HIV drug resistance – brief report 2024

Overview

This brief report summarizes recent information on HIV drug resistance (HIVDR) in the era of integrase-strand transfer inhibitors (INSTI) for HIV prevention and treatment. 

In this report, WHO documents high levels of HIV viral load suppression (>90%) in populations receiving dolutegravir (DTG)-containing antiretroviral therapy (ART). However, recent observational data reveal that HIVDR to DTG is emerging at levels exceeding those observed in clinical trials. Few countries have reported people not achieving viral suppression while receiving DTG-containing ART. However, amongst the surveys reported, levels of DTG resistance ranged from 3.9% to 8.6%, with levels as high as 19.6% observed among highly treatment-experienced people who transitioned to a DTG-containing ART while having high HIV viral loads.

Levels of observed DTG resistance in real world populations receiving ART appear to be higher than anticipated from clinical trials. WHO recommends that countries routinely implement standardised surveillance of HIVDR to follow the prevalence and patterns of resistance among people not achieving suppressed viral load. 

The use of long acting cabotegravir (CAB-LA) for pre-exposure prophylaxis (PrEP) greatly reduces the risk of acquiring HIV. However, INSTI resistance has been observed in some cases with recent CAB-LA exposure, and delayed detection and confirmation of HIV infection can increase the risk of selection of INSTI drug resistance–associated mutations. Despite the possible risk, the roll-out of CAB-LA for PrEP should not be hindered. Scale-up of PrEP should be accompanied by standardized surveillance of drug resistance among people testing positive for HIV while receiving PrEP.