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WHO’s laboratory-based acquired drug resistance survey method yields robust estimates of acquired HIV drug resistance in adults, children and adolescents taking both dolutegravir and non-dolutegravir based regimens by genotyping remnant specimens from routine viral load testing. Results are used to inform programme decision making regarding optimal ART regimens and support evaluation of programme quality with respect to maximizing viral load suppression and minimizing emergence of resistance in people taking ART.
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.
These consolidated guidelines on HIV prevention, testing, treatment, service delivery and monitoring bring together existing and new clinical and programmatic recommendations across different ages, populations and settings, bringing together all relevant WHO guidance on HIV produced since 2016. It serves as an update to the previous edition of the consolidated guidelines on HIV. These guidelines continue to be structured along the continuum of HIV care. Information on new combination prevention approaches, HIV testing, ARV regimens and treatment monitoring are included. There is a new chapter on advanced HIV disease that integrates updated guidance on the management of important HIV comorbidities, including cryptococcal disease, histoplasmosis and tuberculosis. The chapter on general HIV care, contains a new section on palliative care and pain management, and up to date information on treatment of several neglected tropical diseases, such as visceral leishmaniasis and Buruli ulcer. New recommendations for screening and treating of cervical pre-cancer lesions in women living with HIV are also addressed in this chapter. Guidance on service delivery was expanded to help the implementation and strengthening the HIV care cascade. Importantly, this guidance emphasizes the need for differentiated approaches to care for people who are established on ART, such as reduced frequency of clinic visits, use of multi-month drug dispensing and implementation of community ART distribution. The adoption of these efficiencies is essential to improve the quality of care of people receiving treatment and reduce the burden on health facilities, particularly in resource limited settings.