extent of national viral load testing coverage, a particular strategy may be employed.
Pre-exposure medication for the prevention of HIV
Many people who are at high risk of being exposed to HIV take medications every day to lower their risk of contracting the illness. Oral pre-exposure prophylaxis (PrEP) is advised by the WHO as an alternative HIV preventive option.
People using PrEP are less likely to contract HIV, especially those who take their meds as prescribed. However, medication resistance frequently develops among those who contract HIV despite using PrEP. Due to overlapping antiretroviral medication resistance profiles used for both PrEP and treatment, this may result in fewer alternatives for HIV treatment.
WHO advises that countries carry out nationally representative surveys to track the levels of HIV drug resistance among those beginning treatment, those receiving treatment, and those using PrEP who contract HIV in order to monitor the ongoing efficacy of HIV medications used for both treatment and prevention.
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