title: Determinants of virological failure and antiretroviral drug resistance in Mozambique.
abstract: OBJECTIVE
  The objective of this study was to inform public health actions to limit first-line ART failure and HIV drug resistance in Mozambique.
  
  
  METHODS
  This was a cross-sectional study. HIV-1-infected adults on first-line ART for at least 1 year attending routine visits in the Manhiça District Hospital, in a semi-rural area in southern Mozambique with no HIV-1 RNA monitoring available, were evaluated for clinical, socio-demographic, therapeutic, immunological and virological characteristics. Factors associated with HIV-1 RNA ≥1000 copies/mL and HIV drug resistance were determined using multivariate logistic regression.
  
  
  RESULTS
  The study included 334 adults on first-line ART for a median of 3 years, of which 65% (214/332) had suppressed viraemia, 11% (37/332) had low-level viraemia (HIV-1 RNA 150-999 copies/mL) and 24% (81/332) had overt virological failure (HIV-1 RNA ≥1000 copies/mL). HIV drug resistance was detected in 89% of subjects with virological failure, but in none with low-level viraemia. Younger age [OR = 0.97 per additional year (95% CI = 0.94-1.00), P = 0.039], ART initiation at WHO stage III/IV [OR = 2.10 (95% CI = 1.23-3.57), P = 0.003] and low ART adherence [OR = 2.69 (95% CI = 1.39-5.19), P = 0.003] were associated with virological failure. Longer time on ART [OR = 1.55 per additional year (95% CI = 1.00-2.43), P = 0.052] and illiteracy [OR = 0.24 (95% CI = 0.07-0.89), P = 0.033] were associated with HIV drug resistance. Compared with HIV-1 RNA, clinician's judgement of ART failure, based on clinical and immunological outcomes, only achieved 29% sensitivity and misdiagnosed 1 out of every 4.5 subjects.
  
  
  CONCLUSIONS
  Public health programmes in Mozambique should focus on early HIV diagnosis, early ART initiation and adherence support. Virological monitoring drastically improves the diagnosis of ART failure, enabling a better use of resources.
authors.affiliation: Manhiça Health Research Center (CISM), Manhiça, Maputo, Mozambique Barcelona Centre for International Health Research (CRESIB, Hospital Clínic-Universitat de Barcelona), ISGlobal, Barcelona Institute for Global Health, Barcelona, Spain maria.ruperez@isglobal.org.
authors.forename: María
authors.initials: M
authors.lastname: Rupérez
authors.affiliation: IrsiCaixa AIDS Research Institute, Badalona, Catalonia, Spain.
authors.forename: Christian
authors.initials: C
authors.lastname: Pou
authors.affiliation: Manhiça Health Research Center (CISM), Manhiça, Maputo, Mozambique.
authors.forename: Sonia
authors.initials: S
authors.lastname: Maculuve
authors.affiliation: IrsiCaixa AIDS Research Institute, Badalona, Catalonia, Spain.
authors.forename: Samandhy
authors.initials: S
authors.lastname: Cedeño
authors.affiliation: Manhiça Health Research Center (CISM), Manhiça, Maputo, Mozambique.
authors.forename: Leopoldina
authors.initials: L
authors.lastname: Luis
authors.affiliation: IrsiCaixa AIDS Research Institute, Badalona, Catalonia, Spain.
authors.forename: Judith
authors.initials: J
authors.lastname: Rodríguez
authors.affiliation: Barcelona Centre for International Health Research (CRESIB, Hospital Clínic-Universitat de Barcelona), ISGlobal, Barcelona Institute for Global Health, Barcelona, Spain Swiss Tropical and Public Health Institute (Swiss TPH), Basel, Switzerland.
authors.forename: Emilio
authors.initials: E
authors.lastname: Letang
authors.affiliation: Lluita Contra la Sida Foundation, HIV Unit, Hosp Univ Germans Trias i Pujol, Badalona, Catalonia, Spain.
authors.forename: José
authors.initials: J
authors.lastname: Moltó
authors.affiliation: Manhiça Health Research Center (CISM), Manhiça, Maputo, Mozambique.
authors.forename: Eusébio
authors.initials: E
authors.lastname: Macete
authors.affiliation: IrsiCaixa AIDS Research Institute, Badalona, Catalonia, Spain Lluita Contra la Sida Foundation, HIV Unit, Hosp Univ Germans Trias i Pujol, Badalona, Catalonia, Spain Universitat de Vic-Universitat Central de Catalunya, Vic, Catalonia, Spain.
authors.forename: Bonaventura
authors.initials: B
authors.lastname: Clotet
authors.affiliation: Manhiça Health Research Center (CISM), Manhiça, Maputo, Mozambique Barcelona Centre for International Health Research (CRESIB, Hospital Clínic-Universitat de Barcelona), ISGlobal, Barcelona Institute for Global Health, Barcelona, Spain.
authors.forename: Pedro
authors.initials: P
authors.lastname: Alonso
authors.affiliation: Manhiça Health Research Center (CISM), Manhiça, Maputo, Mozambique Barcelona Centre for International Health Research (CRESIB, Hospital Clínic-Universitat de Barcelona), ISGlobal, Barcelona Institute for Global Health, Barcelona, Spain.
authors.forename: Clara
authors.initials: C
authors.lastname: Menéndez
authors.affiliation: Manhiça Health Research Center (CISM), Manhiça, Maputo, Mozambique Barcelona Centre for International Health Research (CRESIB, Hospital Clínic-Universitat de Barcelona), ISGlobal, Barcelona Institute for Global Health, Barcelona, Spain.
authors.forename: Denise
authors.initials: D
authors.lastname: Naniche
authors.affiliation: IrsiCaixa AIDS Research Institute, Badalona, Catalonia, Spain Lluita Contra la Sida Foundation, HIV Unit, Hosp Univ Germans Trias i Pujol, Badalona, Catalonia, Spain Universitat de Vic-Universitat Central de Catalunya, Vic, Catalonia, Spain.
authors.forename: Roger
authors.initials: R
authors.lastname: Paredes
mesh_terms: D000328:Adult; D044966:Anti-Retroviral Agents / Q000627:therapeutic use*; D003430:Cross-Sectional Studies; D016903:Drug Monitoring; D024882:Drug Resistance, Viral; D005260:Female; D005838:Genotype; D060005:Genotyping Techniques; D015658:HIV Infections / Q000188:drug therapy* / Q000821:virology*; D015497:HIV-1 / Q000145:classification / Q000235:genetics* / Q000302:isolation & purification; D006801:Humans; D008297:Male; D008875:Middle Aged; D009073:Mozambique; D013383:Suburban Population; D017211:Treatment Failure
chemical_list: D044966:Anti-Retroviral Agents
keywords: HIV-1; antiretroviral treatment; low-income countries; public health