• Mark J Siedner, MoosaMahomed-Yunus SMS0000-0001-6191-4023University of KwaZulu-Natal, Durban, South Africa (M.S.M., S.P., J.B., G.G., H.S.)., Suzanne McCluskey, Rebecca F Gilbert, Selvan Pillay, Isaac Aturinda, Kevin Ard, Winnie Muyindike, Nicholas Musinguzi, Godfrey Masette, Melendhran Pillay, Pravikrishnen Moodley, Jaysingh Brijkumar, Tamlyn Rautenberg, Gavin George, Rajesh T Gandhi, Brent A Johnson, Henry Sunpath, Mwebesa B Bwana, and Vincent C Marconi.
• Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, Mbarara University of Science and Technology, Mbarara, Uganda, Africa Health Research Institute, KwaZulu-Natal, South Africa, and University of KwaZulu-Natal, Durban, South Africa (M.J.S.).
• Ann. Intern. Med. 2021 Dec 1; 174 (12): 168316921683-1692.

BackgroundVirologic failure in HIV predicts the development of drug resistance and mortality. Genotypic resistance testing (GRT), which is the standard of care after virologic failure in high-income settings, is rarely implemented in sub-Saharan Africa.ObjectiveTo estimate the effectiveness of GRT for improving virologic suppression rates among people with HIV in sub-Saharan Africa for whom first-line therapy fails.DesignPragmatic, unblinded, randomized controlled trial. (ClinicalTrials.gov: NCT02787499).SettingAmbulatory HIV clinics in the public sector in Uganda and South Africa.PatientsAdults receiving first-line antiretroviral therapy with a recent HIV RNA viral load of 1000 copies/mL or higher.InterventionParticipants were randomly assigned to receive standard of care (SOC), including adherence counseling sessions and repeated viral load testing, or immediate GRT.MeasurementsThe primary outcome of interest was achievement of an HIV RNA viral load below 200 copies/mL 9 months after enrollment.ResultsThe trial enrolled 840 persons, divided equally between countries. Approximately half (51%) were women. Most (72%) were receiving a regimen of tenofovir, emtricitabine, and efavirenz at enrollment. The rate of virologic suppression did not differ 9 months after enrollment between the GRT group (63% [263 of 417]) and SOC group (61% [256 of 423]; odds ratio [OR], 1.11 [95% CI, 0.83 to 1.49]; P = 0.46). Among participants with persistent failure (HIV RNA viral load ≥1000 copies/mL) at 9 months, the prevalence of drug resistance was higher in the SOC group (76% [78 of 103] vs. 59% [48 of 82]; OR, 2.30 [CI, 1.22 to 4.35]; P = 0.014). Other secondary outcomes, including 9-month survival and retention in care, were similar between groups.LimitationParticipants were receiving nonnucleoside reverse transcriptase inhibitor-based therapy at enrollment, limiting the generalizability of the findings.ConclusionThe addition of GRT to routine care after first-line virologic failure in Uganda and South Africa did not improve rates of resuppression.Primary Funding SourceThe President's Emergency Plan for AIDS Relief and the National Institute of Allergy and Infectious Diseases.

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