Rising levels of drug-resistant HIV as a result of the rapid scale-up of antiretroviral treatment programmes in sub-Saharan Africa are a potential threat to the control of the HIV epidemic. To discuss potential responses to this concern, the Amsterdam Institute for Global Health and Development (AIGHD) and the Pan-African Studies to Evaluate Resistance (PASER) network convened a closed policy meeting in Lusaka, Zambia on 6 May 2014.
The Policy Meeting's main objective was to bring together national policy makers, health professionals, public health experts, and medical researchers. Cross-discipline interactions created the opportunity for enhanced information exchange and mutual learning about the specific policy challenges posed by emerging HIV drug resistance in the southern African region. Among the 31 participants were representatives of Ministries of Health (South Africa, Swaziland, Zambia and Zimbabwe), the World Health Organization (WHO), communities living with HIV in Zambia, and the Embassy of the Kingdom of the Netherlands. They were joined by the laboratory experts, clinicians, researchers, and the coordinator of the Southern African Development Community regional HIV/AIDS Programme.
Two panel discussions, moderated by Dr. Moses Kamya (Professor of Medicine, Makerere University, Uganda) and Dr. Catherine Hankins (Deputy Director Science, Amsterdam Institute for Global Health and Development), saw lively exchanges. Countries reported good progress in the development of strategic national plans for preventing HIV drug resistance prevention within their national HIV programs. These will contribute to enhancing awareness of HIV drug resistance and early detection, while informing the deployment of preventive measures.
Although Zimbabwe, Zambia, and South Africa have conducted surveys on acquired and transmitted HIV drug resistance recently, these have not yet been repeated and time trends are lacking. Such surveys provide information that is critical to maintaining effective antiretroviral drug regimens and can be pivotal in influencing policy. For instance, Zimbabwe's paediatric HIV drug resistance survey found high levels of resistance associated with non-nucleoside reverse transcriptase inhibitors (NNRTI), leading to a change in the treatment guidelines. Protease inhibitor-based antiretroviral therapy is recommended for treatment initiation before the age of 3 yrs. WHO-recommended Early Warning Indicators (EWIs) for HIV drug resistance are routinely collected in many sites across Zambia and Zimbabwe, where drug stockouts remain a major challenge. EWIs include a timely feedback mechanism to individual sites so that action can be taken locally on programmatic deficiencies.
WHO has launched updated guidelines on HIV drug resistance prevention that include an important shift in assessment strategies from a sentinel approach to nationally representative surveys. Country representatives at the policy meeting viewed this new approach as not only feasible but also likely to generate more useful information at national level.
South Africa is implementing, in collaboration with SATuRN, a central HIV drug resistance database to curate, store and summarize data, including a dashboard to present data on drug resistance mutation patterns by region. Initially, the focus will be on the public sector, with the intention to expand to include private sector data. It is the first country in the region to implement routine viral genotyping for patients who experience therapy failure on their second-line regimen. A central panel of 4 expert clinicians assesses all cases being considered for third-line therapy. Educational efforts are needed to address an important knowledge gap among clinicians concerning when to request HIV drug resistance testing, how to interpret the results, and how to best use 2nd and 3rd line regimens. Current WHO guidelines make no explicit recommendation about the use of viral genotyping to guide antiretroviral drug switching for people who are failing second-line therapy. Discussions on this topic and the issue of optimized use of the dual nucleoside backbone are needed to inform changes in the WHO guidelines.
To date, few laboratories in the region have been accredited by WHO to perform HIV drug resistance testing. Some are moving forward to develop more affordable diagnostic technologies, such as those on dried blood spots. The KEMRI-CDC laboratory in Kisumu is the first to have developed their in-house resistance test into a lab kit that can be purchased commercially. Zambia will begin HIV drug resistance testing at its University Teaching Hospital and Centre for Infectious Disease Research Zambia in the coming months. Zimbabwe and Swaziland do not have in-country laboratory capacity for HIV drug resistance genotyping, but they can make arrangements with existing reference laboratories in the region.
Enhanced interaction between policy, science, and clinical practice is crucial, but creating fertile conditions for it appears challenging. Funding agencies can play a role by advocating for reciprocal interactions through diplomatic channels and can stimulate researchers to conduct effective knowledge translation by disseminating their results and the implications of their findings for public health and policy.
As the community representative of the National Treatment Preparedness Coalition and TALC, Zambia highlighted, there is a lot of confusion, misunderstanding, and superstition about 'acquired' and 'transmitted' resistance among the general public and a very real need for investment in educating the general public about HIV drug resistance. Enhanced and concerted advocacy efforts, such as those successfully conducted to bring about price reductions for antiretroviral drugs, could bring down the price of diagnostics. However, as a South African clinician stated, the costs of viral load testing are still high and the benefits are not massive; priority should still be given to expanding access to HIV treatment and enhancing support for adherence.
PASER is sponsored by the Embassy of the Kingdom of the Netherlands through the regional HIV/AIDS programme for Southern Africa.
The meeting coincided with the 8th International Workshop on HIV Treatment, Pathogenesis, and Prevention Research in Resource-poor Settings (INTEREST). Programme and presentations may be found at: http://www.infectiousdiseasesonline.com/event/workshop/8th-interest-2/.