WHO report 2019: HIV drug resistance reached alarming levels

  • Daniela Ovadia — Agenzia Zoe
  • Medical News
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Key messages

  • In 12 countries (in Africa, Asia and the Americas), HIV drug resistance (HIVDR) - and especially pre-treatment HIV drug resistance (PDR) - to efavirenz and nevirapine among adults initiating first-line ART reached levels above 10%, and women are the most affected.
  • Over half of the HIV infected children (≤18 months) in 9 countries in sub-Saharan Africa carry drug-resistant virus.
  • WHO recommends a rapid adoption of dolutegravir-based first-line regimens, in order to avert the negative effects of resistance to non-nucleoside reverse-transcriptase inhibitors (NNRTIs).


A new report of WHO shows an alarming global increase of HIV drug resistance (HIVDR), commonly classified into 3 main categories: acquired HIV drug resistance, transmitted HIV drug resistance and pre-treatment HIV drug resistance (PDR).

WHO presents findings from 44 nationally representative surveys of HIVDR, implemented in 24 low- and middle-income countries (surveys have been conducted in 49 countries, between 2004 and 2018, and planned in further 35).

Surveys of PDR, detected among antiretroviral drug-naïve people initiating antiretroviral therapy (ART) or people with previous antiretroviral drug exposure initiating or reinitiating first-line ART, have been completed by 18 countries (2014-2018). In 12 (Argentina, Eswatini, Cuba, Guatemala, Honduras, Namibia, Nepal, Nicaragua, Papua New Guinea, South Africa, Uganda and Zimbabwe) the PDR to efavirenz and/or nevirapine among adults initiating first-line ART exceeds 10%.

The prevalence of NNRTIs PDR is nearly twice as high among women than men (11.8% [95% CI 9.4-14.8] versus 7.8% [6.3-9.5], P=0.005) and nearly three times higher among people reinitiating first-line ART, than among antiretroviral drug-naive people (21.1% [95% CI 15.0-28.9) versus 7.8 [6.3-9.6], P≤0.0001). The prevalence of PDR to nucleoside reverse-transcriptase inhibitors (NRTIs) is low (tenofovir 0%-4.5%; emtricitabine or lamivudine 0%-5.7%).

Results of PDR surveys among children younger than 18 months in 9 countries in sub-Saharan Africa (2012-2018) indicate that over half of the infants carry drug-resistant HIV before initiating treatment. Indeed, the prevalence of PDR to efavirenz and nevirapine ranges from 34% (95% CI 27-41%) in Eswatini to 69% (95% CI 62-75%) in Malawi. Further, PDR to NRTIs (abacavir or lamivudine) also exceeds 10% in some countries.

Women comprise a larger proportion of the population living with HIV at the global level (especially in sub-Saharan Africa) and the proportion of people reinitiating ART vary between countries and is increasing. Results highlight the importance of adopting dolutegravir-based first-line regimens, as recommended by WHO, and suggest the need for routinely monitoring resistance in children when NRTIs is given in combination with drugs that have a low genetic barrier for resistance.

Finally, WHO recommends monitoring and responding to gaps in quality indicators at the clinic or programme level which are associated with the emergence of HIVDR. These are higher among individuals with viral non-suppression.


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