Antiretroviral (ARV) drug resistance in the developing world.
ABSTRACT To describe the overall prevalence of ARV resistance in the developing world, focusing on: (1) treatment naïve populations, (2) the resistance consequences of prevention of mother to child transmission (pMTCT) drug regimens, and (3) the relationship of medication adherence to resistance.
We searched PubMed(R), EMBASE, the Cochrane Controlled Clinical Trials Register Database, and the Cochrane Database of Reviews of Effectiveness (DARE). Additional sources of evidence included the Stanford University HIV Drug Resistance Database; reports of WATCH: Worldwide Analysis of Resistance Transmission over Time of Chronically and Acute Infected HIV-1 infected persons; a recent unpublished pMTCT overview; and various conference proceedings. Studies that did not report original research, that reported data already reported in another article, and case studies of fewer than 20 individuals were excluded. Of 1,122 titles identified, 117 journal articles and presentations were included.
We abstracted data on geographic region, number of participants, subject demographics, HIV viral clade, medications taken (if any), years of data collection, how people were selected for resistance testing, and how and when resistance was assessed. Because of study heterogeneity, pooling was not possible; thus, the data are summarized qualitatively. Differences by region, population group, and HIV viral clade are described.
The patterns of ARV resistance among treatment naïve populations worldwide appear to reflect geographic trends in use of ARV medications. A worldwide surveillance program (WATCH) found the rate of resistance (to any drug) among treatment naïve individuals was 5.5 percent in Africa, 7.4 percent in East Asia, 5.7 percent in Southeast Asia, and 6.4 percent in Latin America, lower than in North America (11.4 percent) and Europe (10.6 percent). Resistance data on HIV clades other than A, B, C, and D were too scarce to permit reliable conclusions. We also identified very few studies designed to assess the effect of health services delivery factors or medication adherence on the development of resistance in patients in developing countries. Evidence provided by longitudinal analyses suggests that, among women taking intrapartum single dose nevirapine (SD-NVP) to prevent mother-to-child transmission of HIV, both the overall prevalence of NNRTI resistance as well as the frequency of mutant virus in the overall viral population decreases with time since SD-NVP prophylaxis was received.
In future resistance studies, rare HIV clades should be over-sampled in order to provide statistically meaningful data. Resistance surveillance programs should be maintained throughout the developing world, and data should be reported and analyzed in a consistent and timely manner. Where resources permit, studies of adherence in developing regions should conduct resistance testing.
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ABSTRACT: A national ART program was launched in Tanzania in October 2004. Due to the existence of multiple HIV-1 subtypes and recombinant viruses co-circulating in Tanzania, it is important to monitor rates of drug resistance. The present study determined the prevalence of HIV-1 drug resistance mutations among ART-naive female bar and hotel workers, a high-risk population for HIV-1 infection in Moshi, Tanzania. A partial HIV-1 pol gene was analyzed by single-genome amplification and sequencing in 45 subjects (622 pol sequences total; median number of sequences per subject, 13; IQR 5-20) in samples collected in 2005. The prevalence of HIV-1 subtypes A1, C, and D, and inter-subtype recombinant viruses, was 36%, 29%, 9% and 27%, respectively. Thirteen different recombination patterns included D/A1/D, C/A1, A1/C/A1, A1/U/A1, C/U/A1, C/A1, U/D/U, D/A1/D, A1/C, A1/C, A2/C/A2, CRF10_CD/C/CRF10_CD and CRF35_AD/A1/CRF35_AD. CRF35_AD was identified in Tanzania for the first time. All recombinant viruses in this study were unique, suggesting ongoing recombination processes among circulating HIV-1 variants. The prevalence of multiple infections in this population was 16% (n = 7). Primary HIV-1 drug resistance mutations to RT inhibitors were identified in three (7%) subjects (K65R plus Y181C; N60D; and V106M). In some subjects, polymorphisms were observed at the RT positions 41, 69, 75, 98, 101, 179, 190, and 215. Secondary mutations associated with NNRTIs were observed at the RT positions 90 (7%) and 138 (6%). In the protease gene, three subjects (7%) had M46I/L mutations. All subjects in this study had HIV-1 subtype-specific natural polymorphisms at positions 36, 69, 89 and 93 that are associated with drug resistance in HIV-1 subtype B. These results suggested that HIV-1 drug resistance mutations and natural polymorphisms existed in this population before the initiation of the national ART program. With increasing use of ARV, these results highlight the importance of drug resistance monitoring in Tanzania.PLoS ONE 01/2014; 9(7):e102258. · 3.53 Impact Factor
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ABSTRACT: To assess the impact of long-term combined antiretroviral therapy (cART) on HIV-RNA and HIV-DNA levels in cervicovaginal secretions of HIV-1-infected women with sustained undetectable plasma RNA viral load (PVL); to explore factors predictive of residual viral shedding; and to evaluate the risk of heterosexual transmission. Women with undetectable PVL (<50 copies/mL) for >6 months were included in this cross-sectional study. HIV-RNA and HIV-DNA were measured in blood and cervicovaginal lavage fluid (CVL). Women were systematically tested for genital infections. The risk of transmission to male partners during unprotected intercourse was estimated. Eighty-one women composed the study population: all had HIV-RNA <40 copies/mL in CVL. HIV-DNA was detectable in CVL of 29/78 patients (37%). There was a weak positive correlation between HIV-DNA levels in PBMCs and CVL (r = 0.20; p = 0.08). In multivariate analysis, two factors were associated with HIV-DNA detection in CVL: previous AIDS-defining illnesses (OR = 11; 95%CI = 2-61) and current residual viremia (20<PVL<50 cp/mL) (OR = 3.4; 95%CI = 1.1-10.9). Neither the classes of cART regimen nor the presence of genital bacterial or fungal colonization were associated with HIV-DNA detection in CVL. Twenty-eight percent of the women had unprotected intercourse with their regular HIV-seronegative male partner, for between 8 and 158 months. None of their male partners became infected, after a total of 14 000 exposures. In our experience, HIV-RNA was undetectable in the genital tract of women with sustained control of PVL on cART. HIV-DNA shedding persisted in about one third of cases, with no substantial evidence of residual infectiousness.PLoS ONE 01/2013; 8(8):e69686. · 3.53 Impact Factor
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ABSTRACT: We present a new approach for pathogen surveillance we call Geogenomics. Geogenomics examines the geographic distribution of the genomes of pathogens, with a particular emphasis on those mutations that give rise to drug resistance. We engineered a new web system called Geogenomic Mutational Atlas of Pathogens (GoMAP) that enables investigation of the global distribution of individual drug resistance mutations. As a test case we examined mutations associated with HIV resistance to FDA-approved antiretroviral drugs. GoMAP-HIV makes use of existing public drug resistance and HIV protein sequence data to examine the distribution of 872 drug resistance mutations in ∼502,000 sequences for many countries in the world. We also implemented a broadened classification scheme for HIV drug resistance mutations. Several patterns for geographic distributions of resistance mutations were identified by visual mining using this web tool. GoMAP-HIV is an open access web application available at http://www.bio-toolkit.com/GoMap/project/PLoS ONE 01/2014; 9(3):e92877. · 3.53 Impact Factor