Combatting Virologic Failure in Children with HIV using Targeted Drug Resistance Testing

In resource limited settings, children on antiretroviral therapy (ART) for HIV often face challenges achieving suppression of the virus. Guidelines recommend concentrated adherence counseling and frequent viral load testing for virologic failure, but drug resistance testing is often excluded.

According to a study presented at the Virtual 23^rd International AIDS Conference (AIDS 2020), more frequent drug resistance testing may be a critical component of lower rates of virologic failure among children in these settings.

In the Opt4Kids study, an ongoing randomized trial, investigators from the University of Washington Kenya, the Kenyan Department and Ministry of Health, and the University of Colorado Denver, conducted targeted DRT testing for children with virologic failure in the intervention arm.

A total of 704 children living with HIV between ages 1-14 years were enrolled from 5 government facilities in Kisumu County, Kenya from March-December 2019.

Children were individually randomized 1:1 to standard-of-care or point-of-care viral load testing every 3 months with resistance testing for patients with virologic failure [> 1000 copies/ml]) arms.

Testing in the intervention arm used consensus sequencing and results discussed by a clinical management committee made up of research staff, HIV experts, and health care workers.

The 365 children living with HIV in the intervention arm had a median time on ART of about 70 months, 60 (16%) had at least one drug resistance test requested per protocol and 51 (85%) had drug resistance mutations.

There were also 48 (80%) children living with HIV with drug resistance who had non-nucleoside reverse transcriptase resistance, 36 with nucleoside reverse transcriptase inhibitor resistance, 33 (55%), and 9 (15%) had no resistance.

In 30 children living with HIV (50%) with drug resistance results, an ART regimen change was suggested, 90% of whom were on an NNRTI-based regimen.

The study suggests that among children living with HIV, improved adherence alone is unlikely to result in viral suppression for a sizable number of virologic failure cases. Early resistance testing may be a critical tool in determining appropriate ART.