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By Thapelo Molefe
South Africa has incorporated a new HIV testing strategy into routine public healthcare to help clinicians quickly determine whether a patient’s treatment is failing because of drug resistance or because they have not been taking their medication consistently.
The strategy, developed through the Intensified Treatment Evaluation and Monitoring Approach (ITREMA-2) study, uses a blood test to check whether the HIV medicine dolutegravir is present in a patient’s system when their viral load increases.
Researchers from Wits University, the National Health Laboratory Service (NHLS) and University Medical Center Utrecht say the approach can help ensure that resistance testing is targeted at patients who need it most, while avoiding unnecessary and costly tests.
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“An increased viral load does not automatically mean that treatment is failing because of drug resistance,” said Professor Annemarie Wensing, lead researcher from Wits Ezintsha and University Medical Center Utrecht.
“Measuring dolutegravir in the same sample helps identify who needs resistance testing and provides clinicians and nurses with objective information to better support medication intake.”
The ITREMA-2 study involved 288 people living with HIV receiving treatment at Hillbrow Community Health Centre and Helen Joseph Hospital in Johannesburg.
When a patient’s viral load rises while they are receiving antiretroviral treatment, healthcare workers need to establish why the treatment is no longer controlling the virus.
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Under the new approach, the patient’s blood is first checked for dolutegravir. If the medicine is not detected, this may indicate that the patient has not been taking their medication consistently, making drug resistance less likely.
If dolutegravir is present but the virus continues to multiply, resistance to the medicine becomes a concern and a resistance test can then be conducted.
The researchers said this provides clinicians with an objective way of distinguishing between possible treatment non-adherence and drug resistance instead of immediately assuming that the medication has stopped working.
The approach could also reduce the cost of monitoring patients with confirmed virological failure.
Researchers estimated that laboratory monitoring costs could be 23% lower than under the previous standard approach because unnecessary resistance tests can be avoided.
Dr Kim Steegen, co-principal investigator of the study and a researcher at the NHLS and Wits University, said the research had been conducted in collaboration with the National Department of Health.
“We have worked with the National Department of Health since the onset of the project and kept them informed on the study results as the project progressed,” Steegen said.
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“By doing this, we have been able to include an adapted version of ITREMA-2 into the national guidelines, which means the people who need resistance testing the most can be easily identified.”
It could also allow healthcare workers to provide more targeted adherence support to patients who are struggling to take their medication consistently.
The ITREMA-2 study was published in The Lancet HIV on 2 September.
The study was funded by the Amsterdam Dinner Foundation through Aidsfonds and the Dutch Research Council (NWO).
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