title: Surveillance of HIV Transmitted Drug Resistance in Latin America and the Caribbean: A Systematic Review and Meta-Analysis.
abstract: BACKGROUND
  HIV transmitted drug resistance (TDR) remains at moderate level in Latin America and the Caribbean (LAC). However, different epidemiologic scenarios could influence national and sub-regional TDR levels and trends.
  
  
  RESULTS
  We performed a systematic review of currently available publications on TDR in antiretroviral treatment-naïve adults in LAC. Ninety-eight studies published between January 2000 and June 2015 were included according to critical appraisal criteria and classified by sub-region: Brazil (50), Mesoamerica (17), Southern Cone (16), Andean (8) and Caribbean (7). From these, 81 studies encompassing 11,441 individuals with data on DR mutation frequency were included in a meta-analysis. Overall TDR prevalence in LAC was 7.7% (95% CI: 7.2%-8.2%). An increasing trend was observed for overall TDR when comparing 2000-2005 (6.0%) and 2006-2015 (8.2%) (p<0.0001), which was associated with significant NNRTI TDR increase (p<0.0001). NRTI TDR decreased (4.5% vs. 2.3%, p<0.0001). NNRTI TDR increase was associated mainly with K101E, K103N and G190A. NRTI TDR decrease was associated mainly with M184V, K70R and T215Y. All sub-regions reached moderate overall TDR levels. The rapid increase in TDR to all antiretroviral classes in the Caribbean is notable, as well as the significant increase in NNRTI TDR reaching moderate levels in the Southern Cone. NRTI TDR was dominant in 2000-2005, mainly in the Caribbean, Mesoamerica and Brazil. This dominance was lost in 2006-2015 in all sub-regions, with the Southern Cone and the Caribbean switching to NNRTI dominance. PI TDR remained mostly constant with a significant increase only observed in the Caribbean.
  
  
  CONCLUSIONS
  Given the high conceptual and methodological heterogeneity of HIV TDR studies, implementation of surveys with standardized methodology and national representativeness is warranted to generate reliable to inform public health policies. The observed increasing trend in NNRTI TDR supports the need to strengthen TDR surveillance and programme monitoring and evaluation in LAC.
authors.affiliation: Centre for Research in Infectious Diseases, National Institute of Respiratory Diseases, Mexico City, Mexico.
authors.forename: Santiago
authors.initials: S
authors.lastname: Avila-Rios
authors.affiliation: Clinical Research Section, Huésped Foundation, Buenos Aires, Argentina.
authors.forename: Omar
authors.initials: O
authors.lastname: Sued
authors.affiliation: Department of Medicine, Stanford University, Stanford, California, United States of America.
authors.forename: Soo-Yon
authors.initials: SY
authors.lastname: Rhee
authors.affiliation: Department of Medicine, Stanford University, Stanford, California, United States of America.
authors.forename: Robert W
authors.initials: RW
authors.lastname: Shafer
authors.affiliation: Centre for Research in Infectious Diseases, National Institute of Respiratory Diseases, Mexico City, Mexico.
authors.forename: Gustavo
authors.initials: G
authors.lastname: Reyes-Teran
authors.affiliation: Pan American Health Organization (PAHO), Washington DC, United States of America.
authors.forename: Giovanni
authors.initials: G
authors.lastname: Ravasi
mesh_terms: D000328:Adult; D019380:Anti-HIV Agents / Q000627:therapeutic use; D001938:Brazil; D017691:Caribbean Region; D024882:Drug Resistance, Viral; D062665:Epidemiological Monitoring; D005260:Female; D015658:HIV Infections / Q000188:drug therapy*; D015497:HIV-1 / Q000235:genetics*; D006801:Humans; D007843:Latin America; D008297:Male; D009154:Mutation; D011247:Pregnancy; D011251:Pregnancy Complications, Infectious; D015995:Prevalence
chemical_list: D019380:Anti-HIV Agents