title: Affordable HIV drug-resistance testing for monitoring of antiretroviral therapy in sub-Saharan Africa.
abstract: Increased provision of antiretroviral therapy in sub-Saharan Africa has led to a growing number of patients with therapy failure and acquired drug-resistant HIV, driving the demand for more costly further lines of antiretroviral therapy. In conjunction with accelerated access to viral load monitoring, feasible and affordable technologies to detect drug-resistant HIV could help maximise the durability and rational use of available drug regimens. Potential low-cost technologies include in-house Sanger and next-generation sequencing in centralised laboratories, and point mutation assays and genotype-free systems that predict response to antiretroviral therapy at point-of-care. Strengthening of centralised high-throughput laboratories, including efficient systems for sample referral and results delivery, will increase economies-of-scale while reducing costs. Access barriers can be mitigated by standardisation of in-house assays into commercial kits, use of polyvalent instruments, and adopting price-reducing strategies. A stepwise rollout approach should improve feasibility, prioritising WHO-recommended population-based surveillance and management of complex patient categories, such as patients failing protease inhibitor-based antiretroviral therapy. Implementation research, adaptations of existing WHO guidance, and political commitment, will be key to support the appropriate investments and policy changes. In this Personal View, we discuss the potential role of HIV drug resistance testing for population-based surveillance and individual patient management in sub-Saharan Africa. We review the strengths and challenges of promising low-cost technologies and how they can be implemented.
authors: Department of Global Health, Academic Medical Center of the University of Amsterdam, Amsterdam, Netherlands; Amsterdam Institute for Global Health and Development, Amsterdam, Netherlands.
authors: Seth C
authors: SC
authors: Inzaule
authors: Department of Global Health, Academic Medical Center of the University of Amsterdam, Amsterdam, Netherlands; Amsterdam Institute for Global Health and Development, Amsterdam, Netherlands.
authors: Pascale
authors: P
authors: Ondoa
authors: African Society for Laboratory Medicine, Addis Abeba, Ethiopia; Clinton Health Access Initiative, Gaborone, Botswana.
authors: Trevor
authors: T
authors: Peter
authors: Joint Clinical Research Centre, Kampala, Uganda.
authors: Peter N
authors: PN
authors: Mugyenyi
authors: Department of Molecular Medicine and Haematology, University of the Witwatersrand and National Health Laboratory Service, Johannesburg, South Africa.
authors: Wendy S
authors: WS
authors: Stevens
authors: Department of Global Health, Academic Medical Center of the University of Amsterdam, Amsterdam, Netherlands; Amsterdam Institute for Global Health and Development, Amsterdam, Netherlands.
authors: Tobias F Rinke
authors: TFR
authors: de Wit
authors: Department of Global Health and Department of Internal Medicine, Division of Infectious Diseases, Academic Medical Center of the University of Amsterdam, Amsterdam, Netherlands; Amsterdam Institute for Global Health and Development, Amsterdam, Netherlands. Electronic address: r.hamers@aighd.org.
authors: Raph L
authors: RL
authors: Hamers
mesh_terms: D017954:Africa South of the Sahara / Q000453:epidemiology; D019380:Anti-HIV Agents / Q000191:economics* / Q000627:therapeutic use; D023241:Antiretroviral Therapy, Highly Active / Q000379:methods*; D024882:Drug Resistance, Viral / Q000235:genetics*; D006678:HIV / Q000187:drug effects; D015658:HIV Infections / Q000188:drug therapy; D006801:Humans; D008403:Mass Screening; D009154:Mutation; D019562:Viral Load / Q000187:drug effects
chemical_list: D019380:Anti-HIV Agents