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Global threat from drug resistant HIV in sub-Saharan Africa

BMJ 2012; 344 doi: (Published 18 June 2012) Cite this as: BMJ 2012;344:e4159
  1. Raph L Hamers, research fellow123,
  2. Cissy Kityo, research fellow4,
  3. Joep M A Lange, professor and director12,
  4. Tobias F Rinke de Wit, professor 123,
  5. Peter Mugyenyi, professor and director4
  1. 1Department of Global Health, Academic Medical Centre of the University of Amsterdam, Amsterdam, Netherlands
  2. 2Amsterdam Institute for Global Health and Development, Amsterdam, Netherlands
  3. 3PharmAccess Foundation, Amsterdam, Netherlands
  4. 4Joint Clinical Research Centre, Kampala, Uganda
  1. Correspondence to: R L Hamers r.hamers{at}
  • Accepted 18 April 2012

Roll-out of antiretroviral treatment for HIV in sub-Saharan Africa has been accompanied by rising rates of drug resistance. Raph Hamers and colleagues call for improved patient management and the integration of population based drug resistance surveillance into national treatment programmes

Since its introduction 16 years ago, combination antiretroviral therapy for HIV infection has saved millions of lives. In sub-Saharan Africa, the region with the highest HIV/AIDS burden, high level political commitment and substantial international funding have led to an unparalleled scale-up of access to treatment over the past eight years.1 More than five million Africans infected with HIV are receiving antiretroviral therapy today—nearly half of those who are in immediate need.1 However, little attention has been paid to the potential emergence and spread of drug resistant HIV and its public health implications. Drug resistant HIV variants selected for during treatment failure (acquired resistance) have the potential to limit the response to subsequent treatment and constitute a reservoir for onward transmission to newly infected individuals (transmitted resistance). Drug resistant HIV may severely restrict therapeutic options, and treatment costs will greatly increase when more people need second and third line antiretroviral regimens. It is therefore important for national HIV treatment programmes to monitor and manage mounting drug resistant HIV.

HIV drug resistance

In developed countries, management of combination antiretroviral therapy is based on individualised specialist care that includes frequent monitoring of plasma viral load to detect treatment failure, drug resistance testing to guide regimen choices, and a wide armamentarium of antiretroviral drugs (table).2 In Europe and North America, HIV sequential mono and dual therapies of nucleoside reverse transcriptase inhibitors (NRTIs) initially led to high levels of acquired and transmitted resistance,3 4 5 but careful management and use of more potent antiretroviral regimens have seen levels of transmitted resistance stabilising …

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