HIV-1 drug resistance in antiretroviral-naive patients in sub-Saharan Africa

We read with interest the Correspondence by Anthony Amoroso and colleagues on high HIV-1 drug resistance in Uganda. We recognise their alternative interpretation of our study fi ndings, that besides long community exposure to antiretroviral drugs, poor adherence rates, sub optimum patient retention in care, treatment interruptions, and resultant poor viral suppression outcomes during the antiretroviral therapy scale-up could have exacerbated the development of drug resistance at the community level. However, reports published in the past year show that this reality is not restricted to Fort Portal or to Uganda alone, but aff ects many antiretroviral therapy programmes in the region. Substantial gaps in service delivery and performance have been reported in various antiretroviral therapy programmes in sub-Saharan Africa, particularly with respect to the fragility of drug-supply systems and inadequate retention of patients. Combined WHO data from 907 antiretroviral therapy programmes in the region between 2004 and 2009 suggested that 40% of sites ha d drug stock-outs, 40% lost more than 20% of patients to follow-up, and 74% prescribed antiretroviral therapy congruent with national guidelines to all of their patients. Additionally, a 2012 global metaanalysis on HIV-1 drug resistance in untreated patients, including 26 102 individuals in 42 countries, estimated a rise in transmitted drug resistance in east Africa (29% per year) and southern Africa (14% per year) since roll-out. Moreover, WHO surveys of recently infected populations showed moderate (5–15%) levels of transmitted resistance in Ouagadougou, Burkina Faso, KwaZulu-Natal, South Africa, Kampala, Uganda, and Mombasa, Kenya. This increase is mainly driven by resistance to non-nucleoside reverse transcriptase inhibitors, which is concerning because this drug class is the cornerstone of fi rst-line regimens. Data suggest a rise in the transmission of drug-resistant HIV-1 after roll-out of antiretroviral therapy across Africa, not just in Uganda. Therefore, high HIV drug resistance in Uganda—where ART was introduced before nearby countries—should serve as a warning to other countries. We support the conclusion by Amoroso and colleagues that further scale-up of national HIV-treatment programmes should be accompanied by improved antiretroviral therapy programme functioning and sustainability to preserve the long-term eff ectiveness of antiretroviral therapy regimens, including un inter rupted drug supply, access to routine viral load monitoring, and strategies to optimise patient adherence and retention. Evaluation of population-based drug resistance should be routinely integrated into national HIV programmes.