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Multidrug Resistance Common in Hospitalized Adults With HIV in Malawi Multidrug Resistance Common in Hospitalized Adults With HIV in Malawi

NEW YORK (Reuters Health) – HIV-1 multidrug resistance is common and is associated with increased mortality among adults hospitalized with HIV infection in Malawi, according to a new study.

HIV drug resistance is increasingly common in sub-Saharan Africa, but most data have come from outpatient clinics, researchers say. There are few data describing HIV drug resistance in patients established on antiretroviral therapy (ART) who are admitted to hospital.

Dr. Ankur Gupta-Wright of University College London and London School of Hygiene and Tropical Medicine and colleagues used data from patients enrolled in a large tuberculosis screening trial to evaluate the prevalence of virological failure and HIV drug resistance and their effect on early mortality in patients with HIV admitted to hospital.

All but 16 of the 786 patients included in the analysis had been on first-line ART (for a median 4.7 years), and 606 patients (77%) had advanced HIV on admission.

Overall, 252 patients (32%) had virological failure and an additional 66 (8%) had low-level viremia (50-999 copies per mL), Dr. Gupta-Wright, also at the University of Malawi College of Medicine, in Blantyre, and his colleagues report in The Lancet HIV.

Of the 237 patients whose HIV were successfully sequenced, all were HIV subtype C, and 93% had drug resistance mutations to first-line or second-line drugs.

Only 8% had no detectable resistance to any first-line ART drugs, whereas 54% had resistance to all first-line drugs and 83% had resistance to at least two drugs.

Mortality by day 56 was 20% and was greater among patients with virological failure (25%) than among those without (18%).

Mortality rose with increasing drug resistance. By day 56, mortality was 6% in patients with no drug resistance, 13% in patients with resistance to one drug and 28% in patients with multidrug resistance (P=0.041).

Among samples from patients not taking ART at hospital admission, HIV viral load was higher, and HIV drug resistance was uncommon among those who had never taken ART.

“Patients already established on ART with advanced HIV disease need screening for failure during hospital admission, ideally using rapid assays,” the authors conclude. “Those identified as having ART failure would likely benefit from switching to alternative ART (based on integrase or protease inhibitors, given NNRTI and NRTI resistance).”

“Although the public health approach to ART has led to declines in HIV incidence and mortality, patients with advanced disease (despite engagement with clinics) would benefit from differentiated care, with a focused approach to patients with high viral loads and more frequent viral load testing, review, and monitoring,” they add.

Dr. Gupta-Wright did not respond to a request for comments.

SOURCE: https://bit.ly/3mnuQ55 The Lancet HIV, September 2020.