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The prevalence of antiretroviral drug resistance in the United States.
Richman DD, Morton SC, Wrin T, Hellmann N, Berry S, Shapiro MF, Bozzette SA.
AIDS
2004 Jul 2;18(10):1393-401.
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PubMed entry
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Reviewed by
Susa Coffey, MD
Summary
Richman et al report the prevalence of antiretroviral (ARV) resistance in a subset of patients from the HIV Cost and Service Utilization Study (HCSUS), a cohort that is representative of all HIV-infected adults in care in the United States as of 1996. The study population consisted of 1,797 patients who received care in early 1996 and were alive in 1998. Of these, 1,099 had plasma HIV RNA >=500 copies/mL and had blood samples that were tested for ARV resistance.
Drug resistance (by phenotypic criteria) was detected in 76% of viremic patients.
Resistance to nucleoside analogues (NRTIs) was most common (71%), followed by resistance to protease inhibitors (PIs) (41%), and nonnucleoside reverse transcriptase inhibitors (NNRTIs) (25%). Not surprisingly, resistance was seen more frequently in patients who had been exposed to NRTI therapy prior to 1996 and in those who were currently taking ARV therapy with incomplete viral suppression. However, resistance was also seen in a significant number of patients who reported no prior ARV exposure (10-15%). Other risk factors for ARV resistance included low CD4 nadir and advanced disease, as well as factors such as white race, private insurance status, college education, and MSM (men who have sex with men) risk group; these latter likely reflect greater access to ARV therapy.
Comment
This large study sample shows a strikingly high prevalence of resistance in viremic patients during the study period (1996-98). The current prevalence of ARV resistance in HIV-infected persons in the United States is unclear. It may have declined, as fewer individuals have had prior exposure to nonsuppressive HIV therapy, combination ARV therapy in general is more potent and more tolerable, and resistance testing is more commonly used to guide therapy. However, a number of studies indicate that ARV resistance mutations, both acquired and transmitted, are found in significant numbers of patients and limit the effectiveness of ARV therapy.
Further studies are needed to determine recent trends in ARV resistance in the United States. Nevertheless, these prevalence figures from the early years of potent combination ARV therapy are sobering, and they have significant implications both for treatment strategies and for efforts to prevent transmission of drug-resistant virus.
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