Targeted HIV drug resistance testing moves into routine care in South Africa
Researchers at Wits University, South Africa's National Health Laboratory Service (NHLS) and University Medical Center Utrecht have developed a new way to help people whose HIV viral load increased while they were taking the highly effective standard antiretroviral treatment dolutegravir (DTG).
A new HIV drug resistance testing method is gaining traction in South Africa's healthcare system. The Intensified Treatment Evaluation and Monitoring Approach (ITREMA-2) study, led by researchers from Wits University and University Medical Center Utrecht, aims to prevent the spread of HIV-1 drug resistance in resource-limited settings. The study, published in The Lancet HIV, involved 288 people with HIV at Hillbrow Community Health Centre and Helen Joseph Hospital in Johannesburg.
Instead of relying on guesswork, researchers employed a blood exposure test to determine if the antiretroviral treatment dolutegravir (DTG) was functioning effectively. Professor Annemarie Wensing, lead researcher from Wits Ezintsha and University Medical Center Utrecht, explained that an increased viral load doesn't necessarily indicate treatment failure due to drug resistance.
Measuring DTG levels in the same blood sample helps identify patients who need resistance testing and assists healthcare professionals in providing better support for medication adherence.
When a patient's viral load spikes, doctors face a dilemma: whether to offer counseling to help the patient take their current pills or switch them to a new, more expensive regimen. The ITREMA-2 strategy simplifies this process by using a blood exposure test to decide who needs support with taking their pills and who requires resistance testing to determine if a medication change is necessary.
This approach reduces the need for repeated counseling and expensive resistance tests, which were previously conducted on everyone after virologic failure.
The multidisciplinary research team also examined how this treatment and evaluation strategy could be integrated into routine care. After confirming virologic failure, estimated laboratory monitoring costs were 23% lower with the ITREMA-2 approach compared to the previous standard method, as unnecessary resistance tests could be avoided.
In September 2026, the South African Department of Health implemented an adapted version of the reflex testing strategy in public HIV care, thanks to the collaboration between the ITREMA-2 study team and the national health department.
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