HIV drug resistance report 2019

HIV DRUG RESISTANCE REPORT 2019

HIV DRUG RESISTANCE REPORT 2019 WHO/CDS/HIV/19.21 © World Health Organization 2019 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. If you create a translation of this work, you should add the following disclaimer along with the suggested citation: “This translation was not created by the World Health Organization (WHO). WHO is not responsible for the content or accuracy of this translation. 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However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. Printed in Switzerland iii CONTENTS Definitions iv Acknowledgements iv Executive summary v Section 1. Pretreatment HIV drug resistance among adults initiating first-line antiretroviral therapy 1 Section 2. Pretreatment HIV drug resistance among treatment-naive infants newly diagnosed with HIV 7 Section 3. Acquired HIV drug resistance among adults receiving antiretroviral therapy 10 Section 4. Assessment of programmatic quality indicators associated with the emergence of HIV drug resistance 16 Tables Section 1. Tables of pretreatment HIV drug resistance among adults initiating first-line antiretroviral therapy 19 Population characteristics (Tables 1.1a–e) 19 Prevalence of pretreatment HIV drug resistance (Tables 1.2a–e) 24 Section 2. Tables of pretreatment HIV drug resistance among treatment-naive infants newly diagnosed with HIV 29 Population characteristics (Tables 2.1a–b) 29 Prevalence of pretreatment HIV drug resistance (Tables 2.2a–b) 31 Section 3. Tables of acquired HIV drug resistance among adults receiving antiretroviral therapy 33 Population characteristics (Tables 3.1a–g) 33 Prevalence of viral load suppression (Tables 3.2a–h) 40 Prevalence of acquired HIV drug resistance (Tables 3.3a–h) 40 Table: HIV subtype distribution 56 iv DEFINITIONS HIV drug resistance (HIVDR) is caused by one or more changes (mutation/s) in the genetic structure of HIV that affects the ability of a specific drug or combination of drugs to block replication of the virus. All current antiretroviral (ARV) drugs, including newer classes, are at risk of becoming partly or fully inactive because of the emergence of drug-resistant virus. People receiving ART can acquire HIVDR, and people can also be infected with HIV that is already drug resistant. WHO commonly classify HIVDR into three main categories. 1. Acquired HIV drug resistance (ADR) develops because of viral replication in the presence of ARV drugs. 2. Transmitted HIV drug resistance (TDR) is detected among ARV drug–naive people with no history of ARV drug exposure. TDR occurs when previously uninfected individuals are infected with virus that has drug resistance mutations. 3. Pretreatment HIV drug resistance (PDR) refers to resistance that is detected among ARV drug–naive people initiating ART or people with previous ARV drug exposure initiating or reinitiating first-line ART. PDR is either TDR or ADR or both. PDR may have been transmitted at the time of infection (TDR) or may be acquired through previous ARV drug exposure (such as among women exposed to ARV drugs for preventing mother-to-child transmission of HIV, among people who have received pre-exposure prophylaxis or among individuals reinitiating first-line ART after a period of treatment interruption). ARV drug–naive applies to people with no history of ARV drug exposure. ACKNOWLEDGEMENTS The report was written by Seth Inzaule and Silvia Bertagnolio (WHO, HIV Department), under the coordination of Meg Doherty (WHO, HIV Department). We are extremely grateful for the contributions of Amalia Girón for the statistical analysis. We also thank Neil Parkin, Michael R. Jordan, Natalie Exner and the HIVResNet steering group members for their guidance and support. We acknowledge the contributions of David Breuer for technical editing and Sue Hobbs for layout. This report would not have been possible without the collaboration of national HIV programme managers who supplied the surveillance data that underpin this report and staff from WHO regional and country offices, especially Fatim Cham, Giovanni Ravasi, Linh Le and B.B.Rewari. We thank the WHO HIVResNet Laboratory Network members, who have been essential in producing high-quality drug resistance surveillance data. Financial acknowledgements. This report has been supported in part by the Government of the Netherlands and the United States President’s Emergency Plan for AIDS Relief (PEPFAR) through the United States Centers for Disease Control and Prevention (CDC). We also acknowledge the support of Global Fund and PEPFAR to fund the HIVDR surveys. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the funders. vEXECUTIVE SUMMARY The rise in antimicrobial resistance (AMR) is one of the greatest threats to global health. If it is not urgently addressed, it may result in millions of deaths, an increase in new and hard-to-treat infections and increased health-care costs.1 As a result, combatting AMR, including the threat posed by drug-resistant HIV, is a major goal for the global community. Prevention, monitoring and timely response to population levels of HIV drug resistance (HIVDR) is critical to achieving the WHO/UNAIDS 90–90–90 targets for 2020 that 90% of people living with HIV know their HIV status, 90% of those who know their HIV-positive status are accessing treatment and 90% of the people receiving treatment having suppressed viral loads. These targets reflect the global community’s commitment to eliminating AIDS as a public health threat by 2030. In response to the threat of HIVDR to attaining these goals, the global health community launched a five-year Global Action Plan on HIVDR (2017–2021) that details a roadmap to prevent, monitor and respond to globally increasing levels of HIVDR. In response to the Global Action Plan, countries and funders are increasingly focusing on establishing robust and routine population-level monitoring of HIVDR to accompany the scaling up of antiretroviral therapy (ART) and supporting a safe transition to new antiretroviral (ARV) drugs in first- and second-line ART. 1 No time to wait: securing the future from drug-resistant infections: report to the Secretary-General of the United Nations. New York: Ad Hoc Interagency Coordination Group on Antimicrobial Resistance; 2019 (https://www.who.int/antimicrobial-resistance/interagency- coordination-group/IACG_final_report_EN.pdf?ua=1, accessed 5 July 2019). Substantial progress has been made in monitoring the population-level emergence and transmission of HIVDR. Between 2004 and 2018, 49 countries implemented surveys of HIVDR using WHO-recommended standard methods. A further 35 countries have plans to conduct surveys (Fig. 1). This report presents findings from 44 nationally representative HIVDR surveys implemented in 24 low- and middle-income countries using WHO standard survey methods.2 In 12 of 18 countries reporting survey data to WHO between 2014 and 2018, levels of pretreatment HIVDR (PDR) to efavirenz (EFV) and/or nevirapine (NVP) among adults initiating first-line ART exceeded 10% (Fig. 2). Overall, levels of NNRTI PDR are nearly twice as high among women as among men. These findings are important, since women comprise a larger proportion of the population living with HIV globally and especially in sub-Saharan Africa, the region with the highest burden of HIV infection. Another subpopulation at high risk of PDR is individuals reinitiating first-line ART and reporting previous exposure to ARV drugs (for example, for preventing the mother-to-child transmission of HIV, previous ART for treating HIV infection, post-exposure prophylaxis (PEP) and pre-exposure prophylaxis (PrEP) 2 HIV drug resistance surveillance guidance: 2015 update. Geneva: World Health Organization; 2015 (https://apps.who.int/iris/bitstream/handle/ 10665/204471/9789241510097_eng.pdf;jsessionid=42B6287D67B61D- 47BC29C36FD598DAA8?sequence=1, accessed 5 July 2019). Fig. 1. Implementation of national HIV drug resistance surveys, 2004–2018 0 1,700 3,400850 Kilometers The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. © WHO 2019. All rights reserved. Year of most recent survey 2004-2013 2014-2017 2018-2019 Planned Data Source: World Health Organization Map Production: Information Evidence and Research (IER) World Health Organization Data not available Not applicable HIV DRUG RESISTANCE REPORT 2019vi believed to have been taken since the person became HIV positive). Twelve of 18 surveys included both ARV drug– naive ART initiators and ART starters reporting previous exposure to ARV drugs. Among first-line ART initiators reporting prior ARV drug exposure, PDR to efavirenz and/or nevirapine is nearly three times higher than among ARV drug– naive individuals starting ART. These findings are relevant, since the proportion of people starting treatment reporting previous ARV drug exposure ranged from 1.2% to 26.3% in countries reporting data and is projected to increase with the continuing global scale-up of ART. Fig. 2. NNRTI pretreatment drug resistance in 18 countries reporting national survey data to WHO, 2014–2018 NNRTI resistance is defined as resistance to NVP or EFV. Previous ARV drug exposure: participants self-reporting being exposed to ARV drugs, such as women exposed to ARV drugs for preventing the mother-to-child transmission of HIV who interrupted ART after delivery and restarted care after a period of time; or defaulters restarting ART. Note that white (empty) cells represent lack of information because surveys excluded people with previous ARV drug exposure (Brazil, Colombia, Cuba and Zimbabwe) or no data on previous exposure were available (Nepal and South Africa). Fig. 2. In 12 of 18 countries the NNRTI PDR prevalence had exceeded 10%. Among women, NNRTI PDR was >10% in 14/18 countries, while among men PDR NNRTI prevalence was >10% in 10/18 countries. The NNRTI PDR prevalence among individuals starting first- line ART and reporting previous ARV drug exposure exceeded 10% in all reporting countries. A concerted global response to increasing levels of PDR is of paramount priority to WHO and its global partners. In 2017, WHO issued guidelines recommending using an alternative first-line regimen that does not contain efavirenz or nevirapine in countries in which resistance to these drugs exceeds 10%.1 In addition, 2018 WHO ARV guidelines recommended the rapid adoption of dolutegravir (DTG)-based regimens as the preferred first-line treatment for adults and children that, if implemented, will help avert the negative effects of resistance to non-nucleoside reverse-transcriptase inhibitors (NNRTIs). 1 Guidelines for the public heath response to pretreatment HIV drug resist- ance. Geneva: World Heath Organization; July 2017 (https://www.who. int/hiv/pub/guidelines/hivdr-guidelines-2017/en/) Fig 2: NNRTI pretreatment drug resistance in 18 countries reporting national survey data to WHO, 2014–2018 WHO region Country Survey year Prevalence of NNRTI PDR All (women and men) Women Men ART initiators reporting being ARV drug naive ART initiators reporting previous ARV drug exposure African region Cameroon 2015 Eswatini 2016 Namibia 2015 Uganda 2016 South Africa 2017 Zimbabwe 2015 Region of the Americas Argentina 2014 Brazil 2014 Colombia 2016 Cuba 2017 Guatemala 2016 Honduras 2016 Mexico 2017 Nicaragua 2016 Western Pacific Region and South-East Asia Region Myanmar 2016 Nepal 2016 Papua New Guinea 2017 Viet Nam 2017 Prevalence of PDR to EFV and/or NVP: <10% 10-30% >30% viiHIV DRUG RESISTANCE REPORT 2019 The prevalence of PDR among children ≤18 months diagnosed with HIV through national early infant diagnosis programmes is alarmingly high. Based on surveys conducted in nine countries in sub-Saharan Africa between 2012 and 2018, over half of the infants newly diagnosed with HIV carry a virus that is resistant to efavirenz and/or nevirapine. Levels of PDR to nucleoside reverse-transcriptase inhibitors (NRTIs) also exceed 10% in some countries. Since 2013, WHO has recommended using protease inhibitor (PI)-based ART regimens for children younger than three years old, and in 2018 WHO formally encouraged the phaseout of NNRTIs across age groups, with the introduction of DTG for children with approved dosing. However, in 2017, globally nearly 77% of young children were still receiving nevirapine in first-line ART because of limited supplies of child-friendly drug formulations.1 Continual efforts to expand the capacity of manufacturing lopinavir/ritonavir pellets formulations and to accelerate the investigation and introduction of DTG across lower weight bands are required since the very high levels of PDR make NNRTI-based ART highly suboptimal. Levels of PDR to NRTIs, including abacavir (ABC), are also high in some countries, underscoring the need to routinely monitor population levels of resistance, especially when ABC is given in combination with drugs with relatively low genetic barriers to selecting drug resistance such as NNRTIs or raltegravir (a first-generation integrase inhibitor). Achieving the third 90 target for maximal viral load suppression, thereby preventing the emergence and transmission of HIVDR, is critical for eliminating AIDS as a public health threat by 2030. Three of the nine countries reporting findings from acquired drug resistance (ADR) surveys among adults receiving HIV treatment between 2014 and 2018 showed levels of viral suppression exceeding 90%. Across all the surveys, the prevalence of ADR among people receiving ART ranged from 3% to 29%. Among populations receiving NNRTI-based ART with viral non-suppression, the levels of NNRTI and NRTI resistance ranged from 50% to 97% and from 21% to 91%, respectively. Estimates of dual class resistance (NNRTI and NRTI) ranged between 21% and 91% of individuals for whom NNRTI-based first-line ART failed. 1 ARV market report 2018: The state of the antiretroviral drug market in low- and middle-income countries, 2017–2022. Boston: Clinton Health Access Initiative; 2018 (https://clintonhealthaccess.org/content/uploads/ 2018/09/2018-HIV-Market-Report_FINAL.pdf, accessed 5 July 2019). The high level of HIVDR among people with viral non- suppression on NNRTI-based first-line ART demonstrates the degree to which NNRTI-based regimens are compromised for people with viral non-suppression detected by a single viral load test, indicating the need for rapid switch to second-line ART once failure to suppress viral loads is identified. Equally, the high levels of NRTI resistance at time of treatment failure, including dual-class NRTI resistance, support the need for optimizing the NRTI backbone during treatment switch, as recommended in WHO’s 2019 antiretroviral guidelines. In addition to routine population-level monitoring of HIVDR, preventing drug-resistant HIV is one of the strategic objectives of the Global Action Plan on HIVDR. WHO recommends monitoring and responding to gaps in quality indicators at the clinic or programme level that are associated with the emergence of HIVDR. These indicators include: appropriate prescribing practices, on-time ART pill pick-up (a proxy measure of adherence), retention on ART at 12 months, viral load testing coverage, viral load suppression, ARV drug stock-outs and timely switch to second-line ART. Between 2014 and 2018, 44 of 45 countries with a high burden of HIV reported these data to WHO. Overall data reporting across all the indicators was incomplete suggesting the need for strengthening systems for monitoring data indicating programme quality. Few countries are attaining the expected targets for quality-of-care indicators, suggesting the need for a proactive approach in addressing gaps in the quality of ART service delivery and minimizing the emergence and spread of HIVDR. Retention on ART at 12 months emerges as a programmatic area requiring significant attention and further improvement.

1SECTION 1: PRETREATMENT HIV DRUG RESISTANCE AMONG ADULTS INITIATING FIRST-LINE ANTIRETROVIRAL THERAPY Purpose and methods. PDR surveys provide evidence to inform the selection and effectiveness of first-line treatment, PEP and PrEP. The sample size estimation, sampling methods and statistical analysis are described in detail in the WHO concept note for PDR surveys among adults initiating first-line ART with and without previous ARV drug exposure.1 Goals. The overall goal of these surveys is to generate (1) nationally representative estimates for PDR among individuals initiating ART, regardless of previous ARV drug exposure, (2) nationally representative estimates of PDR among ARV drug–naive HIV treatment initiators and (3) estimates of the proportion of ART initiators reporting previous ARV drug exposure. Survey implementation progress. Between 2014 and 2018, 39 countries implemented surveys of PDR among adults starting or restarting first-line ART; of those, 25 surveys are completed, and 14 surveys are ongoing. Eighteen countries have plans to initiate surveys of PDR (Fig. 1.1). 1 Surveillance of HIV drug resistance in adults initiating anti retroviral therapy (pre-treatment HIV drug resistance). Geneva: World Health Organization; 2014 (https://apps.who.int/iris/bitstream/ handle/10665/112802/9789241507196_eng.pdf;jsessionid= CB4F92166CBA26A57EB421116A09658F? sequence=1, accessed 5 July 2019). Geographical representation. This report summarizes the results from 18 countries that have completed PDR surveys and have reported data to WHO: six from sub- Saharan Africa;2 nine from the WHO Region of the Americas, two from the Western Pacific Region and two from the South-East Asia Region (countries are listed in Fig. 2). In all countries, PDR surveys followed WHO standard methods, except in South Africa, where PDR estimates were generated from a national household survey. Survey populations. Most of the survey participants from sub-Saharan Africa, Nepal and Papua New Guinea were women (ranging from 51% to 73%). Men predominated in surveys from the Americas, Myanmar and Viet Nam (ranging from 59% to 89%). Twelve of the 18 surveys included ART initiators reporting being both ARV drug– naive or previously exposed to ARV drugs (including women with previous ARV drug exposure for preventing the mother-to-child transmission of HIV and individuals reinitiating first-line ART after initial disengagement from care). In these 12 surveys, the proportion of ART starters 2 Included a national household survey from South Africa. Participants in the PDR analysis were people with no detectable ARV drugs in blood and either self-reported not taking daily medication or this information was unknown (http://www.croiconference.org/sessions/ hiv-drug-resistance- south-africa- results-population-based-household-survey). Fig. 1.1 Implementation of national pretreatment drug resistance surveys among adults initiating or re-initiating first-line ART, 2014–2018 0 1,700 3,400850 Kilometers The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. © WHO 2019. All rights reserved. Survey completed and results reported Survey completed Survey ongoing Survey planned Data Source: World Health Organization Map Production: Information Evidence and Research (IER) World Health Organization Data not available Not applicable HIV DRUG RESISTANCE REPORT 20192 with self-reported previous exposure to ARV drugs ranged from 1.2% (95% confidence interval (CI) 0.4–3.7%) in Uganda to 26% (95% CI 20–34%) in Honduras. Previous use of ARV drugs for preventing the mother-to-child transmission of HIV was the most commonly reported type of previous ARV exposure in Cameroon, Eswatini and Uganda, while previous ART followed by treatment discontinuation and then ART re-initiation was more common in Argentina, Honduras, Mexico, Myanmar, Namibia, Papua New Guinea and Viet Nam. (Tables 1.1a–1.1e). Key findings. In 12 of 18 countries that reported survey findings to WHO, PDR to nevirapine/efavirenz in populations initiating first-line ART had reached levels above 10% (Argentina, Eswatini, Cuba, Guatemala, Honduras, Namibia, Nepal, Nicaragua, Papua New Guinea, South Africa,5 Uganda and Zimbabwe) (Fig. 1.2, Tables 1.2a–1.2e). Overall, in a pooled analysis of data from all countries, the prevalence of PDR to efavirenz and/or nevirapine was much higher in specific subpopulations, notably:    The prevalence of NNRTI PDR was nearly twice as high among women than men initiating ART: 11.8% (95%CI 9.4–14.8) versus 7.8% (95%CI 6.3-9.5) p=0.005. In addition, high levels of PDR to efavirenz and/or nevirapine were more common among women than among men across the surveys: 14 of 18 countries had NNRTI PDR ≥10% among women, and only 10 of 18 countries had NNRTI PDR ≥10% among men (Fig. 1.3).    The prevalence of NNRTI PDR was nearly three times higher among people reinitiating first-line ART reporting previous exposure to ARV drugs than among ARV drug–naive people: 21.1% (95%CI 15.0–28.9) versus 7.8 (6.3–9.6), p≤0.0001 (Fig. 1.4). The prevalence of PDR to NRTIs such as tenofovir (TDF) and XTC (emtricitabine (FTC) or lamivudine (3TC)) ranged from 0% to 4.5% and 0% to 5.7%, respectively (Fig. 1.5). 1 Guidelines for the public heath response to pretreatment HIV drug resistance. Geneva: World Heath Organization; July 2017 (https://www.who.int/hiv/pub/guidelines/hivdr-guidelines-2017/en/) Fig. 1.2 NNRTI (EFV/NVP) pretreatment drug resistance (PDR) among first-line ART initiators Viet  Nam Myanmar Colombia Brazil Cameroon Mexico Nepal Eswatini Zimbabwe Argentina Guatemala Namibia Uganda Papua  New  Guinea Nicaragua South  Africa Cuba Honduras 0 5 10 15 20 25 30 35 NNRTI  pretreatment  drug  resistance  prevalence  (95%  CI) NNRTI  PDR >  10% NNRTI  PDR <  10% Fig 1.2 shows NNRTI PDR point prevalence and 95% confidence intervals among the 18 countries reporting data to WHO between 2014 and 2018. The dotted line (10% prevalence) indicates the NNRTI PDR prevalence above which WHO recommends moving away from NNRTI-based ART in first-line.1 The prevalence of NNRTI PDR prevalence had exceeded 10% (vertical dotted line) in 12 countries. In all countries, PDR estimates are generated from nationally representative surveys using standard WHO survey methods, except in South Africa, where PDR estimates are generated from a national household survey. In 14 countries ART initiators regardless of previous ARV drug exposure were included in the PDR survey; in 4 countries (Brazil, Colombia, Cuba, Zimbabwe) only ARV drug- naive individuals starting ART were included in the PDR surveys. NNRTI PDR is defined as PDR to NVP and/or EFV. 3HIV DRUG RESISTANCE REPORT 2019 Drug resistance classification and analysis methods. HIVDR was assessed using the Stanford HIVdb algorithm Version 8.8. Sequences classified as low-, intermediate- or high-level resistance were designated as resistant. Data for all the outcomes were analysed in Stata software 14.0 (StataCorp LP, College Station, TX, USA)1 to generate weighted estimates based on the study design as described in the survey guidance.1 Implication of the findings. The high levels of observed PDR to NNRTIs highlight the need to fast-track the transition to dolutegravir-based first-line regimens in adults and to use PIs in circumstances where levels of PDR are high and the use of dolutegravir is not feasible as per WHO recommendations. The response to high levels of 1 StataCorp. 2015. Stata Statistical Software: Release 14. College Station, TX: StataCorp LP. Fig. 1.3 NNRTI (EFV/NVP) pretreatment drug resistance (by sex) among first-line ART initiators     r  figs Viet  Nam Myanmar Colombia Brazil Cameroon Nepal Argentina Eswatini Mexico Namibia Zimbabwe Uganda Guatemala South  Africa Papua  New  Guinea Nicaragua Honduras Cuba 0 5 10 15 20 25 30 35 40 45 50 55 60 NNRTI  pretreatment  drug  resistance  prevalence  (95%  CI) Men Women Fig. 1.3 shows the prevalence of NNRTI PDR by sex. In a pooled analysis of all surveys, women had significantly higher PDR prevalence than men: 11.8% (95%CI 9.4–14.8) versus 7.8% (95%CI 6.3–9.5) p=0.005. The dotted line (10% prevalence) indicates the NNRTI PDR prevalence above which WHO recommends moving away from NNRTI-based ART. The NNRTI PDR prevalence among women exceeded 10% in 14 of 18 countries versus 10 of 18 countries for men. NNRTI PDR is defined as PDR to NVP or EFV. PDR in countries is varied and is described in Fig. 1.6. In countries in Central and Latin America the levels of PDR to NNRTIs were particularly high, especially in women, suggesting the need to strengthening the health systems, and in particular, to increase access of women to continued and reliable ARV provision. The low prevalence of TDF/ XTC resistance provides reassurance for using this drug combination in PrEP; however, since these two drugs are used in combination as PrEP and as a component of ART first-line regimens, routine surveillance is required to provide continual assurance that these two ARV drugs can be effectively used as both treatment and prophylaxis when PrEP programmes are scaled up in low- and middle- income countries. HIV DRUG RESISTANCE REPORT 20194 Fig. 1.4 NNRTI (EFV and/or NVP) pretreatment drug resistance (by previous ARV drug exposure) among first-line ART initiators Viet  Nam Myanmar Eswatini Uganda Argentina Cameroon Mexico Guatemala Nambia Papua  New  Guinea Honduras Nicaragua 0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100 NNRTI  pretreatment  drug  resistance  prevalence  (95%  CI) ARV  drug  naive Prior  ARV  drug  exposed Fig. 1.4 shows the prevalence of NNRTI PDR among people initiating ART reporting previous ARV drug exposure and among ARV drug-naive people. The dotted line (10% prevalence) indicates the NNRTI PDR prevalence above which WHO recommends moving away from NNRTI-based ART. Compared with ARV drug naive-initiators, people reinitiating ART reporting previous exposure to ARV drugs had a significantly higher NNRTI PDR prevalence: 21.1% (95%CI 15.0–28.9) versus 7.8 (6.3–9.6), p≤0.0001 (pooled analysis form all surveys). Among people reporting previous ARV drug exposure, the prevalence of NNRTI PDR exceeded 10% in all 12 countries that included this group of people. 5HIV DRUG RESISTANCE REPORT 2019 Fig. 1.5 Pretreatment drug resistance among first-line ART initiators, by country and by drug 0% 5% 10% 15% 20% 25% 30% 35% Pr o p o rt io n  o f  A R T   in it ia to rs  w it h  d ru g   re si st an ce NVP EFV EFV/NVP  and  NRTI TDF XTC EFV: efavirenz; NVP: nevirapine; NRTI: nucleoside reverse-transcriptase inhibitors; TDF: tenofovir disoproxil fumarate; XTC: emtricitabine (FTC) or lamivudine (3TC). Fig. 1.5 shows the prevalence of PDR to the drugs used in first-line regimens. As expected, the prevalence of PDR is driven mainly by PDR to EFV and NVP. Across all countries, the prevalence of NRTI PDR was low and ranged from 0% to 6% for FTC/3TC and from 0% to 5% for TDF. HIV DRUG RESISTANCE REPORT 20196 Fig. 1.6 Country response to levels of pretreatment drug resistance (PDR) to efavirenz/nevirapine >10%, as of July 2019 0 1,700 3,400850 Kilometers The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. © WHO 2019. All rights reserved. Adults PDR response Data not available Not applicable Data Source: World Health Organization Map Production: Information Evidence and Research (IER) World Health Organization CUBA: PDR to EFV/NVP 22.8%. National guidelines revised to include the use of DTG as preferred first-line ART for adults and adolescents (and in women of child-bearing potential who are on reliable and consistent contraception GUATEMALA: PDR to EFV/NVP 13.2%. National guidelines revised to include the use of DTG as preferred first-line ART for adults and adolescents (and in women of child-bearing potential who are on reliable and consistent contraception HONDURAS: PDR to EFV/NVP 25.9%. Revision of national guidelines to use DTG as preferred first-line ART planned NAMIBIA: PDR to EFV/NVP 13.8%. National guidelines revised to include the use of DTG as preferred first-line ART for adults and adolescents (in women and girls of childbearing potential through informed choice). NEPAL: PDR to EFV/NVP 10.2%. Revision of national guidelines to use DTG as preferred first-line ART planned PAPUA NEW GUINEA: PDR to EFV/NVP 17.8%. National guidelines revised to include the use of DTG as preferred first- line ART SOUTH AFRICA: PDR to EFV/NVP 23.6%. National guidelines revised to include the use of DTG as preferred first-line ART for adults and adolescents (in women and girls of childbearing potential through informed choice). ESWATINI: PDR to EFV/NVP 10.5%. National guidelines revised to include the use of DTG as preferred first-line ART for adults and adolescents (in women and girls of childbearing potential through informed choice). UGANDA: PDR to EFV/NVP 15.4%. National guidelines revised to include the use of DTG as preferred first-line ART for adults and adolescents (in women and girls of childbearing potential through informed choice). ZIMBABWE: PDR to EFV/NVP 10.9%. National guidelines revised to include the use of DTG as preferred first-line ART for adults and adolescents (in women and girls of childbearing potential through informed choice). PDR to NNRTI>10% Not applicable ARGENTINA: PDR to EFV/NVP 10.9%. National guidelines revised to include the use of DTG as preferred first-line ART for adults and adolescents (and women of child-bearing potential who are on reliable and consistent contraception). Genotypic resistance testing used to guide treatment in women of child-bearing potential not eligible to use DTG NICARAGUA: PDR to EFV/NVP 19.3%. Revision of national guidelines to use DTG as preferred first-line ART planned 7SECTION 2. PRETREATMENT HIV DRUG RESISTANCE AMONG TREATMENT-NAIVE INFANTS NEWLY DIAGNOSED WITH HIV Purpose and methods. These surveys generate estimates of PDR among infants younger than 18 months who have been newly diagnosed with HIV through early infant diagnosis based on virological testing. Findings from these surveys inform the selection of standard first-line ART in children and accelerate the transition from NNRTI- to non-NNRTI-based first-line ART (dolutegravir or PI-based treatment, depending on the weight of the children). In addition, survey findings of NRTI resistance prevalence inform future optimal treatment strategies. The sample size estimation, sampling methods and statistical analysis are described in detail in the WHO guidance for PDR surveys for infants ≤18 months.1 Goal. The overall goal of these surveys for infants ≤18 months newly diagnosed with HIV through early infant diagnosis is to generate (1) nationally representative estimates of PDR among treatment-naive infants, regardless of exposure to prophylactic regimens used for preventing mother-to-child transmission of HIV, (2) nationally representative estimates of PDR among treatment-naive infants with known exposure to ARV drugs for preventing the mother-to-child transmission of HIV (maternal or neonatal portion), (3) nationally representative estimates of PDR among treatment- 1 Surveillance of HIV drug resistance in children newly diagnosed with HIV by early infant diagnosis. Geneva: World Health Organization; 2017 (https://apps.who.int/iris/bitstream/handle/ 10665/259732/9789241512541-eng.pdf?sequence=1, accessed 5 July 2019). naive infants with no or unknown exposure to drugs for preventing the mother-to-child transmission of HIV, and (4) estimates of the proportion of infants newly diagnosed with HIV through early infant diagnosis with reported exposure to ARV drugs for preventing the mother-to-child transmission of HIV. Progress in implementing the surveys and geographical representation. Between 2012 and 2018, 10 countries implemented surveys of PDR among treatment-naive infants ≤18 months. Nine countries have completed the survey, in one country the survey is still ongoing, and two countries are planning the survey. This report summarizes the findings from nine surveys conducted in sub-Saharan Africa (Fig. 2.1). Survey populations. Most infants surveyed had prior ARV drug exposure(s), either ARV drugs taken by the mother to prevent transmission to the infant or taken by the infant to prevent infection. Overall ARV drug exposures ranged from 40% in Cameroon to 85% in Mozambique. Many of the infants, however, had missing information on ARV drugs for preventing the mother-to-child transmission of HIV exposure, ranging from a low of 3% in Zimbabwe to 28% in Nigeria (Tables 2.1 a–b). Fig. 2.1 Implementation of WHO national pretreatment HIV drug resistance surveys among infants newly diagnosed with HIV and treatment naive, 2012–2018 0 1,700 3,400850 Kilometers The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. © WHO 2019. All rights reserved. Survey completed and results reported Survey ongoing Survey planned Data Source: World Health Organization Map Production: Information Evidence and Research (IER) World Health Organization Data not available Not applicable 0 1,700 3,400850 Kilometers The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. © WHO 2019. All rights reserved. Survey completed and results reported Survey ongoing Survey planned Data Source: World Health Organization Map Production: Information Evidence and Research (IER) World Health Organization Data not available Not applicable HIV DRUG RESISTANCE REPORT 20198 Key findings. Overall, prevalence estimates of PDR to efavirenz and nevirapine were very high, ranging from 34% (95% CI 27–41%) in Eswatini to 69% (95% CI 62–75%) in Malawi, indicating that about half of infants newly diagnosed with HIV carry drug-resistant HIV before initiating treatment (Fig. 2.2). PDR to abacavir and lamivudine (the preferred NRTIs for infants) was also high and exceeded 10% in three and four of the nine countries, respectively (Fig. 2.3). (Tables 2.2 a–b) Implications of the findings. Although more than half the infants newly diagnosed in these surveys carried NNRTI-resistant HIV, uptake of WHO recommendations for PI-based first-line regimens for young children is low. In 2017, nearly 77% of young children were receiving NNRTI- based regimens, because of limited supplies of appropriate child-friendly formulations.1 Fig. 2.4 shows the country responses to high levels of PDR among children ≤18 months. The results suggest the need to accelerate access to child-friendly non-NNRTI-based formulations in this vulnerable population to prevent poor treatment outcomes. Survey findings also highlight the increasing levels of PDR to NRTIs in some countries, suggesting the need for caution when using abacavir and lamivudine in combination with drugs that have a low genetic barrier for resistance (nevirapine (NVP) or raltegravir). 1 ARV market report 2018: The state of the antiretroviral drug market in low- and middle-income countries, 2017–2022. Boston: Clinton Health Access Initiative; 2018 (https://clintonhealth access.org/content/ uploads/2018/09/2018-HIV-Market-Report_ FINAL.pdf, accessed 5 July 2019). Fig. 2.2 NNRTI (EFV and/or NVP) pretreatment drug resistance among treatment-naive infants newly diagnosed with HIV, 2012–2018 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% Malawi           2016 Zimbabwe   2012 South  Africa   2014 Togo                 2012 Mozambique   2012 Nigeria           2016 Cameroon   2014 Uganda           2011 Eswatini       2011 Pr o p o rt io n  w it h  N N R TI  D R  (% ) All PMTCT  + PMTCT  -­‐/unk NNRTI PDR is defined as PDR to NVP or EFV. PMTCT: prevention of mother-to-child HIV transmission; PMTCT+: exposed to maternal and neonatal PMTCT-prophylactic ARV drugs; PMTCT -/unk: either PMTCT unexposed or with missing information on PMTCT exposure; unk: unknown. Fig. 2.2 shows the prevalence of NNRTI PDR among infants ≤18 months newly diagnosed with HIV and ARV naive. Overall, NNRTI PDR is alarmingly high with nearly half of young children having drug-resistant HIV before initiating treatment. Although the prevalence of NNRTI PDR is higher among those reporting exposure to PMTCT, children with unknown or no PMTCT exposure also have a high prevalence of NNRTI PDR. 9HIV DRUG RESISTANCE REPORT 2019 Fig. 2.3 Prevalence of NRTI HIV drug resistance among treatment-naive infants newly diagnosed with HIV, by drug and country 0% 5% 10% 15% 20% 25% 30% Nigeria         2016 Malawi         2016 Togo                 2012 South  Africa   2014 Cameroon   2014 Zimbabwe   2012 Uganda       2011 Mozambique   2012 Eswatini       2011 Pr o p o rt io n  w it h  D R  (% ) any  NRTI ABC XTC AZT TDF Legend: ABC: abacavir; AZT: zidovudine; NRTI: nucleoside reverse-transcriptase inhibitor; TDF: tenofovir disoproxil fumarate; XTC: emtricitabine (FTC) or lamivudine (3TC) Fig. 2.4 Country response to high levels of pretreatment drug resistance (PDR) among infants, as of July 2019 0 1,700 3,400850 Kilometers The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. © WHO 2019. All rights reserved. Infants PDR response Data not available Not applicable Data Source: World Health Organization Map Production: Information Evidence and Research (IER) World Health Organization ESWATINI: PDR to EFV/NVP 34.0%. LPV-r is the preferred and most-commonly used first-line ART for children <3 years. Discussions are ongoing to use DTG for children ≥20kg CAMEROON: PDR to EFV/NVP 47.0%. LPV-r is the preferred first-line ART for children <3 years in the national guidelines and discussions are ongoing to use DTG for children ≥20kg; however, NNRTIs are still the most commonly used first-line pediatric regimens MALAWI: PDR to EFV/NVP 68.8%. Adoption of LPV-r or INSTI as the preferred first-line ART in the national guidelines in process; NNRTIs are currently the first-line pediatric regimens MOZAMBIQUE: PDR to EFV/NVP 56%. LPV-r is the preferred first-line ART for children <3 years in the national guidelines and discussions are ongoing to use DTG for children ≥20kg ; however, NNRTIs are still the most commonly used first-line pediatric regimens NIGERIA: PDR to EFV/NVP 48.6%. LPV-r is the preferred first-line ART for children <3 years in the national guidelines and discussions are ongoing to use DTG for children ≥20kg ; however, NNRTIs are still the most commonly used first-line pediatric regimens (~91% of children) SOUTH AFRICA: PDR to EFV/NVP 63.7%. LPV-r is the preferred and most-commonly used first-line ART for children <3 years. Discussions are ongoing to use DTG for children ≥20kg TOGO: PDR to EFV/NVP 57.3%. LPV-r is the preferred first-line ART in the national guidelines UGANDA: PDR to EFV/NVP 35.7%. LPV-r is the preferred and most commonly used first-line ART for children <3 years. Discussions are ongoing to use DTG for children ≥20kg ZIMBABWE: PDR to EFV/NVP 63.9%. LPV-r is the preferred first-line ART for children <3 years in the national guidelines and discussions are ongoing to use DTG for children ≥20kg ; however, NNRTIs are still the most commonly used first-line pediatric regimens High levels of pretreatment HIV drug resistance (PDR) to efavirenz/nevirapine Data not available Not applicable Fig. 2.3 shows the prevalence of NRTI HIVDR among ARV-naive children ≤18 months newly diagnosed with HIV. The prevalence of NRTI resistance is also high, exceeding 10% for ABC, XTC and AZT in some countries. 10 SECTION 3. ACQUIRED HIV DRUG RESISTANCE AMONG ADULTS RECEIVING ANTIRETROVIRAL THERAPY Purpose and methods. Surveys of acquired HIV drug resistance (ADR) provide information needed to assess the performance of programmes in maximizing population- level viral suppression and inform the optimal selection of second- and third-line ART. The sample size estimation, sampling methods and statistical analysis are described in detail in the WHO guidance for ADR surveys of adults receiving ART.1 Goal. The overall goal of these cross-sectional surveys is to generate nationally representative estimates of (1) viral load suppression and (2) HIVDR in populations receiving ART for 12 (±3) months (referred to as early time point surveys) and ≥48 months (referred to as late time point surveys). Geographical representation. Between 2014 and 2018, 23 countries implemented 47 surveys of ADR among adults receiving ART; of these, 19 surveys have been completed and 26 are ongoing. Fifteen countries have plans to conduct ADR surveys (Fig. 3.1). This report summarizes the results from 17 surveys (nine surveys reporting data from the early time point and eight surveys from the late time point) conducted in nine countries: five from sub-Saharan Africa, three from the WHO Region of the Americas and one from the Western Pacific Region. Survey populations. Most of the participants from sub-Saharan Africa in surveys from both time points were women (ranging from 60% to 78%); men were predominant in the surveys from the early time point in the WHO Region of the Americas and in Viet Nam (ranging from 65% to 70%). However, there were fewer men in surveys assessing ADR at the late time point in the Region of the Americas (ranging from 41% to 62%), with most participants being women in Honduras (59%). 1 Surveillance of HIV drug resistance in adults receiving ART (acquired HIV drug resistance). Geneva: World Health Organization; 2014 (https:// apps.who.int/iris/bitstream/handle/10665/112801/9789241507073_eng. pdf?sequence=1, accessed 5 July 2019). The mean time on ART among participants enrolled in the early time point surveys ranged from 11.8 months in Viet Nam to 17.9 months in Cameroon;2 the mean time on ART ranged from 52.2 months in Senegal to 102.3 months in Honduras among people enrolled in the late time point survey. In all surveys, the most common regimen was TDF + 3TC or FTC + EFV. In surveys of people on ART for 12 months ±3 months, nearly all participants were receiving NNRTI-based first-line ART ranging from 88% in Nicaragua to 100% in Zambia. In late time point surveys, the proportion of participants receiving NNRTI-based first-line ART ranged from 75% in Nicaragua to 99% in Senegal. In the late time point survey, TDF + XTC + EFV was the most common regimen in Cameroon, Guatemala, Senegal and Viet Nam, but NVP and zidovudine (AZT) were also substantially used in all countries. In particular, AZT + XTC + EFV was the most common regimen in Honduras and Nicaragua, and AZT + XTC + NVP was the predominant regimen in Eswatini and Uganda. The proportion of people receiving second-line regimens was low across all surveys, ranging from 0.2% in Eswatini to 2% in Nicaragua in the early time point survey and from 1% in Senegal to 14% in Nicaragua for participants in the late time point survey (Tables 3.1 a–g). HIVDR classification and analysis methods. HIVDR was assessed using the Stanford HIVdb algorithm Version 8.8. Sequences classified as low-, intermediate- or high-level resistance were designated as resistant. Data for all the outcomes were analysed in Stata software 14.0 (StataCorp LP, College Station, TX, USA)3 to generate weighted estimates based on the study design as described in the WHO ADR survey concept guidance.4 2 In Cameroon, individuals receiving ART for 12–24 months were included in the 12-month ADR survey. 3 StataCorp. 2015. Stata Statistical Software: Release 14. College Station, TX: StataCorp LP. 4 HIV drug resistance surveillance guidance: 2015 update. Geneva: World Health Organization; 2015 (https://apps.who.int/iris/ bitstream/ handle/10665/204471/9789241510097_eng.pdf;jsessionid= 42B6287D67B61D47BC29C36FD598DAA8? sequence=1, accessed 5 July 2019). 11HIV DRUG RESISTANCE REPORT 2019 Fig. 3.1 Implementation of WHO acquired HIV drug resistance national surveys among adults receiving antiretroviral therapy, 2014–2018 0 1,700 3,400850 Kilometers The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. © WHO 2019. All rights reserved. Survey completed and results reported Survey completed Survey ongoing Survey planned Data Source: World Health Organization Map Production: Information Evidence and Research (IER) World Health Organization Data not available Not applicable Key findings. Overall, four of nine countries achieved the third 90–90–90 target for viral load suppression of ≥90% in the early time point survey and three of eight in the late time point survey. However, in three of nine countries, viral load suppression fell below the 90% target by 10–20 percentage points (Fig. 3.2). The prevalence of viral load suppression for early time point surveys ranged from 72% in Cameroon to 95% in Vietnam. In contrast, the prevalence of viral load suppression in the late time point survey was comparatively lower in five of eight countries that reported data from both time points; these differences were significant in two countries: Honduras and Uganda (Fig. 3.3 and 3.4 and Tables 3.2 a–h). Considering a conservative approach when people not retained in care are classified as not having suppressed viral loads, the prevalence of viral load suppression among the four countries reporting reliable retention data dropped by between 12 and 22 percentage points (Guatemala from 89% to 67%, Honduras from 90% to 73%, Nicaragua from 78% to 57% and Viet Nam from 96% to 84%), highlighting the need to account for retention when estimating viral load suppression (Tables 3.2 a–h). Overall, the prevalence of any HIVDR among all individuals receiving treatment ranged from 3% in Viet Nam to 29% in Honduras and was overall slightly higher in the late time point surveys (Tables 3.3 a–h). Among populations for whom NNRTI-based first-line treatment failed, the level of NNRTI resistance in the early time point survey ranged from 50% in Eswatini to 97% in Uganda, and the prevalence of dual-class NNRTI and NRTI resistance ranged from 21% in Senegal to 91% in Uganda. In most late time point surveys, the prevalence of NNRTI, NRTI and dual-class NNRTI and NRTI resistance was higher than the estimates observed at the early time point (Fig. 3.3–3.8). HIV DRUG RESISTANCE REPORT 201912 Implications of the findings. Although the observed high levels of viral load suppression are reassuring, some countries report much lower prevalence estimates of viral suppression especially among people on ART for a longer period of time. The heterogeneous levels of viral load suppression between countries demonstrate clear differences in programme performance between countries. Overall, the quality of service delivery needs to be strengthened, including addressing specific needs especially among long-term treated people to meet the 90% target for viral load suppression. The drop in viral load suppression estimates when people who were lost from care are considered as having viral non-suppression indicate the need to reinforce retention. The high levels of HIVDR to both NNRTI and NRTI among participants with viral non-suppression indicate the need to scale up viral load testing and promptly switch individuals with confirmed failure to second-line ART. The observed high levels of NRTI resistance, including dual-class TDF + XTC resistance, suggest the need to optimize the NRTI backbone when switch to second line ART is done among people with non-suppressed viral loads. Viral load monitoring before treatment substitutions including from TDF + XTC + NNRTI to TDF + XTC + DTG is encouraged and considered good practice, as a significant proportion of people failing NNRTI-based ART have resistance to both TDF and XTC. Fig. 3.2 Viral load suppression among adults receiving ART for 12 and ≥ 48 months (national ADR surveys), 2014–2018 All surveys followed WHO standard survey methods. Survey methods adaptations: in Cameroon, participants who had been receiving treatment for 12–24 months were included in the early time point survey (12 months) i. In Senegal, participants who had been receiving treatment for ≥40 months were included in the late time point survey (≥48 months). Weighted estimates. 0 10 20 30 40 50 60 70 80 90 100 Viet  Nam               2017 Uganda             2016 Eswatini             2016 Zambia                   2016 Honduras             2016 Guatemala             2016 Senegal             2017 Nicaragua             2016 Cameroon             2015 Pe rc en ta ge  w it h   vi ra l  l oa d   <1 00 0   co pi es /m L 12  months ≥48  months   Fig. 3.2 shows the prevalence of viral load suppression across the two survey time points. Overall, the prevalence of viral load suppression was higher at the early time point (12 months) than the late time point (≥48 months), but the difference was only statistically significant in Honduras and Uganda. 13HIV DRUG RESISTANCE REPORT 2019 Fig. 3.3 Prevalence of acquired HIV drug resistance by drug class and country (early time point survey, 12 months) EFV: efavirenz; NVP: nevirapine; NRTI: nucleoside reverse-transcriptase inhibitors; TDF: tenofovir disoproxil fumarate; XTC: emtricitabine (FTC) or lamivudine (3TC). The early time point survey in Cameroon included participants who had been receiving treatment for 12–24 months. Weighted estimates. Fig. 3.4 Prevalence of acquired HIV drug resistance by drug class and country (late time point survey, ≥48 months) EFV: efavirenz; NVP: nevirapine; NRTI: nucleoside reverse-transcriptase inhibitors; TDF: tenofovir disoproxil fumarate; XTC: emtricitabine (FTC) or lamivudine (3TC). The survey in Senegal included participants who had been receiving treatment for ≥40 months. Weighted estimates. VietNam36 2014 87.00% 79.90% 87.70% 87.00% 82.10% 84.80% 10.50% 14.90% 9.90% 10.50% 13.10% <-­‐  add  N  under  country  n 30 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Uganda         2016 Honduras   2016 Nicaragua   2016 Guatemala   2016 Zambia         2016 Vietnam     2017 Senegal         2017 Cameroon   2015 Eswatini   2016 Pr o p o rt io n  w it h  d ru g   re si st an ce ADR12 NVP EFV EFV/NVP  and  NRTI NRTI XTC TDF 93 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Uganda         2016 Honduras   2016 Nicaragua   2016 Guatemala   2016 Vietnam     2017 Senegal         2017 Cameroon   2015 Eswatini   2016 Pr o p o rt io n  w it h  d ru g   re si st an ce ADR48 NVP EFV EFV/NVP  and  NRTI NRTI XTC TDF Fig. 3.3 shows the prevalence of ADR for commonly used first-line drugs among participants for whom treatment failed in the early- time point survey. The prevalence of EFV and NVP ADR ranged from 50% in Eswatini to 97% in Uganda, and the prevalence of NRTI ADR ranged from 21% in Senegal to 91% in Uganda. Fig. 3.4 shows the prevalence of ADR for commonly used first-line drugs among participants for whom treatment failed in the late- time point survey. The prevalence of EFV and NVP ADR ranged from 71% in Nicaragua to 92% in Senegal, and the prevalence of NRTI ADR ranged from 57% in Senegal to 87% in Uganda. Overall HIVDR genotyping failure rates varied across the different surveys. It is therefore possible that HIVDR may be overestimated or underestimated if genotyping failures are correlated with the presence or absence of HIVDR. In addition, the small sample size for the ADR estimates may result in imprecise estimates necessitating caution in the interpretation. HIV DRUG RESISTANCE REPORT 201914 Fig. 3.6 NNRTI mutations associated with acquired drug resistance by country (late time point survey, ≥48 months) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% any  NNRTI   SDRM L100I K101EP K103NS V106AM E138A Y181  any Y188  any G190  any P225H M230L M ut at io n   Pr ev al en ce Cameroon  2015 Guatemala  2016 Nicaragua  2016 Uganda  2016 Viet  Nam  2017 Honduras  2016 Senegal  2017 Eswatini  2016 NNRTI: non-nucleoside reverse-transcriptase inhibitors; SDRM: surveillance drug resistance mutations. Unweighted estimates. The late time point survey in Senegal included participants who had been receiving treatment for ≥40 months. Fig. 3.6 shows the patterns of NNRTI ADR mutations among individuals for whom treatment failed in the late time point survey. K103N/S was the predominant mutation in all countries. Fig. 3.5 NNRTI mutations associated with acquired drug resistance by country (early time point survey, 12 months) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% any  NNRTI   SDRM L100I K101EP K103NS V106AM E138A Y181  any Y188  any G190  any P225H M230L M ut at io n   pr ev al en ce Cameroon  2015 Guatemala  2016 Nicaragua  2016 Uganda  2016 Viet  Nam  2017 Zambia  2016 Honduras  2016 Senegal  2017 Eswatini  2016 NNRTI: non-nucleoside reverse-transcriptase inhibitors; SDRM: surveillance drug resistance mutations. Unweighted estimates. The early-time point survey in Cameroon included participants who had been receiving treatment for 12–24 months. Fig. 3.5 shows the patterns of NNRTI ADR mutations among individuals for whom treatment failed in the early time point survey. K103N/S was the predominant mutation in all countries except for Eswatini and Zambia, where V106A/M predominated. 15HIV DRUG RESISTANCE REPORT 2019 Fig. 3.7 NRTI mutations associated with acquired drug resistance by country (early time point survey, 12 months) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% any  NRTI   SDRM M41L K65R D67EGN T69D K70ER L74IV V75AMST Y115F M184IV L210W T215  any K219  any M ut at io n   Pr ev al en ce Cameroon  2015 Guatemala  2016 Nicaragua  2016 Uganda  2016 Viet  Nam  2017 Zambia  2016 Honduras  2016 Senegal  2017 Eswatini  2016 NRTI: nucleoside reverse-transcriptase inhibitors; SDRM: surveillance drug resistance mutations. The early time point survey in Cameroon included participants who had been receiving treatment for 12–24 months. Unweighted estimates. Fig. 3.8 NRTI mutations associated with acquired drug resistance by country (late time point survey, ≥48 months) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% any  NRTI   SDRM M41L K65R D67EGN T69D K70ER L74IV V75AMST Y115F M184IV L210W T215  any K219  any M ut at io n   Pr ev al en ce Cameroon  2015 Guatemala  2016 Nicaragua  2016 Uganda  2016 Viet  Nam  2017 Honduras  2016 Senegal  2017 Eswatini  2016 NRTI: nucleoside reverse-transcriptase inhibitors; SDRM: surveillance drug resistance mutations. The late time point survey in Senegal included participants who had been receiving treatment for ≥40 months. Unweighted estimates. Fig. 3.7 shows the patterns of NRTI ADR mutations among individuals for whom treatment failed in the early time point survey. M184V was the most frequent NRTI mutation in all countries except for Senegal, where K65R predominated. Fig. 3.8 shows the patterns of NRTI ADR mutations among individuals for whom treatment failed in the early time point survey. M184V was the most frequent NRTI mutation in all countries. 16 SECTION 4. ASSESSMENT OF PROGRAMMATIC QUALITY INDICATORS ASSOCIATED WITH THE EMERGENCE OF HIVDR Preventing HIVDR is critical for the long-term success of ART programmes and is achieved by optimizing the quality of ART service delivery. Attaining high-quality ART service delivery involves routinely monitoring quality-of-care indicators associated with and predictive of the emergence of drug-resistant HIV. Identifying gaps in service delivery and, if found to be present, swift implementation of specific and evidence-informed actions to improve clinic and programme performance are critical. Key quality- of-care indicators associated with the prevention of HIVDR include: appropriate prescribing practices (use of internationally recommended triple drug regimens), on-time ART pill pick-up (a proxy measure of appropriate adherence to ART), retention on ART 12 months after initiation, viral load testing coverage (assesses adequate treatment monitoring for identification and switch of regimen in people for whom ART is failing), viral load suppression, ARV drug stock-outs and timely switch to second-line ART (proxy measure on how well a country uses viral load testing results to identify failure and switch people in a timely manner to the next line of treatment). Key findings Country-level assessment. Between 2015 and 2018, 44 of 45 WHO focus countries reported data on programmatic quality indicators through the UNAIDS Global AIDS Monitoring system.1 Where available, viral load suppression data from a PEPFAR (United States President’s Emergency Plan for AIDS Relief) population health indicator survey were used.2 The targets for the country-level programmatic quality indicators are classified based on the targets for clinic-level WHO early warning indicators of HIVDR.3 To provide as minimally biased estimates as possible, only data from countries reporting nationally representative data or data from ≥70% of all ART clinics in the country are summarized below (Fig. 4.1).    Retention 12 months after ART initiation. The proportions of countries with classifiable data were 1 of 45 (2%) in 2015, 15 of 45 (33%) in 2016 and 18 of 45 (40%) in 2017. The proportion of reporting countries meeting the 1 Global AIDS Monitoring [online database]. Geneva: UNAIDS; 2019 (https://www.unaids.org/en/dataanalysis/knowyour response/ globalaidsprogressreporting, accessed 5 July 2019). 2 https://phia.icap.columbia.edu 3 Consolidated guidelines on person-centred HIV patient monitoring and case surveillance guidelines (section 2.4.6) and Annex 2.4.6: HIVDR EWI sampling, abstraction and reporting guidance. Geneva: World Health Organization; 2017 (https://www. who.int/hiv/pub/guidelines/ WHO_Consolidated_Guidelines_Annexes_2.4.6.pdf?ua=1, accessed 5 July 2019). target of ≥85% retention was 100% (1 of 1) in 2015, 40% (6 of 15) in 2016 and 28% in 2017 (5 of 18).    Viral load testing coverage. The proportions of countries with data were 19 of 45 (42%) in 2015, 18 of 45 (40%) in 2016 and 29 of 45 (64%) in 2017. The proportions of reporting countries achieving the target of ≥70% were 16% (3 of 19) in 2015, 17% (3 of 18) in 2016 and 31% (9 of 29) in 2017.    Viral load suppression. The proportions of countries with classifiable data were 3 of 45 (6%) in 2015, 8 of 45 (18%) in 2016 and 15 of 45 (33%) in 2017. Among these countries, none met the target of ≥90% viral load suppression in 2015 (0 of 3), 50% (4 of 8) in 2016 and 13% (2 of 15) in 2017.    Drug stock-outs. The proportions of countries reporting were 28 of 45 (62%) in 2015, 32 of 45 (71%) in 2016 and 30 of 45 (67%) in 2017. The proportion of reporting countries meeting the target of zero drug stock- outs was 46% (13 of 28) in 2015, 50% in 2016 (16 of 32) and 53% in 2017 (16 of 30).    Proportion of people receiving second-line ART. The proportion of people switched to second-line ART is a proxy measure of how well a country identifies people failing treatment and switches them to a more effective regimen, thus preventing the accumulation of HIVDR. Programmatic and survey data show that about 5–30% of people receiving ART have viral non-suppression and thus may need to switch to second-line ART. The proportions of countries reporting the proportion of people receiving second-line ART were 17 of 45 (38%) in 2015, 16 of 45 (36%) in 2016 and 29 of 45 (64%) in 2017. The proportions of reporting countries that met the target of having at least 5% of people receiving a second-line regimen were 59% (10 of 17) in 2015, 56% (9 of 16) in 2016 and 45% (13 of 29) in 2017. Clinic-level retention assessment. Between 2015 and 2018, nine countries reported clinic-level data (early warning indicators of HIV drug resistance)3 to WHO: Benin, Burkina Faso, Dominican Republic, Egypt, Ethiopia, Ghana, Myanmar, Uganda, United Republic of Tanzania and Zimbabwe. All 10 countries reported data on adult populations; Myanmar and Zimbabwe reported separate data on adults and children. Data on most indicators were variedly reported since countries did not monitor all the indicators. Retention was widely reported and thus is included in this report. 17HIV DRUG RESISTANCE REPORT 2019 Fig. 4.1 Countries with a high burden of HIV infection meeting targets for the quality-of-care indicators associated with the emergence of HIVDR, 2015–2017 Figure 4.1 summarizes data on programmatic quality indicators associated with HIVDR from 45 WHO HIV focus countries. Overall data reporting was varied and not all countries met the reporting criteria for national-representativeness. Few countries attained the targets for quality of care indicators, but there was a signal of improvement for 2 of the 5 indicators: viral load testing coverage (number of countries meeting target improved from 16% in 2015 to 31% in 2017) and drug stock-outs (number of countries meeting target improved from 46% in 2015 to 53% in 2017). Of note, not all of the same countries reported the same indicators during the reporting period, limiting the ability to assess trends within and between countries over time. Source: UNAIDSInfo, UNAIDS/WHO Global AIDS Monitoring tool and WHO/AIDS Medicines and Diagnostics Survey on the use of ARV medicines and laboratory technologies and implementation of WHO related Guidelines. aViral load suppression data (from 11 countries) were obtained from PHIA (Population health impact survey supported by PEPFAR) b Countries’ datasets were included if they comprise ≥70% of the people newly initiating ART or <70% but reported to be nationally representative c The data originated from countries responding with the proportion of people receiving treatment who received a viral load test in the 12 months period. Countries’ datasets were included if data were collected from everyone receiving ART or from a nationally representative data set. However, the results may overestimate viral load testing coverage in countries in which viral load testing coverage is estimated based on the number of tests done and thus may not be able to account for multiple tests per patient e Countries’ datasets were included if viral load testing coverage was ≥70%; or <70% and reported to be nationally representative. Fig 4.1: Countries with a high burden of HIV infection meeting targets for the quality-of-care indicators associated with the emergence of HIVDR, 2015–2017 Retention on ART at 12 monthb Viral load testing coveragec Viral load suppression at 12 monthsd Drug Stock-out Proportion of people on second- line ART 2015 2016 2017 2015 2016 2017 2015 2016 2017 2015 2016 2017 2015 2016 2017 Angola Botswana Brazil Cambodia Cameroona Chad China Cote d’Ivoirea Democratic Republic of the Congo Dominican Republic Ethiopiaa Eswatinia Ghana Guatemala Haiti India Indonesia Iran (Islamic Republic of) Jamaica Kenya Lesothoa Malawia Malaysia Mali Mexico Morocco Mozambique Myanmar Namibiaa Nigeria Pakistan Papua New Guinea Philippines Russian Federation Somalia South Africa South Sudan Sudan Thailand Ugandaa Ukraine United Republic of Tanzaniaa Viet Nam Zambiaa Zimbabwea Data not available Data reported but not national representative or ≥70% of eligible population Excellent performance: targets for retention at 12 months (>85%), viral load testing coverage (≥70%), viral load suppression (≥90%), drug stock-outs (0%), proportion of people on second-line ART (≥5%) Fair performance: targets for retention at 12 months (75-85%), viral load suppression (80-<90%) Unsatisfactory performance: retention (<75%), viral load testing coverage (<70%), viral load suppression (<80%), drug stock-outs (>0%), proportion of people on second-line ART (<5%) HIV DRUG RESISTANCE REPORT 201918    All nine countries reported clinic-level data on 12-month retention1 on ART among people newly initiating ART. The proportion of clinics that met the target of ≥85% exceeded 60% in eight of the 10 countries and ranged from a low of 2% in Ghana to 100% in Benin (Fig. 4.2). Implication of the findings. Not all focus countries reported all quality of care indicators, and not all reported the same indicators over time; in addition, not all countries meet the reporting criteria for national representativeness. In general, data reporting was inadequate, suggesting the need for strengthening systems for collection and reporting data indicating programme quality. Few countries attained the targets for quality-of-care indicators, suggesting an 1 Retention is defined as % of patients retained on ART 12 months after ART initiation (numerator: number of people who are alive and on ART 12 months after initiating treatment; denominator: number of people who initiated ART and who were expected to achieve the 12-month outcomes within the reporting period, including those who have died since starting therapy, those who have stopped ART and those who have died since starting therapy, and those recorded as lost to follow-up at month 12). urgent need for a proactive approach in addressing clear gaps in the quality of ART service delivery and in promoting practices which minimize the emergence and transmission of drug-resistant HIV. In particular, both programme- and clinic-level data indicate low rates of retention on ART; this may undermine the global efforts towards attaining epidemic control, since participants lost to follow up may be at a high risk of fuelling the HIV epidemic, including an HIVDR epidemic. More efforts are needed to elucidate the causes of low retention and implement context-specific interventions, including differentiated service delivery approaches, among others. Fig. 4.2 Proportion of clinics achieving targets of quality of care indicators associated with the emergence of HIV drug resistance (Early Warning Indicators of HIVDR, EWI): focus on retention on ART at 12 months1 Fig. 4.2 shows 12-month retention on ART among people newly initiating ART in 10 countries reporting data to WHO. The data are reported by clinic, and the figure indicates the proportion of clinics with unsatisfactory, fair and excellent retention outcomes. Overall, the levels of retention were suboptimal in most clinics; the proportion of clinics that met the target of ≥85% of people retained in care (excellent outcome) ranged from 2% in Ghana to 63% in the Dominican Republic. Only Benin reported achieving this target for all the clinics. ĞŶŝŶ ;ϮϬϭϳͿ ƵƌŬŝŶĂ &ĂƐŽ ;ϮϬϭϱͿ ƚŚŝŽƉŝĂ ;ϮϬϭϲͿ 'ŚĂŶĂ ;ϮϬϭϲͿ hŶŝƚĞĚ ZĞƉƵďůŝĐ ŽĨ dĂŶnjĂŶŝĂ ;ϮϬϭϲͿ hŐĂŶĚĂ ;ϮϬϭϲͿ ŝŵďĂďǁĞ ;ĂĚƵůƚƐ ĂŶĚ ĐŚŝůĚƌĞŶ͕ ϮϬϭϳͿ ŽŵŝŶŝĐĂŶ ZĞƉƵďůŝĐ ;ϮϬϭϱͿ ŐLJƉƚ ;ϮϬϭϳͿ DLJĂŶŵĂƌ ;ĂĚƵůƚƐ ĂŶĚ ĐŚŝůĚƌĞŶ͕ ϮϬϭϰͿ DLJĂŶŵĂƌ ;ĂĚƵůƚƐ ĂŶĚ ĐŚŝůĚƌĞŶ͕ ϮϬϭϱͿ WƌŽƉŽƌƚŝŽŶŽĨĐůŝŶŝĐƐǁŝƚŚƵŶŬŶŽǁŶƌĞƐƵůƚƐ ϯ ϴ ϭϰ WƌŽƉŽƌƚŝŽŶŽĨĐůŝŶŝĐƐǁŝƚŚƵŶƐĂƚŝƐĨĂĐƚŽƌLJ;фϳϱйͿƌĞƐƵůƚƐ ϲϳ ϭϯ ϵϭ ϰϮ ϱϭ Ϯϵ Ϯϯ ϱϰ ϱ ϭϭ WƌŽƉŽƌƚŝŽŶŽĨĐůŝŶŝĐƐǁŝƚŚĨĂŝƌ;ϳϱ–ϴϱйͿƌĞƐƵůƚƐ ϭϳ ϯϱ ϳ ϯϲ Ϯϳ ϭϵ ϭϰ ϴ ϰϰ ϰϯ WƌŽƉŽƌƚŝŽŶŽĨĐůŝŶŝĐƐǁŝƚŚĞdžĐĞůůĞŶƚ;хϴϱйͿƌĞƐƵůƚƐ ϭϬϬ ϭϯ ϱϮ Ϯ ϭϰ ϮϮ ϯϴ ϲϯ ϯϴ ϱϭ ϰϲ EƵŵďĞƌŽĨĐůŝŶŝĐƐƉƌŽǀŝĚŝŶŐZd ϭϭϰ ϭϬϴ ϭϮϯϬ ϭϴϬϬ ϭϴϬϯ ϭϱϳϯ ϳϮ ϭϯ ϭϰϭ ϭϰϭ EƵŵďĞƌŽĨĐůŝŶŝĐƐƌĞƉŽƌƚŝŶŐĞĂƌůLJǁĂƌŶŝŶŐŝŶĚŝĐĂƚŽƌƐ ϳ ϯϬ ϵϰ ϮϬϯ ϯϲ ϯϬϰ ϰϯ ϮϮ ϭϯ ϰϭ ϰϭ Ϭ ϭϬ ϮϬ ϯϬ ϰϬ ϱϬ ϲϬ ϳϬ ϴϬ ϵϬ ϭϬϬ WƌŽƉŽƌƚŝŽŶŽĨĐůŝŶŝĐƐǁŝƚŚĞdžĐĞůůĞŶƚ;хϴϱйͿƌĞƐƵůƚƐ WƌŽƉŽƌƚŝŽŶŽĨĐůŝŶŝĐƐǁŝƚŚĨĂŝƌ;ϳϱ–ϴϱйͿƌĞƐƵůƚƐ WƌŽƉŽƌƚŝŽŶŽĨĐůŝŶŝĐƐǁŝƚŚƵŶƐĂƚŝƐĨĂĐƚŽƌLJ;фϳϱйͿƌĞƐƵůƚƐ WƌŽƉŽƌƚŝŽŶŽĨĐůŝŶŝĐƐǁŝƚŚƵŶŬŶŽǁŶƌĞƐƵůƚƐ 19 TABLES Section 1. Pretreatment HIV drug resistance among adults initiating first-line antiretroviral therapy Table 1.1a. Population characteristics of national PDR surveys – Africa Cameroon (start year 2015) Eswatini (start year 2016) Namibia (start year 2015) N = 321 N = 398 N = 383 n % (95% CI)a n % (95% CI)a n % (95% CI)a Gender Women 203 65.4 (60.0–70.6) 279 73.3 (63.2–81.5) 248 64.8 (59.3–69.8) Men 118 34.6 (29.4–40.1) 119 26.7 (18.5–36.8) 135 35.2 (30.1–40.7) Other 0 – 0 – 0 – Unknown 0 – 0 – 0 – Meanb age (95% CI), yearsb Initiated first-line 37.7 (36.5–38.9) 34.4 (31.6–37.2) 35.3 (33.5–37.1) NNRTI-basedc 320 100.0 (99.7–100.0) 0 – 379 99.7 (98.0–100.0) PI-basedd 1 <0.5 0 – 0 – DTG-based 0 – 0 – 0 – Unknown 0 – 398 100.0 1 <0.5 Backbone: TDF-based 276 87.7 (78.0–93.5) 0 – 360 94.7 (91.8–96.7) Backbone: AZT-based 45 12.3 (6.5–22.0) 0 – 15 3.9 (2.3–6.6) Backbone: d4T-based 0 – 0 – 0 – Previous ARV drug exposure Yes 29 7.8 (4.2–14.0) 40 10.7 (6.8–16.4) 69 18.0 (13.2–24.0) No 223 80.6 (72.2–86.9) 358 89.3 (83.6–93.2) 313 81.7 (75.6–86.6) Unknown 69 11.6 (6.2–20.9) 0 – 1 <0.5 Previous ARVdrug exposure (women) Yes 22 10.0 (5.1–18.7) 36 14.2 (8.7–22.5) 48 19.4 (14.7–24.5) No 137 77.3 (67.4–84.5) 243 85.8 (77.5–91.4) 199 80.2 (74.6–84.9) Unknown 44 12.7 (6.8–22.6) 0 – 1 <0.5 Previous ARV drug exposure (men) Yes 7 3.6 (1.1–11.0) 4 0.9 (0.2–3.2) 21 15.6 (10.1–23.1) No 86 86.8 (77.1–92.7) 115 99.1 (96.8–99.8) 114 84.4 (76.9–89.9) Unknown 25 9.6 (4.5–19.3) 0 – – – Type of ARV drug exposure PMTCT 14 47.4 (17.2–79.7) 25 60.6 (29.7–84.9) 16 23.2 (13.3–37.1) ART 9 24.0 (5.7–62.4) 11 16.1 (5.4–39.4) 53 76.8 (62.8–86.6) Other 6 28.6 (4.6–76.9) 0 – 0 – Unknown 0 – 4 23.3 (4.5–66.3) 0 – a Study design – weighted proportion and 95% confidence interval. b Study design – weighted mean and 95% confidence interval. c NNRTI-based first-line regimens include EFV or NVP. d PI-based first-line regimens include ATV/r, DRV/r or LPV/r. HIV DRUG RESISTANCE REPORT 201920 Table 1.1.b. Population characteristics of national PDR surveys – Africa Ugandaa (start year 2016) Zimbabweb (start year 2015) N = 342 N = 353 n % (95% CI)c n % (95% CI)c Gender Women 208 61.4 (51.8–70.2) 207 56.7 (50.1–63.0) Men 133 38.4 (29.7–48.0) 145 43.3 (36.9–49.8) Other 0 – – – Unknown 0 – 1 <0.5 Mean aged (95% CI), years Initiated first-line 34.1 (31.2–37.0) 34.7 (32.6–36.8) NNRTI-basede 321 100.0 353 100.0 PI-basedf 0 – 0 – DTG-based 0 – 0 – Unknown 0 – 0 – Backbone: TDF-based 305 94.5 (86.8–97.8) 353 100.0 Backbone: AZT-based 16 5.5 (2.2–13.2) 0 – Backbone: d4T-based 0 – 0 – Previous ARV drug exposure Yes 9 1.2 (0.4–3.7) NA NA No 296 88.9 (77.2–95.0) NA NA Unknown 37 9.9 (4.2–21.2) NA NA Previous ARV drug exposure (women) Yes 5 0.9 (0.2–3.8) NA NA No 177 89.6 (74.9–96.1) NA NA Unknown 26 9.5 (3.3–24.8) NA NA Previous ARV drug exposure (men) Yes 4 1.8 (0.5–6.4) NA NA No 118 87.8 (76.9–94.0) NA NA Unknown 11 10.4 (4.9–20.9) NA NA Type of ARV drug exposure PMTCT 14 47.4 (17.2–79.7) NA NA ART 9 24.0 (5.7–62.4) NA NA Other 6 28.6 (4.6–76.9) NA NA Unknown 0 – NA NA a One participant had missing data for gender and 21 participants had missing data for initiated first-line. b Previously ARV drug–exposed participants were not included in the survey. c Study design–weighted proportion and 95% confidence interval. d Study design–weighted mean and 95% confidence interval. e NNRTI-based first-line regimens include EFV or NVP. f PI-based first-line regimens include ATV/r, DRV/r or LPV/r. NA: not available, since individuals with previous ARV drug exposure were excluded from the survey. 21HIV DRUG RESISTANCE REPORT 2019 Table 1.1.c. Population characteristics of national PDR surveys – the Americas Argentina (start year 2014) Brazila (start year 2014)b Cubac (start year 2017) Colombiad (start year 2016) N = 294 N = 1390 N = 150 N = 192 n % (95% CI)e n % (95% CI)e n % (95% CI)e n % (95% CI)e Gender Women 97 33.3 (27.0–40.2) 380 30.3 (26.7–34.1) 30 20.3 (15.4–26.3) 22 11.5 (8.1–15.9) Men 195 65.9 (58.8–72.4) 874 69.7 (65.8–73.3) 120 79.7 (73.7–84.6) 170 88.5 (84.1–91.9) Other 2 0.8 (0.2–3.2) 0 – 0 – 0 – Unknown 0 – 0 – 0 – 0 – Meanf age (95% CI), years Initiated first-line 36.2 (34.8–37.7) 35.6 (35.0–36.2) 35.1 (31.8–38.5) 31.7 (30.5–32.9) NNRTI-basedg 202 68.4 (58.3–77.1) NA NA 94 62.1 (53.2–70.3) NA NA PI-basedh 89 30.1 (22.2–41.0) NA NA 26 17.2 (10.2–27.4) NA NA Others 3 0.7 (0.2–2.3) NA NA 2 1.0 (0.2–4.1) NA NA Backbone: TDF-based 219 71.0 (55.6–82.8) NA NA 96 62.3 (52.4–71.3) NA NA Backbone: AZT-based 52 18.9 (12.4–27.7) NA NA 43 31.4 (22.3–42.1) NA NA Backbone: d4T-based 0 – NA NA 0 – NA NA Backbone: others 23 10.1 (3.5–25.8) NA NA 0 – NA NA Previous ARV drug exposure Yes 54 18.6 (12.2–27.3) NA NA NA NA NA NA No 239 81.0 (72.4–87.4) NA NA NA NA NA NA Unknown 1 <0.5 NA NA NA NA NA NA Previous ARV drug exposure (women) Yes 27 29.0 (18.0–43.3) NA NA NA NA NA NA No 70 71.0 (56.7–82.1) NA NA NA NA NA NA Unknown 0 – NA NA NA NA NA NA Previous ARV drug exposure (men) Yes 27 13.6 (8.4–21.3) NA NA NA NA NA NA No 167 85.9 (78.3–91.1) NA NA NA NA NA NA Unknown 1 <0.5 NA NA NA NA NA NA Type of ARV drug exposure PMTCT 10 20.7 (10.2–37.6) NA NA NA NA NA NA ART 43 77.0 (62.1–87.3) NA NA NA NA NA NA Other 1 <0.5 NA NA NA NA NA NA Unknown 0 – NA NA NA NA NA NA a Previously ARV drug–exposed participants were not included in the survey; initiated first-line was not available; 137 participants had missing information for gender, and 185 had missing information for age. b Survey enrolment between 2013 and 2016, with the majority (~80%) of survey participants enrolled in 2014. c Previously exposed participants were not included in the survey. d Previously exposed participants were not included in the survey; initiated first-line was not available. e Study design–weighted proportion and 95% confidence interval. f Study design–weighted mean and 95% confidence interval. g NNRTI-based first-line regimens include EFV or NVP. h PI-based first-line regimens include ATV/r, DRV/r or LPV/r. NA: not available. HIV DRUG RESISTANCE REPORT 201922 Table 1.1d. Characteristics of the population for PDR surveys – the Americas Guatemalaa (start year 2016) Honduras (start year 2016) Mexicob (start year 2017) Nicaraguac (start year 2016) N = 241 N = 194 N = 2006 N = 171 n % (95% CI)d n % (95% CI)d n % (95% CI)d n % (95% CI)d Gender Women 66 32.7 (20.1–48.4) 61 36.1 (27.8–45.4) 328 15.2 (13.8–16.7) 48 28.1 (21.5–35.7) Men 173 66.7 (51.0–79.4) 126 59.1 (50.5–67.1) 1676 84.6 (83.1–86.0) 123 71.9 (64.3–78.5) Other 2 0.6 (0.2–2.3) 7 4.8 (2.1–13.0) 2 0.2 (0.1–0.7) 0 – Unknown 0 – 0 – 0 – 0 – Meane age (95% CI), years Initiated first-line 32.9 (31.8–34.1) 33.5 (31.7–35.2) 31.9 (31.4–32.3) 34.2 (32.5–35.9) NNRTI-basedf 220 96.7 (91.3–98.8) 172 86.3 (80.4–90.7) 415 19.3 (17.7–20.9) 165 97.1 (94.7–98.4) PI-basedg 5 2.9 (1.0–8.3) 2 0.5 (0.2–1.0) 64 3.1 (2.4–3.9) 5 2.9 (1.6–5.3) DTG-based 0 – 0 – 53 2.5 (1.9–3.2) 0 – Unknown 1 <0.5 19 13.0 (8.7–18.9) 1400 71.6 (69.7–73.4) 0 – Backbone: TDF-based 215 94.0 (89.8–96.7) 144 69.7 (61.5–76.8) 548 25.8 (24.1–27.7) 152 89.4 (83.8–93.3) Backbone: AZT-based 8 4.9 (2.5–9.3) 30 16.7 (11.7–23.3) 12 0.6 (0.4–1.1) 16 9.4 (5.8–15.0) Backbone: d4T-based 0 – 0 – 0 – 0 – Previous ARV drug exposure Yes 7 2.8 (0.7–11.1) 41 26.3 (20.1–33.5) 158 7.4 (6.3–8.7) 21 12.3 (5.8–24.3) No 229 93.9 (81.9–98.1) 134 61.3 (53.3–68.7) 1848 92.6 (91.3–93.7) 146 85.4 (75.4–91.7) Unknown 5 3.3 (0.8–12.9) 19 12.4 (8.1–18.7) 0 – 4 2.3 (1.0–5.4) Previous ARV drug exposure (women) Yes 3 5.7 (1.1–9.3) 19 36.0 (22.3–52.4) 55 16.8 (12.9–21.5) 13 27.1 (16.6–40.9) No 60 91.1 (79.3–96.4) 35 51.2 (34.1–68.1) 273 83.2 (78.5–87.1) 34 70.8 (56.5–82.0) Unknown 3 3.3 (1.5–19.5) 7 12.8 (5.8–16.1) 0 – 1 2.1 (0.2–15.8) Previous ARV drug exposure (men) Yes 4 2.6 (0.9–6.9) 22 22.5 (14.8–32.6) 103 5.7 (4.6–7.1) 8 6.5 (3.0–13.6) No 167 95.3 (88.9–98.1) 92 64.3 (54.5–73.1) 1573 94.3 (92.9–95.4) 112 91.2 (83.7–95.3) Unknown 2 2.1 (0.5–9.4) 12 13.2 (7.2–23.0) 0 – 3 2.4 (0.7–7.9) Previous ARV drug exposure (others) Yes NA NA 0 – 0 – NA NA No NA NA 7 100 2 100 NA NA Unknown NA NA 0 – 0 – NA NA Type of ARV drug exposure PMTCT 1 12.0 (0.1–94.0) 3 7.9 (2.1–25.1) 0 – 8 38.1 (18.3–62.8) ART 0 – 36 90.8 (74.7–97.1) 154 97.1 (91.6–99.0) 2 9.5 (1.2–47.6) Other 0 – 0 – 4 2.9 (1.0–8.4) 1 4.8 (0.3–41.9) Unknown 6 88.0 (6.0–99.9) 2 1.3 (0.3–6.8) 0 – 10 47.6 (34.9–60.6) a 15 participants had missing data for initiated first-line. b 23 participants had missing data for age. c One participant had missing data for initiated first-line. d Study design–weighted proportion and 95% confidence interval. e Study design–weighted mean and 95% confidence interval. f NNRTI-based first-line regimens include EFV or NVP. g PI-based first-line regimens include ATV/r, DRV/r or LPV/r. NA: not available, since individuals with previous ARV drug exposure were excluded from the survey. 23HIV DRUG RESISTANCE REPORT 2019 Table 1.1e. Characteristics of the population for PDR surveys – South-East Asia and the Western Pacific Myanmara (start year 2016) Nepal (start year 2016) Papua New Guineab (start year 2017) Viet Nam (start year 2017) N = 327 N = 274 N = 337 N = 409 n % (95% CI)c n % (95% CI)c n % (95% CI)c n % (95% CI)c Gender Women 115 36.6 (29.8–43.9) 143 50.8 (44.2–57.3) 207 62.5 (57.9–66.8) 122 29.9 (22.8–38.0) Men 206 63.4 (56.1–70.2) 123 46.4 (39.9–53.1) 128 37.0 (33.0–41.3) 287 70.1 (62.0–77.2) Other 0 – 1 0.2 (0.0–0.6) 0 – 0 – Unknown 0 – 7 2.7 (1.6–4.5) 2 0.5 (0.1–2.3) 0 – Meand age (95% CI), years Initiated first-line 35.6 (34.1–37.2) 34.7 (33.6–35.7) 31.4 (30.4–32.5) 34.2 (32.8–35.6) NNRTI-basede 263 100.0 0 – 312 100.0 (98.8–100.0) 0 – PI-basedf 0 – 0 – 0 0 – DTG-based 0 – 00 – 0 0 - Unknown 0 – 274 100.0 0 409 100.0 Backbone: TDF-based 250 93.9 (88.9–96.8) 0 – 267 84.0 (63.1–94.2) 0 – Backbone: AZT-based 7 3.7 (1.5–8.8) 0 – 43 15.4 (5.7–35.4) 0 – Backbone: d4T-based 3 0.8 (0.2–2.9) 0 – 2 0.5 (0.1–3.5) 0 – Others 3 0 – 0 – 0 – Previous ARV drug exposure Yes 32 8.4 (5.0–13.8) 0 – 69 20.9 (13.8–30.3) 28 7.0 (4.1–11.7) No 287 90.0 (83.7–94.0) 0 – 268 79.1 (69.7–86.2) 371 89.8 (82.7–94.2) Unknown 8 1.6 (0.5–5.6) 274 100.0 0 – 10 3.2 (0.8–12.6) Previous ARV drug exposure (women) Yes 19 9.0 (4.8–16.1) 0 – 51 25.4 (19.2–32.9) 14 12.3 (5.6–24.9) No 185 90.2 (82.2–94.8) 0 – 156 74.6 (67.1–80.8) 107 85.9 (72.9–93.2) Unknown 2 0.8 (0.2–4.4) 143 100.0 0 – 1 1.8 (0.8–12.6) Previous ARV drug exposure (men) Yes 13 7.6 (2.9–18.9) 0 – 17 12.8 (4.7–30.2) 14 4.7 (2.3–9.5) No 102 92.4 (81.1–97.1) 0 – 111 87.2 (69.8–95.3) 264 91.5 (83.2–95.9) Unknown 0 – 123 100.0 0 – 9 3.8 (1.0–13.8) Previous ARV drug exposure (others) Yes NA NA 0 1 51.8 (5.3–95.4) NA NA No NA NA 0 1 48.2 (4.6–94.7) NA NA Unknown NA NA 1 100.0 0 – NA NA Type of ARV drug exposure PMTCT 4 10.1 (2.9–29.7) NA 0 7 30.9 (9.7–65.1) ART 24 76.3 (41.2 –93.7) NA 68 100.0 (94.7–100.0) 21 69.1 (34.9–90.4) Other 3 13.2 (2.7–45.5) NA 0 0 – Unknown 1 <0.5 NA 0 0 – a Six participants had missing information for age and gender, and 64 participants had missing information for initiated first-line. b One participant had missing information on data for type of previous ARV drug exposure, and 25 participants had missing information for initiated first-line. c Study design–weighted proportion and 95% confidence interval. d Study design-weighted mean and 95% confidence interval. e NNRTI-based first-line regimens include EFV or NVP. f PI-based first-line regimens include ATV/r, DRV/r or LPV/r. NA: not available. HIV DRUG RESISTANCE REPORT 201924 Table 1.2a. National prevalence estimates of PDR – Africa Cameroon Eswatini Namibiab n/N Prevalence % (95% CI) n/N Prevalence % (95% CI) n/N Prevalence % (95% CI) Alla Any 24/321 8.3 (4.4–15.0) 34/266 11.6 (7.1–18.4) 56/383 14.6 (11.6–18.2) NNRTI 23/321 8.1 (4.3–14.7) 31/266 10.5 (6.3–17.0) 53/383 13.8 (11.1–17.1) NRTI 5/321 2.4 (0.4–12.9) 4/266 1.0 (0.3–3.3) 6/383 1.6 (0.6–3.8) PI 1/321 0.2 (0.0–1.7) 2/266 0.9 (0.2–4.2) 2/383 0.5 (0.1–2.2) NNRTI+NRTI 5/321 2.4 (0.4–12.9) 3/266 0.8 (0.2–3.2) 5/383 1.3 (0.5–3.6) Women Any 17/203 10.6 (5.2–20.3) 24/173 14.6 (9.1–22.6) 39/248 15.7 (11.3–21.5) NNRTI 16/203 10.2 (4.9–20.0) 21/173 12.8 (7.6–20.7) 37/248 14.9 (10.7–20.4) NRTI 4/203 3.6 (0.6–18.7) 4/173 1.7 (0.5–5.1) 4/248 1.6 (0.5–5.3) PI 1/203 0.3 (0.0–2.6) 2/173 1.5 (0.3–6.4) 2/248 0.8 (0.2–3.2) NNRTI+NRTI 4/203 3.6 (0.6–18.7) 3/173 1.3 (0.4–5.0) 4/248 1.6 (0.5–5.3) Men Any 7/118 4.0 (1.4–10.4) 10/93 6.9 (2.6–17.3) 17/135 12.6 (9.1–17.2) NNRTI 7/118 4.0 (1.4–10.4) 10/93 6.9 (2.6–17.3) 16/135 11.9 (8.2–16.8) NRTI 1/118 0.1 (0.0–0.8) 0/93 – 2/135 1.5 (0.3–6.2) PI 0/118 – 0/93 – 0/135 – NNRTI+NRTI 1/118 0.1 (0.0–0.8) 0/93 – 1/135 0.7 (0.1–6.0) Treatment naive Any 13/223 7.9 (3.8–15.9) 29/240 11.0 (6.6–17.6) 31/313 9.9 (6.5–14.9) NNRTI 12/223 7.7 (3.6–15.7) 26/240 9.7 (5.8–15.9) 29/313 9.3 (6.1–13.8) NRTI 2/223 2.8 (0.4–16.3) 3/240 0.8 (0.2–3.1) 1/313 0.3 (0.0–2.5) PI 1/223 0.3 (0.0–2.1) 2/240 1.0 (0.2–4.8) 2/313 0.6 (0.2–2.6) NNRTI+NRTI 2/223 2.8 (0.4–16.3) 2/240 0.5 (0.1–3.2) 1/313 0.3 (0.0–2.5) Treatment naive (women) Any 11/137 11.8 (5.5–23.3) 19/150 13.9 (8.5–21.8) 22/199 11.1 (7.3–16.5) NNRTI 10/137 11.3 (5.2–22.9) 16/150 11.7 (6.9–19.1) 20/199 10.1 (6.4–15.4) NRTI 2/137 4.5 (0.8–21.8) 3/150 1.3 (0.3–5.2) 1/199 0.5 (0–3.9) PI 1/137 0.4 (0–3.2) 2/150 1.8 (0.4–7.6) 2/199 1.0 (0.2–4.3) NNRTI+NRTI 2/137 4.5 (0.8–21.8) 2/150 0.9 (0.2–5.2) 1/199 0.5 (0–3.9) Treatment naive (men) Any 2/86 1.5 (0.4–5.9) 10/90 7.1 (2.6–18.2) 9/114 7.9 (4.0–15.0) NNRTI 2/86 1.5 (0.4–5.9) 10/90 7.1 (2.6–18.2) 9/114 7.9 (4.0–15.0) NRTI 0/86 – 0/90 – 0/114 – PI 0/86 – 0/90 – 0/114 – NNRTI+NRTI 0/86 – 0/90 – 0/114 – Previously exposed Any 8/29 20.5 (6.8–47.8) 5/26 16.1 (6.1–36.3) 25/69 36.2 (25.6–48.5) NNRTI 8/29 20.5 (6.8–47.8) 5/26 16.1 (6.1–36.3) 24/69 34.8 (25.2–45.8) NRTI 3/29 1.6 (0.2–9.9) 1/26 2.8 (0.4–17.3) 5/69 7.2 (2.7–18.2) PI 0/29 – 0/26 – 0/69 – NNRTI+NRTI 3/29 1.6 (0.2–9.9) 1/26 2.8 (0.4–17.3) 4/69 5.8 (1.7–17.9) Previously exposed (women) Any 4/22 12.9 (3.1–40.9) 5/23 17.7 (6.7–39.2) 17/48 35.4 (22.7–50.6) NNRTI 4/22 12.9 (3.1–40.9) 5/23 17.7 (6.7–39.2) 17/48 35.4 (22.7–50.6) NRTI 2/22 1.2 (0.2–7.1) 1/23 3.1 (0.4–18.8) 3/48 6.3 (2.0–18.3) PI 0/22 – 0/23 – 0/48 – NNRTI+NRTI 2/22 1.2 (0.2–7.1) 0/23 – 3/48 6.3 (2.0–18.3) Previously exposed (men) Any 4/7 60.6 (12.7–94.2) 0/3 – 8/21 38.1 (19.4–61.2) NNRTI 4/7 60.6 (12.7–94.2) 0/3 – 7/21 33.3 (15.9–56.9) NRTI 1/7 3.3 (0.4–21.1) 0/3 – 2/21 9.5 (2.2–32.9) PI 0/7 – 0/3 – 0/21 – NNRTI+NRTI 1/7 3.3 (0.4–21.1) 0/3 – 1/21 4.8 (0.6–29.5) a Estimates of HIVDR for all ART initiators include ARV-naive individuals, those with previous ARV drug exposure and those with unknown ARV drug exposure. b Unweighted estimates differs from the weighted estimate that has been reported elsewhere (doi: 10.1093/jac/dky278) NA: not available, since individuals with previous ARV drug exposure were excluded from the survey. NNRTI resistance is defined as resistance to nevirapine (NVP) efavirenz (EFV); NRTI resistance is defined as resistance to any NRTI and any PI resistance is defined as resistance to atazanavir/ritonavir (ATV/r), lopinavir/ritonavir (LPV/r) or darunavir/ritonavir (DRV/r). Any HIVDR is defined as resistance to NVP/EFV, any NRTI, ATV/r, LPV/r or DRV/r. HIVDR is determined using the Stanford HIVdb algorithm: sequences classified as having low-, intermediate- or high-level resistance are considered resistant. 25HIV DRUG RESISTANCE REPORT 2019 Table 1.2b. National prevalence estimates of PDR – Africa Uganda Zimbabwe n/N Prevalence % (95% CI) n/N Prevalence % (95% CI) Alla Any 48/342 17.4 (12.1–24.3) NA NA NNRTI 43/342 15.4 (10.3–22.5) NA NA NRTI 11/342 5.1 (2.4–10.3) NA NA PI 2/342 1.0 (0.2–4.6) NA NA NNRTI+NRTI 8/342 4.1 (1.8–9.0) NA NA Women Any 31/208 19.2 (11.8–29.8) NA NA NNRTI 28/208 16.5 (9.5–27.2) NA NA NRTI 9/208 7.3 (3.3–15.4) NA NA PI 1/208 1.3 (0.2–7.5) NA NA NNRTI+NRTI 7/208 5.9 (2.4–13.9) NA NA Men Any 17/133 14.5 (9.9–20.7) NA NA NNRTI 15/133 13.7 (9.1–20.3) NA NA NRTI 2/133 1.5 (0.3–7.1) NA NA PI 1/133 0.4 (0.0–3.6) NA NA NNRTI+NRTI 1/133 1.2 (0.2–8.1) NA NA Treatment naive Any 44/296 18.1 (12.7–25.2) 34/353 10.9 (7.1–16.4) NNRTI 39/296 15.9 (10.2–24.0) 34/353 10.9 (7.1–16.4) NRTI 11/296 5.7 (2.7–11.5) 3/353 0.8 (0.2–3.3) PI 2/296 1.1 (0.2–5.4) 0/353 – NNRTI+NRTI 8/296 4.6 (2.1–9.9) 3/353 0.8 (0.2–3.3) Treatment naive (women) Any 27/177 19.2 (11.5–30.3) 26/207 16.1 (10.9–23.0) NNRTI 24/177 16.1 (8.3–29.0) 26/207 16.1 (10.9–23.0) NRTI 9/177 8.2 (3.7–16.9) 3/207 1.4 (0.4–5.6) PI 1/177 1.4 (0.2–8.6) 0/207 – NNRTI+NRTI 7/177 6.6 (2.7–15.1) 3/207 1.4 (0.4–5.6) Treatment naive (men) Any 17/118 16.5 (11.4–23.2) 8/145 4.1 (1.1–14.3) NNRTI 15/118 15.7 (10.5–22.6) 8/145 4.1 (1.1–14.3) NRTI 2/118 1.7 (0.3–8.3) 0/145 – PI 1/118 <0.5 0/145 – NNRTI+NRTI 1/118 1.4 (0.2–9.4) 0/145 – Previously exposed Any 2/9 17.5 (2.3–65.2) NA NA NNRTI 2/9 17.5 (2.3–65.2) NA NA NRTI 0/9 – NA NA PI 0/9 – NA NA NNRTI+NRTI 0/9 – NA NA Previously exposed (women) Any 2/5 38.4 (9.4–79.0) NA NA NNRTI 2/5 38.4 (9.4–79.0) NA NA NRTI 0/5 – NA NA PI 0/5 – NA NA NNRTI+NRTI 0/5 – NA NA Previously exposed (men) Any 0/4 – NA NA NNRTI 0/4 – NA NA NRTI 0/4 – NA NA PI 0/4 – NA NA NNRTI+NRTI 0/4 – NA NA a Estimates of HIVDR in all ART initiators include ARV-naive individuals, those with previous ARV drug exposure and those with unknown ARV drug exposure. NA: not available, since individuals with previous ARV drug exposure were excluded from the survey. NNRTI resistance is defined as resistance to nevirapine (NVP) or efavirenz (EFV); NRTI resistance is defined as resistance to any NRTI and any PI resistance is defined as resistance to atazanavir/ritonavir (ATV/r), lopinavir/ritonavir (LPV/r), or darunavir/ritonavir (DRV/r). Any HIVDR is defined as resistance to NVP/EFV, any NRTI, ATV/r, LPV/r or DRV/r. HIVDR is determined using the Stanford HIVdb algorithm: sequences classified as having low-, intermediate- or high-level resistance are considered resistant. HIV DRUG RESISTANCE REPORT 201926 Table 1.2c. National prevalence estimates of PDR – the Americas Argentina Brazil Cuba Colombia n/N Prevalence % (95% CI) n/N Prevalence % (95% CI) n/N Prevalence % (95% CI) n/N Prevalence % (95% CI) Alla Any 41/294 13.8 (10.3–18.3) NA NA NA NA NA NA NNRTI 33/294 10.9 (8.2–14.3) NA NA NA NA NA NA NRTI 10/294 3.7 (1.9–7.0) NA NA NA NA NA NA PI 6/294 1.9 (0.7–4.8) NA NA NA NA NA NA NNRTI+NRTI 5/294 1.7 (0.6–4.6) NA NA NA NA NA NA Women Any 14/97 15.5 (9.7–24.0) NA NA NA NA NA NA NNRTI 12/97 11.9 (6.5–20.9) NA NA NA NA NA NA NRTI 5/97 6.2 (2.3–15.4) NA NA NA NA NA NA PI 1/97 1.2 (0.1–8.3) NA NA NA NA NA NA NNRTI+NRTI 4/97 3.7 (1.1–12.2) NA NA NA NA NA NA Men Any 27/195 13.1 (8.8–19.2) NA NA NA NA NA NA NNRTI 21/195 10.5 (6.9–15.8) NA NA NA NA NA NA NRTI 5/195 2.4 (0.9–6.4) NA NA NA NA NA NA PI 5/195 2.3 (0.9–5.4) NA NA NA NA NA NA NNRTI+NRTI 1/195 0.6 (0.1–4.4) NA NA NA NA NA NA Treatment naive Any 31/239 12.8 (9.2–17.4) 137/1391 9.8 (8.1–12.0) 42/141 29.1 (22.8–36.3) 19/192 9.9 (7.5–12.9) NNRTI 24/239 9.4 (6.4–13.4) 94/1391 6.8 (5.6–8.1) 33/141 22.8 (15.8–31.6) 12/192 6.3 (3.8–10.2) NRTI 8/239 3.6 (1.7–7.6) 50/1391 3.6 (2.8–4.7) 15/141 9.9 (6.2–15.6) 7/192 3.6 (1.7–7.6) PI 5/239 2.1 (0.7–5.9) 13/1391 0.9 (0.6–1.5) 2/141 1.4 (0.3–5.7) 0/192 – NNRTI+NRTI 3/239 1.1 (0.3–3.6) 17/1391 1.2 (0.8–1.9) 6/141 3.6 (1.8–7.3) 0/192 – Treatment naive (women) Any 11/70 17.1 (9.8–28.1) 26/380 6.8 (5.5–8.5) 10/27 39.5 (20.3–62.6) 2/22 9.1 (2.1–31.5) NNRTI 9/70 11.9 (6.0–22.3) 19/380 5.0 (3.8–6.6) 8/27 33.3 (14.9–58.7) 1/22 4.5 (0.6–26.9) NRTI 3/70 5.5 (1.5–18.2) 11/380 2.9 (1.7–4.9) 5/27 15.4 (5.9–34.6) 1/22 4.5 (0.5–30.5) PI 1/70 1.6 (0.2–11.4) 1/380 0.3 (0.0–2.1) 1/27 4.2 (0.5–27.0) 0/22 – NNRTI+NRTI 2/70 2.0 (0.5–8.2) 5/380 1.3 (0.7–2.5) 3/27 9.2 (2.6–27.7) 0/22 – Treatment naive (men) Any 20/167 11.2 (7.0–17.4) 100/874 11.4 (9.2–14.2) 32/114 26.5 (20.2–34.0) 17/170 10.0 (7.5–13.3) NNRTI 15/167 8.4 (5.0–14.0) 66/874 7.6 (6.0–9.5) 25/114 20.2 (14.2–27.9) 11/170 6.5 (4.0–10.4) NRTI 5/167 2.8 (1.0–7.5) 37/874 4.2 (3.2–5.6) 10/114 8.6 (4.4–16.2) 6/170 3.5 (1.5–7.9) PI 4/167 2.3 (0.9–6.1) 11/874 1.3 (0.7–2.3) 1/114 0.8 (0.1–6.1) 0/170 – NNRTI+NRTI 1/167 0.7 (0.1–5.3) 11/874 1.3 (0.7–2.3) 3/114 2.3 (0.7–6.9) 0/170 – Previously exposed (all) Any 10/54 18.6 (10.7–30.4) NA NA NA NA NA NA NNRTI 9/54 17.8 (10.0–29.5) NA NA NA NA NA NA NRTI 2/54 4.1 (0.7–20.7) NA NA NA NA NA NA PI 1/54 0.9 (0.1–4.9) NA NA NA NA NA NA NNRTI+NRTI 2/54 4.1 (0.7–20.7) NA NA NA NA NA NA Previously exposed (women) Any 3/27 11.8 (3.8–31.3) NA NA NA NA NA NA NNRTI 3/27 11.8 (3.8–31.3) NA NA NA NA NA NA NRTI 2/27 7.8 (1.5–32.3) NA NA NA NA NA NA PI 0/27 – NA NA NA NA NA NA NNRTI+NRTI 2/27 7.8 (1.5–32.3) NA NA NA NA NA NA Previously exposed (men) Any 7/27 26.0 (11.9–47.8) NA NA NA NA NA NA NNRTI 6/27 24.2 (10.7–46.1) NA NA NA NA NA NA NRTI 0 – NA NA NA NA NA NA PI 1/27 1.8 (0.3–9.5) NA NA NA NA NA NA NNRTI+NRTI 0 – NA NA NA NA NA NA a Estimates of HIVDR in all ART initiators include ARV-naive individuals, those with previous ARV drug exposure and those with unknown ARV drug exposure. NA: not available, since individuals with previous ARV drug exposure were excluded from the survey. NNRTI resistance is defined as resistance to nevirapine (NVP) or efavirenz (EFV); NRTI resistance is defined as resistance to any NRTI and any PI resistance is defined as resistance to atazanavir/ritonavir (ATV/r), lopinavir/ritonavir (LPV/r), or darunavir/ritonavir (DRV/r). Any HIVDR is defined as resistance to NVP/EFV, any NRTI, ATV/r, LPV/r or DRV/r. HIVDR is determined using the Stanford HIVdb algorithm: sequences classified as having low-, intermediate- or high-level resistance are considered resistant. 27HIV DRUG RESISTANCE REPORT 2019 Table 1.2d. National prevalence estimates of PDR – the Americas Guatemala Honduras Mexico Nicaragua n/N Prevalence % (95% CI) n/N Prevalence % (95% CI) n/N Prevalence % (95% CI) n/N Prevalence % (95% CI) Alla Any 34/241 15.1 (11.5–19.6) 48/161 26.9 (20.2–34.9) 261/2006 12.6 (11.2–14.0) 40/171 23.4 (14.4–35.6) NNRTI 29/241 13.2 (8.8–19.4) 45/161 25.9 (19.2–33.9) 205/2006 9.9 (8.7–11.2) 33/171 19.3 (12.2–29.1) NRTI 9/241 3.2 (1.5–6.8) 15/161 6.9 (4.0–11.7) 64/2006 3.2 (2.5–4.1) 18/171 10.5 (4.9–21.1) PI 2/241 0.6 (0.1–3.7) 0/161 – 29/2006 1.4 (1.0–2.0) 0/171 – NNRTI+NRTI 4/241 1.3 (0.4–3.9) 12/161 5.8 (3.1–10.7) 25/2006 1.3 (0.9–1.9) 11/171 6.4 (2.7–14.7) Women Any 10/66 19.2 (11.1–31.2) 18/50 32.4 (18.1–50.9) 56/328 17.5 (13.4–22.6) 18/48 37.5 (20.8–57.8) NNRTI 10/66 19.2 (11.1–31.2) 18/50 32.4 (18.1–50.9) 43/328 13.6 (10.0–18.2) 15/48 31.3 (19.6–45.8) NRTI 1/66 1.0 (0.1–9.1) 6/50 9.2 (3.1–24.1) 16/328 4.7 (2.8–7.9) 7/48 14.6 (5.0–35.5) PI 0/66 – 0/50 – 7/328 2.4 (1.1–5.2) 0/48 – NNRTI+NRTI 1/66 1.0 (0.1–9.1) 6/50 9.2 (3.1–24.1) 7/328 2.2 (1.0–4.6) 4/48 8.3 (2.8–22.4) Men Any 24/173 13.2 (9.6–17.9) 27/105 23.5 (15.7–33.7) 205/1676 11.7 (10.3–13.3) 22/123 17.9 (9.9–30.2) NNRTI 19/173 10.4 (6.4–16.4) 24/105 21.8 (14.2–32.0) 162/1676 9.2 (8.0–10.7) 18/123 14.6 (8.0–25.3) NRTI 8/173 4.3 (2.1–8.5) 8/105 5.5 (2.8–10.6) 48/1676 2.9 (2.2–3.9) 11/123 8.9 (4.0–18.8) PI 2/173 0.9 (0.1–5.1) 0/105 – 22/1676 1.2 (0.8–1.9) 0/123 – NNRTI+NRTI 3/173 1.4 (0.7–3.1) 5/105 3.8 (0.2–8.9) 18/1676 1.1 (0.7–1.8) 7/123 5.7 (2.4–13.1) Treatment naive Any 31/229 14.9 (11.0–19.9) 26/112 16.9 (11.2–24.6) 206/1848 11.1 (9.7–12.6) 23/146 15.8 (8.8–26.6) NNRTI 27/229 13.3 (8.5–20.1) 24/112 15.6 (10.2–23.1) 161/1848 8.6 (7.4–9.9) 16/146 11.0 (6.0–19.3) NRTI 8/229 3.0 (1.5–6.0) 10/112 6.4 (3.4–11.6) 39/1848 2.3 (1.7–3.1) 10/146 6.8 (2.7–16.1) PI 2/229 0.6 (0.1–3.8) 0/112 – 22/1848 1.2 (0.8–1.8) 0/146 – NNRTI+NRTI 4/229 1.4 (0.4–4.2) 8/112 5.1 (2.6–10.0) 9/1848 0.5 (0.3–1.1) 3/146 2.1 (0.6–7.0) Treatment naive (women) Any 9/60 19.9 (9.8–36.3) 7/28 13.5 (5.2–30.7) 37/273 13.9 (9.9–19.2) 7/34 20.6 (7.8–44.4) NNRTI 9/60 19.9 (9.8–36.3) 7/28 13.5 (5.2–30.7) 28/273 10.4 (7.0–15.2) 4/34 11.8 (5.7–22.7) NRTI 1/60 1.1 (0.4–3.0) 3/28 6.1 (1.4–22.6) 7/273 2.3 (1.0–5.2) 3/34 8.8 (1.7–35.2) PI 0/60 – 0/28 – 4/273 1.6 (0.6–4.6) 0/34 – NNRTI+NRTI 1/60 1.1 (0.4–3.0) 3/28 6.1 (1.4–22.6) 2/273 0.4 (0.1–1.7) 0/34 – Treatment naive (men) Any 22/167 12.7 (9.3–17.3) 16/78 16.9 (9.6–27.9) 169/1573 10.7 (9.2–12.3) 16/112 14.3 (7.6–25.3) NNRTI 18/167 10.3 (7.1–14.7) 14/78 14.9 (8.3–25.3) 133/1573 8.3 (7.0–9.8) 12/112 10.7 (5.3–20.5) NRTI 7/167 4.0 (2.5–6.3) 6/78 6.5 (2.7–14.7) 32/1573 2.3 (1.6–3.2) 7/112 6.3 (2.4–15.2) PI 2/167 0.9 (0.4–2.0) 0/78 – 18/1573 1.1 (0.7–1.8) 0/112 – NNRTI+NRTI 3/167 1.5 (0.8–2.8) 4/78 4.5 (1.6–12.0) 7/1573 0.6 (0.3–1.2) 3/112 2.7 (0.8–9.1) Previously exposed Any 3/7 38.7 (12.6–73.4) 18/33 54.8 (33.3–74.6) 55/158 31.3 (24.1–39.7) 16/21 76.2 (52.9–90.1) NNRTI 2/7 26.7 (3.2–80.1) 17/33 53.8 (32.4–73.8) 44/158 26.2 (19.5–34.3) 16/21 76.2 (52.9–90.1) NRTI 1/7 12.0 (1.6–53.8) 4/33 10.6 (2.8–33.3) 25/158 15.0 (10.1–21.8) 7/21 33.3 (13.9–60.8) PI 0/7 – 0/33 – 7/158 4.0 (1.8–8.5) 0/21 – NNRTI+NRTI 0/7 – 3/33 9.6 (2.2–33.4) 16/158 10.8 (6.6–17.2) 7/21 33.3 (13.9–60.8) Previously exposed (women) Any 1/3 34.5 (6.3–80.6) 10/16 64.8 (29.7–88.9) 19/55 35.5 (22.4–51.2) 10/13 76.9 (54.8–90.2) NNRTI 1/3 34.5 (6.3–80.6) 10/16 64.8 (29.7–88.9) 15/55 29.5 (17.4–45.6) 10/13 76.9 (54.8–90.2) NRTI 0/3 – 2/16 14.5 (2.5–52.7) 9/55 16.8 (8.5–30.5) 3/13 23.1 (8.3–49.8) PI 0/3 – 0/16 – 3/55 6.2 (1.8–19.2) 0/13 – NNRTI+NRTI 0/3 – 2/16 14.5 (2.5–52.7) 5/55 10.8 (4.3–24.3) 3/13 23.1 (8.3–49.8) Previously exposed (men) Any 2/4 41.4 (12.2–78.2) 8/17 43.6 (17.2–74.3) 36/103 29.1 (20.5–39.5) 6/8 75 (37.5–93.8) NNRTI 1/4 21.8 (36.9–66.9) 7/17 41.5 (15.7–72.9) 29/103 24.5 (16.8–34.2) 6/8 75 (37.5–93.8) NRTI 1/4 19.6 (5.6–50.0) 2/17 6.3 (1.2–27.4) 16/103 14.1 (8.5–22.4) 4/8 50 (17.9–82.2) PI 0/4 – 0/17 – 4/103 2.8 (1.1–7.3) 0/8 – NNRTI+NRTI 0/4 – 1/17 4.2 (0.5–29.1) 11/103 10.8 (6.0–18.8) 4/8 50 (17.9–82.2) a Estimates of HIVDR in all ART initiators include ARV-naive individuals, those with previous ARV drug exposure, and those with unknown ARV drug exposure; NNRTI resistance is defined as resistance to nevirapine (NVP) efavirenz (EFV); NRTI resistance is defined as resistance to any NRTI, and any PI resistance is defined as resistance to atazanavir/ ritonavir, lopinavir/ritonavir (LPV/r), or darunavir/ritonavir (DRV/r); Any HIVDR is defined as resistance to NVP/EFV, any NRTI, ATV/r, LPV/r or DRV/r. HIVDR is determined using the Stanford HIVdb algorithm: sequences classified as having low-, intermediate- or high-level resistance are considered “resistant”. HIV DRUG RESISTANCE REPORT 201928 Table 1.2e. National prevalence estimates of PDR – South-East Asia and the Western Pacific Myanmar Nepal Papua New Guinea Viet Nam n/N Prevalence % (95% CI) n/N Prevalence % (95% CI) n/N Prevalence % (95% CI) n/N Prevalence % (95% CI) Alla Any 21/327 5.4 (3.1–9.2) 26/184 12.9 (8.8–18.5) 51/315 18.4 (13.8–24.3) 22/340 5.8 (3.4–9.5) NNRTI 16/327 3.9 (2.1–7.4) 21/184 10.2 (6.7–15.4) 49/315 17.8 (13.6–23.0) 15/340 3.4 (1.8–6.2) NRTI 5/327 1.4 (0.5–3.7) 14/184 7.8 (4.7–12.6) 13/315 5.6 (1.6–17.1) 13/340 3.5 (1.8–6.8) PI 1/326 0.2 (0.0–1.8) 0/184 – 0/315 – 0/333 – NNRTI+NRTI 1/327 0.2 (0.0–1.3) 9/184 5.1 (2.7–9.5) 11/315 4.9 (1.5–14.5) 6/340 1.2 (0.5–2.8) Women Any 7/115 5.2 (2.1–12.2) 12/84 13.4 (7.5–22.8) 36/193 21.7 (16.7–27.7) 2/95 2.5 (0.5–11.5) NNRTI 5/115 3.6 (1.2–10.3) 10/84 11.1 (5.8–20.2) 36/193 21.7 (16.7–27.7) 0/95 – NRTI 2/115 1.6 (0.3–7.4) 7/84 9.4 (4.4–18.8) 7/193 5.0 (1.2–18.3) 2/95 2.5 (0.5–11.5) PI 0/115 – 0/84 – 0/193 – 0/93 – NNRTI+NRTI 0/115 – 5/84 7.1 (2.9–16.4) 7/193 5.0 (1.2–18.3) 0/95 – Men Any 13/206 5.3 (2.9–9.7) 13/94 12.1 (7.2–19.7) 14/120 12.3 (5.3–26.0) 20/245 7.0 (3.9–12.3) NNRTI 10/206 3.9 (1.9–7.9) 11/94 10.2 (5.8–17.5) 12/120 10.5 (4.5–22.6) 15/245 4.7 (2.5–8.6) NRTI 3/206 1.3 (0.4–4.5) 6/94 5.7 (2.7–11.3) 6/120 6.5 (2.1–18.3) 11/245 3.9 (1.7–8.5) PI 1/205 0.4 (0.0–2.9) – – 0/120 – 0/240 – NNRTI+NRTI 1/206 0.3 (0.0–2.1) 4/94 3.8 (1.6–8.9) 4/120 4.8 (1.7–12.3) 6/245 1.6 (0.6–4.0) Treatment naive Any 14/287 4.3 (2.3–8.0) NA NA 30/254 12.3 (7.8–18.9) 16/310 4.6 (2.5–8.4) NNRTI 9/287 2.7 (1.2–6.0) NA NA 28/254 11.5 (7.0–18.5) 10/310 2.7 (1.3–5.5) NRTI 5/287 1.5 (0.6–4.2) NA NA 6/254 2.7 (1.0–7.1) 10/310 2.7 (1.2–6.1) PI 1/286 0.3 (0.0–2.0) NA NA 0/254 – 0/305 – NNRTI+NRTI 1/287 0.2 (0.0–1.4) NA NA 4/254 1.8 (0.6–5.9) 4/310 0.9 (0.3–2.8) Treatment naive (women) Any 6/102 5.5 (2.2–13.1) NA NA 17/145 12.7 (7.8–20.2) 2/87 2.7 (0.6–12.3) NNRTI 4/102 3.8 (1.2–11.1) NA NA 17/145 12.7 (7.8–20.2) 0/87 – NRTI 2/102 1.7 (0.4–8.0) NA NA 1/145 0.7 (0.1–5.5) 2/87 2.7 (0.6–12.3) PI 0/102 – NA NA 0/145 – 0/87 – NNRTI+NRTI 0/102 – NA NA 1/145 0.7 (0.1–5.5) 0/87 – Treatment naive (men) Any 8/185 3.6 (1.6–8.0) NA NA 12/108 11.0 (4.3–25.3) 14/223 5.3 (2.6–10.6) NNRTI 5/185 2.1 (0.8–5.7) NA NA 10/108 9.1 (3.2–23.4) 10/223 3.8 (1.9–7.5) NRTI 3/185 1.4 (0.4–5.0) NA NA 5/108 5.4 (1.9–14.2) 8/223 2.7 (1.0–7.5) PI 1/185 <0.05 NA NA 0/108 – 0/218 – NNRTI+NRTI 1/185 <0.05 NA NA 3/108 3.5 (1.1–10.3) 4/223 1.2 (0.4–4.0) Previously exposed Any 6/32 15.7 (5.5–37.4) NA NA 21/61 42.4 (29.1–56.9) 4/20 11.1 (2.9–33.9) NNRTI 6/32 15.7 (5.5–37.4) NA NA 21/61 42.4 (29.1–56.9) 4/20 11.1 (2.9–33.9) NRTI 0/32 – NA NA 7/61 16.9 (4.1–49.1) 2/20 6.5 (1.4–24.7) PI 0/32 – NA NA 0/61 – 0/18 – NNRTI+NRTI 0/32 – NA NA 7/61 16.9 (4.1–49.1) 2/20 6.5 (1.4–24.7) Previously exposed (women) Any 1/13 1.1 (0.2–7.5) NA NA 19/48 46.8 (33.4–60.7) 0/7 – NNRTI 1/13 1.1 (0.2–7.5) NA NA 19/48 46.8 (33.4–60.7) 0/7 – NRTI 0/13 – NA NA 6/48 17.1 (4.2–49.5) 0/7 – PI 0/13 – NA NA 0/48 – 0/5 – NNRTI+NRTI 0/13 – NA NA 6/48 17.1 (4.2–49.5) 0/7 – Previously exposed (men) Any 5/19 22.8 (8.3–49.1) NA NA 2/12 24.6 (7.2–57.7) 4/13 16.6 (3.9–49.1) NNRTI 5/19 22.8 (8.3–49.1) NA NA 2/12 24.6 (7.2–57.7) 4/13 16.6 (3.9–49.1) NRTI 0/19 – NA NA 1/12 17.2 (2.8–60.0) 2/13 9.7 (2.2–33.9) PI 0/19 – NA NA 0/12 – 0/13 – NNRTI+NRTI 0/19 – NA NA 1/12 17.2 (2.8–60.0) 2/13 9.7 (2.2–33.9) a Estimates of HIVDR in all ART initiators include ARV-naive individuals, those with previous ARV drug exposure and those with unknown ARV drug exposure. NA: not available, since individuals with previous ARV drug exposure were excluded from the survey. NNRTI resistance is defined as resistance to nevirapine (NVP) efavirenz (EFV). NRTI resistance is defined as resistance to any NRTI, and any PI resistance is defined as resistance to atazanavir/ritonavir (ATV/r), lopinavir/ritonavir (LPV/r), or darunavir/ritonavir (DRV/r). Any HIVDR is defined as resistance to NVP/EFV, any NRTI, ATV/r, LPV/r or DRV/r. HIVDR is determined using the Stanford HIVdb algorithm: sequences classified as having low-, intermediate- or high-level resistance are considered resistant. 29HIV DRUG RESISTANCE REPORT 2019 Section 2. Pretreatment HIV drug resistance among treatment-naive infants newly diagnosed with HIV Table 2.1a. Population characteristics of PDR surveys in infants – Africa Cameroon (start year 2014)a Eswatini (start year 2011) Malawi (start year 2016)b Mozambique (start year 2012) N = 380 N = 197 N = 405 N = 400 n Prevalence % (95% CI)c n Prevalence % (95% CI) n Prevalence % (95% CI) n Prevalence % (95% CI) Gender Female – – 96 48.7 (41.7–55.8) 176 38.2 (32.8–43.8) 195 48.8 (43.8–53.7) Male – – 91 46.2 (39.2–53.2) 167 47.2 (41.5–53.0) 170 42.5 (37.6–47.4) Unknown – – 10 5.1 (2.0–8.2) 62 14.6 (11.0–19.2) 35 8.8 (6.0–11.5) Mean age (95% CI), years 5.8 (5.3–6.3)d 5.87 (5.28–6.45) 5.1 (4.6–5.6)d 4.55 (4.20–4.90) ≤6 months 136 38.9 (34.0–44.1) 82 41.6 (34.7–48.6) 147 37.7 (32.0–43.8) 97 24.3 (20.0–28.5) >6 months 226 61.1 (55.9–66.0) 115 58.4 (51.4–65.3) 252 62.3 (56.2–68.0) 300 75.8 (71.5–80.0) PMTCT exposure status Yes 158 40.3 (35.4–45.3) 148 75.1 (69.0–81.2) 308 77.3 (71.9–81.9) 338 84.5 (80.9–88.1) No 148 41.0 (36.2–46.1) 22 11.2 (6.7–15.6) 3 1.6 (0.5–5.3) 16 4.0 (2.1–5.9) Unknown 74 18.7 (15.1–22.9) 27 13.7 (8.9–18.6) 94 21.1 (16.7–26.3) 46 11.5 (8.4–14.6) Breastfeeding status Yes 270 71.1 (66.3–75.5) 123 62.4 (55.6–69.3) 265 66.2 (60.2–71.8) 0 – No 18 4.8 (3.0–7.5) 66 33.5 (26.9–40.2) 140 33.8 (28.2–39.8) 0 – Unknown 92 24.1 (20.0–28.8) 8 4.1 (1.3–6.8) 0 – 400 100 Type of PMTCT exposure status Maternal prophylaxis 101 24.3 (20.4–28.5) 125 63.5 (56.7–70.2) 302 76.0 (70.5–80.7) 260 65.0 (60.3–69.7) Infant prophylaxis 119 30.9 (26.4–35.8) 128 65.0 (58.3–71.7) 141 31.5 (26.5–37.0) 304 76.0 (71.8–80.2) Both maternal ART and infant prophylaxis 62 17.7 (14.1–22.1) 105 53.3 (46.3–60.3) 135 30.4 (25.4–35.8) 226 56.5 (51.6–61.4) a All participants had missing data for gender and 18 participants had missing data for age. b Six infants missing data on age. c Study design–weighted proportion and 95% confidence interval. d Study design–weighted mean and 95% confidence interval. HIV DRUG RESISTANCE REPORT 201930 Table 2.1b. Population characteristics of PDR surveys in infants – Africa Nigeria (start year 2016)a Togo (start year 2012) Uganda (start year 2011) Zimbabwe (start year 2012) N = 547 N = 201 N = 224 N = 201 n/N Prevalence % (95% CI)b n/N Prevalence % (95% CI)b n/N Prevalence % (95% CI)b n/N Prevalence % (95% CI)b Gender Female 242 43.7 (39.0–48.4) 105 52.2 (45.3–59.1) 121 54.0 (47.4–60.6) 116 51.1 (44.5–57.7) Male 252 44.9 (40.1–49.8) 95 47.3 (40.4–54.2) 103 46.0 (39.4–52.6) 105 46.3 (39.7–52.8) Unknown 53 11.4 (8.8–14.8) 1 <0.5 0 6 2.6 (0.05–4.75) Mean age (95% CI), years 6.04 (5.60–6.47) c 6.03 (5.40–6.66)c 6.70 (6.07–7.34) 5.99 (5.38–6.61) ≤6 months 200 40.4 (35.4–45.6) 81 40.3 (33.7–47.3) 99 44.2 (37.6–50.8) 99 43.6 (37.1–50.1) >6 months 288 59.6 (54.4–64.6) 120 59.7 (52.7–66.3) 125 55.8 (49.2–62.4) 128 56.4 (49.9–62.9) PMTCT exposure status Yes 259 52.1 (47.7–56.5) 131 65.2 (58.3–71.5) 178 79.5 (74.1–84.8) 174 76.7 (71.1–82.2) No 117 20.3 (16.7–24.4) 41 20.4 (15.3–26.6) 35 15.6 (10.8–20.4) 46 20.3 (15.0–25.5) Unknown 171 27.6 (24.1–31.5) 29 14.4 (10.2–20.0) 11 4.9 (2.1–7.8) 7 3.1 (0.8–5.3) Breastfeeding status Yes 414 79.2 (75.4–82.5) 156 77.6 (71.3–82.9) 162 72.3 (66.4–78.2) 172 75.8 (70.2–81.4) No 44 5.2 (3.8–7.0) 18 9.0 (5.7–13.8) 41 18.3 (13.2–23.4) 35 15.4 (10.7–20.2) Unknown 89 15.7 (12.7–19.2) 27 13.4 (9.3–18.9) 21 9.4 (5.5–13.2) 20 8.8 (5.1–12.5) Type of PMTCT exposure status Maternal prophylaxis 209 41.2 (36.9–45.6) 90 44.8 (38.0–51.8) 164 73.2 (67.3–79.1) 134 60.8 (54.4–67.2) Infant prophylaxis 183 37.3 (33.1–41.7) 111 55.2 (48.2–62.0) 142 63.4 (57.0–69.8) 151 66.5 (60.3–72.7) Both maternal ART and infant prophylaxis 133 28.3 (24.3–32.6) 70 44.8 (38.0–51.8) 128 57.1 (50.6–63.7) 115 50.7 (44.1–57.2) a 59 infants missing data on age. b Study design–weighted proportion and 95% confidence interval. c Study design–weighted mean and 95% confidence interval. 31HIV DRUG RESISTANCE REPORT 2019 Table 2.2a. Prevalence estimates of PDR in infants – Africa Cameroon Eswatini Malawi Mozambique n/N Prevalence % (95% CI) n/N Prevalence % (95% CI) n/N Prevalence % (95% CI) n/N Prevalence % (95% CI) All Any 189/380 48.8 (43.9–53.8) 69/197 35.0 (28.3–41.7) 146/232 69.2 (62.1–75.5) 229/400 57.3 (52.4–62.1) NNRTI 182/380 47.0 (42.1–52.0) 67/197 34.0 (27.4–40.6) 145/232 68.8 (61.7–75.1) 224/400 56.0 (51.1–60.9) NRTI 40/380 10.3 (7.6–13.8) 4/197 2.0 (0.04–4.0) 47/232 25.8 (17.5–36.4) 26/400 6.5 (4.1–8.9) PI 0/380 – NA NA 0/232 – NA NA NNRTI+NRTI 33/380 8.5 (6.1–11.7) 2/197 1.0 (0.04–2.4) 46/232 25.4 (17.1–36.0) 21/400 5.3 (3.1–7.4) PMTCT exposed Any 101/158 63.8 (55.9–71.0) 63/148 41.9 (34.5–50.6) 133/199 73.9 (66.7–80.0) 205/338 60.7 (55.4–65.9) NNRTI 100/158 63.2 (55.3–70.4) 61/148 41.2 (33.2–49.2) 132/199 73.4 (66.3–79.6) 200/338 59.2 (53.9–64.4) NRTI 21/158 13.1 (8.7–19.4) 4/148 2.7 (0.1–5.3) 42/199 27.8 (18.7–39.3) 21/338 6.2 (3.6–8.8) PI 0/158 – NA NA 0/199 – NA NA NNRTI+NRTI 20/158 12.5 (8.2–18.7) 2/148 1.4 (–0.1–3.2) 41/199 27.4 (18.3–38.9) 16/338 4.7 (2.5–7.0) PMTCT unexposed or unknown Any 88/222 38.5 (32.4–45.0) 6/49 12.2 (2.7–21.8) 13/30 35.4 (16.6–60.1) 24/62 38.7 (26.2–51.2) NNRTI 82/222 35.8 (29.9–42.3) 6/49 12.2 (2.7–21.8) 13/30 35.4 (16.6–60.1) 24/62 38.7 (26.2–51.2) NRTI 19/222 8.3 (5.4–12.8) 0/49 – 5/30 10.1 (2.4–33.7) 5/62 8.1 (1.09–15.0) PI 0/222 – NA NA 0/30 – NA NA NNRTI+NRTI 13/222 5.7 (3.3–9.6) 0/49 – 5/30 10.1 (2.4–33.7) 5/62 8.1 (1.09–15.0) NNRTI resistance is defined as resistance to nevirapine (NVP) or efavirenz (EFV). NRTI resistance is defined as resistance to any NRTI, and any PI resistance is defined as resistance to atazanavir/ritonavir (ATV/r), lopinavir/ritonavir (LPV/r), or darunavir/ritonavir (DRV/r). Any HIVDR is defined as resistance to NVP/EFV, any NRTI, ATV/r, LPV/r or DRV/r. HIVDR is determined using the Stanford HIVdb algorithm: sequences classified as having low-, intermediate- or high-level resistance are considered resistant. HIV DRUG RESISTANCE REPORT 201932 Table 2.2b. Prevalence estimates of PDR among infants – Africa Nigeria Togo Uganda Zimbabwe n/N Prevalence % (95% CI) n/N Prevalence % (95% CI) n/N Prevalence % (95% CI) n/N Prevalence % (95% CI) All Any 198/423 50.1 (44.6–55.6) 123/199 61.8 (54.8–68.3) 86/224 38.4 (32.0–44.8) 145/227 63.9 (57.6–70.2) NNRTI 192/423 48.6 (43.1–54.0) 114/199 57.3 (50.3–64.0) 80/224 35.7 (29.4–42.0) 145/227 63.9 (57.6–70.2) NRTI 91/423 22.9 (18.4–28.0) 33/199 16.6 (12.0–22.5) 19/224 8.5 (4.8–12.2) 22/227 9.7 (5.8–13.6) PI 0/423 – NA NA NA NA NA NA NNRTI+NRTI 85/423 21.3 (17.0–26.4) 24/199 12.1 (8.2–17.4) 13/224 5.8 (2.7–8.9) 22/227 9.7 (5.8–13.6) PMTCT exposed Any 110/194 57.2 (49.7–64.4) 97/130 74.6 (66.4–81.4) 73/178 41.0 (33.7–48.3) 130/174 74.7 (68.2–81.2) NNRTI 107/194 55.4 (48.0–62.6) 94/130 72.3 (63.9–79.4) 69/178 38.8 (31.5–46.0) 130/174 74.7 (68.2–81.2) NRTI 61/194 30.5 (23.9–38.0) 21/130 16.2 (10.7–23.6) 15/178 8.4 (4.3–12.5) 21/174 12.1 (7.2–16.9) PI 0/286 – NA NA NA NA NA NA NNRTI+NRTI 58/194 28.6 (22.2–36.0) 18/130 13.8 (8.9–21.0) 11/178 6.2 (2.6–9.7) 21/174 12.1 (7.2–16.9) PMTCT unexposed or unknown Any 88/229 42.6 (34.9–50.6) 26/69 37.7 (27.0–49.7) 13/46 28.3 (14.7–41.8) 15/53 28.3 (15.8–40.8) NNRTI 85/229 41.4 (33.8–49.5) 20/69 29.0 (19.5–40.8) 11/46 23.9 (11.1–36.7) 15/53 28.3 (15.8–40.8) NRTI 30/229 14.8 (9.6–22.2) 12/69 17.4 (10.1–28.3) 4/46 8.7 (0.2–17.2) 1/53 1.9 (0–5.7) PI 0/229 – NA NA NA NA NA NA NNRTI+NRTI 27/229 13.7 (8.6–21) 6/69 8.7 (3.9–18.1) 2/46 4.3 (0–10.5) 1/53 1.9 (0–5.7) NNRTI resistance is defined as resistance to nevirapine (NVP) efavirenz (EFV). NRTI resistance is defined as resistance to any NRTI, and any PI resistance is defined as resistance to atazanavir/ritonavir (ATV/r), lopinavir/ritonavir (LPV/r), or darunavir/ritonavir (DRV/r). Any HIVDR is defined as resistance to NVP/EFV, any NRTI, ATV/r, LPV/r or DRV/r. HIVDR is determined using the Stanford HIVdb algorithm: sequences classified as having low-, intermediate- or high-level resistance are considered “resistant”. 33HIV DRUG RESISTANCE REPORT 2019 Section 3. Acquired HIV Drug Resistance among adults receiving antiretroviral treatment Table 3.1a. Population characteristics of early time point (12 months) for ADR surveys – Africa Cameroon (12–24 months) Eswatini (12 ±3 months) Senegal (12 ±3 months) N = 1064 (start year 2015) N = 375 (start year 2016) N = 255 (start year 2017) n % (95% CI)a n % (95% CI)a n % (95% CI)a Gender Women 808 77.9 (75.4–80.2) 270 72.1 (65.4–77.9) 184 72.7 (63.6–80.3) Men 256 22.1 (19.8–24.6) 105 27.9 (22.1–34.6) 71 27.3 (19.7–36.4) Meanb age (95% CI), years 40.0 (39.4–40.7) 36.0 (34.5–37.6) 42.1 (38.8–45.4) Individuals on first-line ART 1050 99.0 (98.1–99.5) 374 99.8 (98.8–100.0) 252 99.3 (96.7–99.9) Individuals on NNRTI- based first-line ART 1048 98.9 (97.8–99.4) 368 98.1 (95.7–99.1) 249 95.4 (86.6–98.5) Individuals on second- line ART 14 1.0 (0.6–1.9) 1 0.2 (0.0–1.2) 1 0.5 (0.1–3.7) Current ART TDF + XTC + EFV 758 71.4 (63.3–78.4) 330 87.4 (81.8–91.5) 236 88.9 (80.1–94.1) TDF + XTC + NVP 109 9.0 (6.1–13.0) 7 1.6 (0.7–3.5) 2 0.6 (0.1–2.9) AZT + XTC + EFV 32 3.6 (2.1–6.3) 12 3.9 (2.1–7.3) 0 0 AZT + XTC + NVP 148 14.8 (10.5–20.4) 5 1.7 (0.6–4.6) 0 0 D4T + XTC + EFV 0 0 2 0.5 (0.1–2.1) 0 0 D4T + XTC + NVP 0 0 0 0 0 0 PI-based regimen 16 1.1 (0.6–2.2) 1 0.2 (0.0–1.2) 1 0.5 (0.1–3.7) INI-based regimen 0 0 0 0 0 0 Other 1 <0.5 12 2.9 (1.3–6.6) 14 8.8 (4.0–18.2) Unknown 0 0 6 1.8 (0.7–4.2) 2 1.2 (0.2–5.5) Mean time on ART (95% CI), months 17.9 (17.4–18.4) 12.5 (12.3–12.7) 12.3 (11.9–12.7) a Study design–weighted proportion and 95% confidence interval. b Study design–weighted mean and 95% confidence interval. HIV DRUG RESISTANCE REPORT 201934 Table 3.1b. Population characteristics of early time point (12 months) for ADR surveys – Africa Ugandaa (12 ±3 months) Zambiab (12 ±3 months) N = 533 (start year 2016) N = 454 (start year 2016) n % (95% CI)c n % (95% CI)c Gender Women 351 65.9 (59.3–72.0) 257 60.0 (56.3–63.4) Men 182 34.1 (28.0–40.7) 197 40.1 (36.6–43.7) Meand age (95% CI), years 33.2 (31.1–35.2) 37.9 (36.4–39.4) Individuals on first-line ART 533 100.0 453 100.0 (99.6–100) Individuals on NNRTI-based first-line ART 533 100.0 453 100.0 (99.6–100) Individuals on second-line ART 0 1 <0.5 Current ART TDF + XTC + EFV 473 96.4 (86.7–99.1) 450 99.8 (99.3–100.0) TDF + XTC + NVP 0 0 3 <0.5 AZT + XTC + EFV 25 2.3 (0.5–9.8) 0 0 AZT + XTC + NVP 33 1.3 (0.4–4.5) 0 0 D4T + XTC + EFV 0 0 0 0 D4T + XTC + NVP 0 0 0 0 PI-based regimen 0 0 1 <0.5 INI-based regimen 0 0 0 0 Other 2 0.1 (0.0–0.6) 0 0 Unknown 0 0 0 0 Mean time on ART (95% CI), months 12.6 (12.2–12.9) 12.2 (11.8–12.6) a Included only participants on first-line ART. b Three participants had missing data for age. c Study design–weighted proportion and 95% confidence interval. d Study design–weighted mean and 95% confidence interval. 35HIV DRUG RESISTANCE REPORT 2019 Table 3.1c. Population characteristics of early time point (12 months) for ADR surveys – the Americas Guatemala (12 ± 3 months) Honduras (12 ± 3 months) Nicaragua (12 ± 3 months) N = 222 (start year 2016) N = 168 (start year 2016) N = 114 (start year 2016) n % (95% CI)a n % (95% CI)a n % (95% CI)a Gender Women 66 29.7 (21.1–40.1) 61 35.0 (28.6–42.1) 38 33.5 (24.3–44.0) Men 156 70.3 (59.9–78.9) 107 65.0 (57.9–71.4) 76 66.6 (56.0–75.7) Meanb age (95% CI), years 35.7 (33.8–37.6) 34.9 (34.9–36.3) 32.3 (30.9–33.8) Individuals on first-line ART 220 99.1 (96.4–99.8) 167 99.1 (95.3–99.8) 110 97.8 (97.7–97.9) Individuals on NNRTI-based first-line ART 216 97.3 (93.8–98.9) 166 98.5 (95.2–99.5) 104 88.4 (76.2–94.8) Individuals on second-line ART 2 0.9 (0.4–2.1) 1 0.9 (0.2–4.7) 4 2.2 (2.1–2.3) Current ART TDF + XTC + EFV 199 89.6 (74.5–96.2) 157 93.0 (89.5–95.5) 91 75.2 (64.7–83.3) TDF + XTC + NVP 0 – 1 0.8 (0.2–4.3) 0 AZT + XTC + EFV 3 1.4 (0.4–4.8) 4 1.9 (1.0–3.5) 13 13.3 (10.6–16.4) AZT + XTC + NVP 3 1.4 (0.3–5.2) 0 – 0 – D4T + XTC + EFV 0 – 0 – 0 – D4T + XTC + NVP 0 – 0 – 0 – PI-based regimen 6 2.7 (1.1–6.2) 1 0.6 (0.1–2.8) 8 10.5 (4.3–23.2) INI-based regimen 0 – 1 0.6 (0.1–2.8) 0 – Other 11 5.0 (1.2–17.7) 4 3.0 (1.3–6.6) 2 1.1 (1.0–1.1) Unknown 0 – 0 – 0 – Mean time on ART (95% CI), months 12.2 (12.0–12.4) 12.1 (11.8–12.4) 12.1 (11.7–12.4) a Study design–weighted proportion and 95% confidence interval. b Study design–weighted mean and 95% confidence interval. HIV DRUG RESISTANCE REPORT 201936 Table 3.1d. Population characteristics of early time point (12 months) for ADR surveys – Western Pacific Viet Nam (12 ± 3 months) N = 429 (start year 2017) n % (95% CI)a Gender Women 139 31.4 (23.9–40.0) Men 290 68.6 (60.0–76.1) Mean ageb (95% CI), years 35.7 (33.8–37.6) Individuals on first-line ART 423 98.4 (95.5–99.4) Individuals on NNRTI-based first-line ART 423 98.4 (95.5–99.4) Individuals on second-line ART 6 1.6 (0.6–4.5) Current ART TDF + XTC + EFV 419 97.5 (94.7–98.9) TDF + XTC + NVP 2 0.2 (0.1–1.0) AZT + XTC + EFV 2 0.7 (0.2–2.6) AZT + XTC + NVP 3 0.7 (0.2–2.3) D4T + XTC + EFV 0 0 D4T + XTC + NVP 1 0.3 (0.0–2.4) PI-based regimen 1 0.3 (0.0–2.0) INI-based regimen 0 0 Other 1 0.3 (0.0–2.0) Unknown 0 0 Mean time on ART (95% CI), months 11.8 (11.4–12.2) a Study design–weighted proportion and 95% confidence interval. b Study design–weighted mean and 95% confidence interval 37HIV DRUG RESISTANCE REPORT 2019 Table 3.1e. Population characteristics of late time point (≥48 months) for ADR surveys – Africa Cameroon (48–60 months) Eswatini (≥48 months) Senegal (≥40 months) Ugandaa (≥48 months) N = 388 (start year 2015) N = 500 (start year 2016) N = 315 (start year 2017) N = 1062 (start year 2017) n % (95% CI)b n % (95% CI)b n % (95% CI)b n % (95% CI)b Gender Women 287 75.3 (66.6–82.3) 359 70.3 (65.4–74.7) 239 76.5 (69.2–82.4) 693 65.6 (62.2–68.9) Men 101 24.7 (17.7–33.4) 141 29.8 (25.3–34.7) 76 23.5 (17.6–30.8) 369 44.4 (31.1–37.8) Meanc age (95% CI), years 43.1 (42.0–44.3) 43.4 (41.3–45.6) 43.8 (42.0–45.6) 44.6 (43.7–45.5) Individuals on first-line ART 364 94.4 (83.9–98.2) 468 93.6 (90.4–95.8) 311 98.8 (96.4–99.6) 1062 100.0 (99.6–100.0) Individuals on NNRTI-based first- line ART 364 94.4 (83.9–98.2) 464 92.7 (89.4–95.0) 311 98.8 (96.4–99.6) 1061 99.9 (99.2–100.0) Individuals on second-line ART 24 5.6 (2.0–15.1) 32 6.4 (4.2–9.6) 3 1.1 (0.3–3.6) 0 0 Current ART TDF + XTC + EFV 229 58.8 (46.2–70.3) 148 29.4 (23.7–35.9) 235 75.1 (64.6–83.2) 244 23.0 (18.3–28.5) TDF + XTC + NVP 58 16.0 (7.9–29.8) 23 5.1 (3.2–7.8) 1 0.4 (0.1–2.5) 122 10.4 (7.7–13.8) AZT + XTC + EFV 4 1.0 (0.1–6.5) 50 11.1 (7.6–16.0) 13 7.1 (2.1–20.8) 106 9.7 (7.2–12.9) AZT + XTC + NVP 73 18.6 (9.1–34.3) 178 33.4 (27.8–39.4) 62 16.2 (11.2–23.0) 586 56.6 (49.6–63.4) D4T + XTC + EFV 0 0 24 5.2 (3.4–7.9) 0 0 0 0 D4T + XTC + NVP 0 0 31 6.6 (4.6–9.2) 0 0 0 0 PI-based regimen 23 5.4 (1.8–15.4) 25 5.0 (3.0–8.2) 4 1.2 (0.4–3.6) 1 0.1 (0–0.8) Other 1 <0.5 10 2.0 (1.1–3.6) 0 0 3 0 Unknown 0 0 11 2.3 (1.2–4.3) 0 0 0 0 Mean time on ART (95% CI), months 53.3 (52.1–54.6) 85.2 (81.5–88.9) 52.2 (48.4–56.0) 88.5 (80.3–96.6) a Included only participants on first-line ART. b Study design–weighted proportion and 95% confidence interval. c Study design–weighted mean and 95% confidence interval. HIV DRUG RESISTANCE REPORT 201938 Table 3.1f. Population characteristics of late time point (≥48 months) for ADR surveys – the Americas Guatemala (≥48 months) Honduras (≥48 months) Nicaragua (≥48 months) N = 377 (start year 2016) N = 367 (start year 2016) N = 350 (start year 2016) n % (95% CI)a n % (95% CI)a n % (95% CI)a Gender Women 161 42.7 (35.0–50.7) 212 58.8 (51.8–65.5) 134 43.0 (35.8–50.5) Men 214 56.8 (48.5–64.7) 154 41.0 (34.3–48.1) 219 57.0 (49.5–64.2) Others 2 0.5 (0.1–2.1) 1 0.1 (0.1–0.1) 0 0 Meanb age (95% CI), years 42.7 (41.4–43.9) 43.4 (41.7–45.0) 38.7 (37.2–39.0) Individuals on first-line ART 350 92.9 (81.8–97.4) 298 86.0 (81.8–89.4) 303 84.8 (79.2–89.1) Individuals on NNRTI- based first-line ART 323 85.7 (78.3–90.9) 290 84.2 (79.9–87.6) 264 74.9 (69.2–79.9) Individuals on second- line ART 27 7.1 (5.4–9.4) 62 12.5 (9.3–16.7) 49 14.4 (10.4–19.5) Current ART TDF + XTC + EFV 185 49.0 (43.5–54.6) 57 12.3 (9.7–15.5) 117 32.4 (26.8–38.6) TDF + XTC + NVP 27 7.2 (4.1–12.3) 9 1.7 (1.2–2.4) 2 0.8 (0.2–3.0) AZT + XTC + EFV 70 18.5 (14.7–23.1) 210 65.3 (60.1–70.3) 130 36.6 (30.3–43.4) AZT + XTC + NVP 14 3.7 (1.8–7.7) 1 0.4 (0.1–2.0) 3 1.5 (0.5–4.8) D4T + XTC + EFV 0 0 0 0 0 0 D4T + XTC + NVP 0 0 0 0 0 0 PI-based regimen 52 13.8 (8.5–21.6) 67 13.6 (10.3–17.8) 59 18.6 (14.1–24.1) Other 29 7.7 (3.6–15.9) 23 6.7 (4.5–10.0) 42 10.0 (7.3–13.6) Unknown 0 0 0 0 0 0 Mean time on ART (95% CI), months 91.8 (84.5–99.1) 102.3 (97.5–107.0) 82.1 (76.8–87.4) a Study design–weighted proportion and 95% confidence interval. b Study design–weighted mean and 95% confidence interval. 39HIV DRUG RESISTANCE REPORT 2019 Table 3.1g. Population characteristics of late time point (≥48 months) for ADR surveys – Western Pacific Viet Nam (≥48 months) N = 723 (start year 2017) n % (95% CI)a Gender Women 267 37.6 (33.2–42.1) Men 456 62.4 (57.9–66.8) Meanb age (95% CI), years 41.0 (40.1–41.8) Individuals on first-line ART 688 94.8 (92.1–96.7) Individuals on NNRTI-based first-line ART 658 91.7 (88.1–94.2) Individuals on second-line ART 35 5.2 (3.3–7.9) Current ART TDF + XTC + EFV 436 62.6 (55.6–69.1) TDF + XTC + NVP 6 0.9 (0.4–1.9) AZT + XTC + EFV 81 11.0 (7.8–15.2) AZT + XTC + NVP 134 17.1 (13.0–22.1) D4T + XTC + EFV 1 0.1 (0.0–1.0) D4T + XTC + NVP 0 0 PI-based regimen 58 7.2 (5.0–10.3) Other 7 1.1 (0.4–3.1) Unknown 0 0 Mean time on ART (95% CI), months 87.8 (83.1–92.5) a Study design–weighted proportion and 95% confidence interval. b Study design–weighted mean and 95% confidence interval. HIV DRUG RESISTANCE REPORT 201940 Table 3.2a. Prevalence of viral load suppression for individuals on ART, early time point (12 months), ADR surveys – Africa Cameroon (12–24 months) Eswatinia (12±3 months) Senegal (12±3 months) n Prevalence % (95% CI) n Prevalence % (95% CI) n Prevalence % (95% CI) Cut-off viral load <1000 copies/mL Viral load suppression among individuals on ART 796/1064 72.1 (66.2–77.2) 340/375 90.5 (86.3–93.5) 211/255 86.5 (79.4–91.5) Viral load suppression among individuals on first-line ART 786/1050 72.1 (66.5–77.2) 340/375 90.6 (86.5–93.6) 208/252 86.4 (79.2–91.4) Viral load suppression among individuals on first-line NNRTI-based ART 785/1048 72.1 (66.4–77.2) 335/368 90.8 (86.6–93.8) 206/249 86.0 (78.8–91.0) Viral load suppression among individuals on TDF-based first- line NNRTI-based ART 668/887 74.9 (70.2–79.1) 303/334 90.7 (86.4–93.7) 196/238 85.4 (78.0–90.6) Viral load suppression among individuals on AZT-based first-line NNRTI-based ART 117/180 60.2 (49.1–70.4) 15/17 85.9 (58.4–96.3) 0/238 0 Viral load suppression among individuals on PI-based second-line ART 10/14 65.5 (34.9–87.1) 0/1 0 1/1 100.0 Viral load suppression among women on ART 624/808 75.0 (69.4–79.9) 249/270 92.0 (88.2–94.7) 154/184 86.8 (78.9–92.0) Viral load suppression among men on ART 172/256 61.6 (51.7–70.6) 91/105 86.5 (74.1–93.5) 57/71 85.8 (72.0–93.5) a Viral suppression defined as viral load ≤2005 copies/mL based on DBS, lower limit of detection by the Roche free viral elution platform. 41HIV DRUG RESISTANCE REPORT 2019 Table 3.2b. Prevalence of viral load suppression for individuals on ART, early time point (12 months), ADR surveys – Africa Uganda (12±3 months) Zambia (12±3 months) n/N Prevalence % (95% CI) n/N Prevalence % (95% CI) Cut-off viral load <1000 copies/mL Viral load suppression among individuals on ART 493/533 94.6 (92.8–96.0) 409/454 90.0 (80.1–94.2) Viral load suppression among individuals on first-line ART 493/533 94.6 (92.8–96.0) 408/453 88.9 (80.2–94.1) Viral load suppression among individuals on first-line NNRTI-based ART 493/533 94.6 (92.8–96.0) 408/453 88.9 (80.2–94.1) Viral load suppression among individuals on TDF-based first-line NNRTI-based ART 493/533 94.6 (92.8–96.0) 408/453 88.9 (80.2–94.1) Viral load suppression among individuals on AZT-based first-line NNRTI-based ART 53/58 94.9 (86.9–98.1) 0/453 0 Viral load suppression among individuals on PI-based second-line ART NA NA 1/1 100.0 Viral load suppression among women on ART 324/351 93.1 (91.4–94.5) 228/257 86.3 (74.1–93.3) Viral load suppression among women on men 169/182 97.6 (90.8–99.4) 181/197 92.9 (83.5–97.1) Cut-off viral load <400 copies/mL Viral load suppression among individuals on ART NA NA 397/454 85.3 (68.1–94.0) Viral load suppression among individuals on first-line ART NA NA 396/453 85.3 (68.1–94.0) Viral load suppression among individuals on first-line NNRTI-based ART NA NA 396/453 85.3 (68.1–94.0) Viral load suppression among individuals on TDF-based first-line NNRTI-based ART NA NA 396/453 85.3 (68.1–94.0) Viral load suppression among individuals on AZT-based first-line NNRTI-based ART NA NA 0 0 Viral load suppression among individuals on PI-based second-line ART NA NA 1/1 100 Viral load suppression among women on ART NA NA 223/257 83.4 (64.7–93.2) Viral load suppression among men on ART NA NA 174/197 88.1 (70.2–95.9) Cut-off viral load <50 copies/mL Viral load suppression among individuals on ART NA NA 350/454 75.3 (56.1–87.9) Viral load suppression among individuals on first-line ART NA NA 350/453 75.3 (56.0–87.9) Viral load suppression among individuals on first-line NNRTI-based ART NA NA 349/453 75.2 (56.0–87.9) Viral load suppression among individuals on TDF-based first-line NNRTI-based ART NA NA 349/453 75.2 (56.0–87.9) Viral load suppression among individuals on AZT-based first-line NNRTI-based ART NA NA 0 0 Viral load suppression among individuals on PI-based second-line ART NA NA 1/1 100 Viral load suppression among women on ART NA NA 196/257 76.3 (58.2–88.1) Viral load suppression among men on ART NA NA 154/197 73.7 (49.2–89.1) HIV DRUG RESISTANCE REPORT 201942 Table 3.2c. Prevalence of viral load suppression for individuals on ART, early time point (12 months), ADR surveys – the Americas Guatemalaa (12±3 months) Hondurasb (12±3 months) Nicaraguac (12±3 months) n/N Prevalence % (95% CI) n/N Prevalence % (95% CI) n/N Prevalence % (95% CI) Cut-off viral load <1000copies/mL Viral load suppression among individuals on ART (on treatment analysis)d 197/222 88.7 (77.4–94.8) 150/168 89.7 (85.1–93.0) 86/114 77.8 (67.1–85.8) Viral load suppression among individuals on ART (intention-to-treat analysis)e 197/222 66.9 (60.2–73.6) 150/168 72.7 (68.6–76.7) 86/114 57.1 (49.2–65.1) Viral load suppression among individuals on first-line ART 195/220 88.6 (77.1–94.7) 149/167 89.6 (85.0–93.0) 82/110 77.3 (66.4–85.5) Viral load suppression among individuals on first-line NNRTI-based ART 193/216 89.3 (79.2–94.9) 148/166 89.6 (84.9–92.9) 78/104 80.7 (76.1–84.7) Viral load suppression among individuals on TDF- based first-line NNRTI-based ART 181/199 91.0 (81.6–95.8) 142/158 90.4 (85.8–93.6) 67/91 80.0 (75.9–83.6) Viral load suppression among individuals on AZT- based first-line NNRTI-based ART 4/6 66.7 (13.8–96.2) 5/7 66.1 (35.0–87.7) 15/19 68.3 (37.7–88.5) Viral load suppression among individuals on PI-based second-line ART 2/2 100 1/1 100.0 4/4 100.0 Viral load suppression among women on ART 56/66 84.8 (73.0–92.0) 52/61 87.0 (77.4–92.9) 28/38 66.4 (42.7–84.0) Viral load suppression among men on ART 141/156 90.4 (76.0–96.5) 98/107 91.2 (83.6–95.5) 58/76 83.5 (73.8–90.2) Cut-off viral load <400 copies/mL Viral load suppression among individuals on ART 196/222 88.3 (76.1–94.7) 149/168 89.4 (84.5–92.7) 81/114 74.8 (64.4–83.0) Viral load suppression among individuals on first-line ART 194/220 88.2 (75.9–94.7) 148/167 89.3 (84.7–92.6) 79/110 75.4 (64.6–83.7) Viral load suppression among individuals on first-line NNRTI-based ART 192/216 88.9 (77.9–94.8) 147/166 89.2 (84.6–92.6) 75/104 78.6 (73.8–82.7) Viral load suppression among individuals on TDF- based first-line NNRTI-based ART 180/199 90.5 (80.0–95.7) 141/158 90.0 (85.5–93.3) 65/91 78.5 (74.2–82.2) Viral load suppression among individuals on AZT- based first-line NNRTI-based ART 4/6 66.7 (13.8–96.2) 5/7 66.1 (35.0–87.7) 14/19 65.1 (36.8–85.6) Viral load suppression among individuals on PI-based second-line ART 2/2 100 1/1 100.0 2/4 50 (50–50) Viral load suppression among women on ART 56/66 84.8 (73.0–92.0) 51/61 86.0 (78.3–91.3) 26/38 63.0 (42.9–79.4) Viral load suppression among men on ART 140/156 89.7 (73.7–96.5) 98/107 91.2 (83.6–95.5) 55/76 80.8 (76.7–84.3) Cut-off viral load <50 copies/mL Viral load suppression among individuals on ART 178/222 80.2 (70.2–87.4) 125/168 73.1 (65.9–79.3) 71/114 67.9 (57.8–76.6) Viral load suppression among individuals on first-line ART 177/220 80.5 (71.0–87.4) 125/167 73.8 (66.5–80.0) 69/110 68.3 (57.9–77.1) Viral load suppression among individuals on first-line NNRTI-based ART 175/216 81.0 (72.7–87.2) 124/166 73.6 (66.3–79.8) 65/104 70.7 (65.4–75.6) Viral load suppression among individuals on TDF- based first-line NNRTI-based ART 165/199 82.9 (75.5–88.5) 119/158 74.1 (66.6–80.5) 56/91 70.2 (64.9–75.0) Viral load suppression among individuals on AZT- based first-line NNRTI-based ART 4/6 66.7 (13.8–96.2) 4/7 55.2 (28.5–79.2) 13/19 61.9 (35.7–82.6) Viral load suppression among individuals on PI-based second-line ART 1/1 50.0 (33.2–96.7) 0/1 <0.5 2/4 50 (50–50) Viral load suppression among women on ART 53/66 80.3 (61.8–91.1) 41/61 67.4 (56.2–76.9) 23/38 57.4 (39.2–73.8) Viral load suppression among men on ART 125/156 80.1 (70.1–87.4) 84/107 76.2 (66.5–83.6) 48/76 73.2 (67.5–78.1) National retention prevalence for adults ≥15 years old: a75%, b81% and c73%. Source: UNAIDS/WHO Global AIDS Monitoring tool. d Prevalence of viral load suppression assessed from participants in the survey. e Prevalence of viral load suppression extrapolated to the 12-month cohort that initiated treatment together with the individuals participating in the survey: adjusting for loss to follow-up and accounting for deaths and transfers out. 43HIV DRUG RESISTANCE REPORT 2019 Table 3.2d. Prevalence of viral load suppression for individuals on ART, early time point (12 months), ADR surveys – Western Pacific Viet Nama (12±3 months) n Prevalence % (95% CI) Cut-off viral load <1000 copies/mL Viral load suppression among individuals on ART (on treatment analysis)b 411/429 95.5 (91.3–97.8) Viral load suppression among individuals on ART (intention-to-treat analysis)c 411/429 84.0 (78.4–88.4) Viral load suppression among individuals on first-line ART 407/423 96.0 (91.7–98.1) Viral load suppression among individuals on first-line NNRTI-based ART 407/423 96.0 (91.7–98.1) Viral load suppression among individuals on TDF-based first-line NNRTI-based ART 404/421 95.7 (91.4–97.9) Viral load suppression among individuals on AZT-based first-line NNRTI-based ART 6/7 87.7 (42.3–98.6) Viral load suppression among individuals on PI-based second-line ART 4/6 69.0 (30.8–91.7) Viral load suppression among women on ART 133/139 94.2 (83.7–98.1) Viral load suppression among men on ART 278/290 96.2 (92.9–98.0) Cut-off viral load <400 copies/mL Viral load suppression among individuals on ART 406/429 94.0 (89.4–96.5) Viral load suppression among individuals on first-line ART 402/423 94.3 (89.7–96.9) Viral load suppression among individuals on first-line NNRTI-based ART 402/423 94.3 (89.7–96.9) Viral load suppression among individuals on TDF-based first-line NNRTI-based ART 399/421 94.0 (89.4–96.6) Viral load suppression among individuals on AZT-based first-line NNRTI-based ART 6/7 87.7 (42.3–98.6) Viral load suppression among individuals on PI-based second-line ART 4/6 69.0 (30.8–91.7) Viral load suppression among women on ART 130/139 91.0 (81.1–95.9) Viral load suppression among men on ART 276/290 95.2 (91.6–97.3) Cut-off viral load <50 copies/mL Viral load suppression among individuals on ART 369/429 84.6 (78.7–89.1) Viral load suppression among individuals on first-line ART 366/423 85.1 (78.8–90.0) Viral load suppression among individuals on first-line NNRTI-based ART 366/423 85.1 (78.8–90.0) Viral load suppression among individuals on TDF-based first-line NNRTI-based ART 363/421 84.7 (78.5–89.4) Viral load suppression among individuals on AZT-based first-line NNRTI-based ART 5/7 74.2 (38.3–93.0) Viral load suppression among individuals on PI-based second-line ART 3/6 53.0 (27.6–76.9) Viral load suppression among women on ART 120/139 85.5 (75.6–91.7) Viral load suppression among men on ART 249/290 84.2 (73.3–91.1) a National retention prevalence 89% (95% CI: 85–92%) estimated from sites participating in the survey. b Prevalence of viral load suppression assessed from participants in the survey. c Prevalence of viral load suppression extrapolated to the 12-month cohort that initiated treatment together with the individuals participating in the survey: adjusting for loss to follow-up and accounting for deaths and transfers out. HIV DRUG RESISTANCE REPORT 201944 Table 3.2e. Prevalence of viral load suppression for individuals on ART, late time point (≥48 months), national ADR surveys – Africa Cameroon (48–60 months) Eswatinia (≥48 months) Senegal (≥40 months) n/N Prevalence % (95% CI) n/N Prevalence % (95% CI) n/N Prevalence % (95% CI) Cut-off viral load <1000 copies/mL Viral load suppression among individuals on ART 267/388 67.8 (55.8–77.7) 468/500 93.7 (90.4–95.9) 270/315 88.1 (81.2–92.7) Viral load suppression among individuals on first-line ART 255/364 68.7 (56.0–79.1) 443/468 94.7 (91.3–96.8) 267/311 88.2 (81.2–92.8) Viral load suppression among individuals on first-line NNRTI-based ART 255/364 68.7 (56.0–79.1) 441/464 95.1 (91.6–97.2) 267/311 88.2 (81.2–92.8) Viral load suppression among individuals on TDF-based first-line NNRTI-based ART 210/287 70.8 (57.4–81.4) 164/171 96.0 (90.6–98.3) 206/236 88.5 (80.6–93.5) Viral load suppression among individuals on AZT-based first-line NNRTI-based ART 45/77 60.6 (42.7–76.1) 217/228 95.1 (90.6–97.5) 61/75 87.1 (73.6–94.2) Viral load suppression among individuals on PI-based second-line ART 12/24 51.1 (34.6–67.5) 25/32 78.8 (62.1–89.4) 2/3 83.2 (32.4–98.1) Viral load suppression among women on ART 202/287 69.4 (57.2–79.3) 339/359 94.1 (89.6–96.7) 208/239 89.3 (81.9–93.8) Viral load suppression among men on ART 65/101 62.7 (41.8–79.7) 129/141 92.6 (86.9–96.0) 62/76 84.4 (69.7–92.8) a Viral suppression defined as viral load ≤2005 copies/mL based on DBS, lower limit of detection by the Roche free viral elution platform. 45HIV DRUG RESISTANCE REPORT 2019 Table 3.2f. Prevalence of viral load suppression for individuals on ART, late time point (≥48 months), national ADR surveys – Africa Uganda (≥48 months) n/N Prevalence % (95% CI) Cut-off viral load <1000 copies/mL Viral load suppression among individuals on ART 923/1062 88.0 (84.6–90.7) Viral load suppression among individuals on first-line ART 923/1062 88.0 (84.6–90.7) Viral load suppression among individuals on first-line NNRTI-based ART 922/1061 88.0 (84.6–90.7) Viral load suppression among individuals on TDF-based first-line NNRTI-based ART 328/366 90.7 (84.9–94.4) Viral load suppression among individuals on AZT-based first-line NNRTI-based ART 591/692 86.6 (82.4–89.9) Viral load suppression among individuals on PI-based second-line ART 0/0 0 Viral load suppression among women on ART 606/693 88.3 (85.2–90.8) Viral load suppression among men on ART 317/369 87.4 (81.6–91.6) HIV DRUG RESISTANCE REPORT 201946 Table 3.2g. Prevalence of viral load suppression for individuals on ART, late time point (≥48 months), national ADR surveys – the Americas Guatemala (≥48 months) Honduras (≥48 months) Nicaragua (≥48 months) n/N Prevalence % (95% CI) n/N Prevalence % (95% CI) n/N Prevalence % (95% CI) Viral load <1000 copies/mL Viral load suppression among individuals on ART 328/377 86.9 (70.4–94.8) 246/367 67.9 (61.7–73.6) 240/353 70.3 (66.7–73.8) Viral load suppression among individuals on first-line ART 308/350 87.9 (71.5–95.4) 203/298 68.9 (61.7–75.3) 208/303 70.9 (66.8–74.6) Viral load suppression among individuals on first-line NNRTI-based ART 286/323 88.4 (71.8–95.8) 198/290 69.2 (61.8–75.7) 182/264 70.3 (65.7–74.4) Viral load suppression among individuals on TDF- based first-line NNRTI-based ART 188/212 88.6 (72.8–95.7) 38/60 64.6 (54.0–73.9) 77/113 70.4 (64.8–75.6) Viral load suppression among individuals on AZT- based first-line NNRTI-based ART 72/84 85.5 (59.2–96.0) 161/227 71.9 (63.2–79.2) 112/159 71.9 (65.8–77.3) Viral load suppression among individuals on PI-based second-line ART 20/27 74.1 (54.0–87.4) 41/62 66.5 (54.4–76.8) 31/49 65.3 (53.9–75.2) Viral load suppression among women on ART 137/161 85.0 (67.2–94.0) 141/212 69.4 (61.3–76.5) 92/134 72.5 (65.2–78.8) Viral load suppression among men on ART 189/214 88.2 (71.8–95.7) 105/154 66.1 (54.9–75.7) 148/219 68.7 (62.2–74.5) Viral load <400 copies/mL Viral load suppression among individuals on ART 323/377 85.6 (69.5–93.9) 233/367 63.9 (57.1–70.1) 229/353 66.9 (61.7–71.8) Viral load suppression among individuals on first-line ART 304/350 86.7 (70.9–94.6) 194/298 65.0 (57.4–72.0) 199/303 67.8 (62.6–72.4) Viral load suppression among individuals on first-line NNRTI-based ART 283/323 87.5 (70.7–95.3) 189/290 65.2 (57.4–72.3) 174/264 66.9 (61.3–72.1) Viral load suppression among individuals on TDF- based first-line NNRTI-based ART 185/212 87.1 (70.7–95.0) 38/60 64.6 (54.0–73.9) 75/113 69.1 (61.0–76.2) Viral load suppression among individuals on AZT- based first-line NNRTI-based ART 72/84 85.5 (59.2–96.0) 152/227 67.1 (57.9–75.1) 106/159 67.4 (60.4–73.6) Viral load suppression among individuals on PI-based second-line ART 19/27 70.4 (51.2–84.3) 37/62 60.8 (47.8–72.4) 29/49 60.6 (44.9–74.3) Viral load suppression among women on ART 134/161 83.1 (67.0–92.2) 133/212 64.1 (55.0–72.3) 89/134 69.1 (60.0–77.0) Viral load suppression among men on ART 187/214 87.3 (69.6–95.4) 100/154 63.8 (53.8–72.8) 140/219 65.2 (59.4–70.7) Viral load <50 copies/mL Viral load suppression among individuals on ART 301/377 79.7 (61.4–90.7) 204/367 57.6 (50.9–64.0) 180/353 52.2 (46.9–57.5) Viral load suppression among individuals on first-line ART 286/350 81.6 (63.3–91.9) 174/298 59.5 (51.9–66.7) 158/303 53.6 (48.3–58.9) Viral load suppression among individuals on first-line NNRTI-based ART 266/323 82.2 (63.1–92.6) 170/290 59.8 (52.0–67.1) 139/264 53.8 (48.2–59.4) Viral load suppression among individuals on TDF- based first-line NNRTI-based ART 174/212 82.0 (64.0–92.1) 34/60 58.6 (47.7–68.7) 63/113 59.2 (50.6–67.3) Viral load suppression among individuals on AZT- based first-line NNRTI-based ART 68/84 80.8 (52.8–94.0) 139/227 62.3 (53.2–70.6) 81/159 52.1 (44.7–59.4) Viral load suppression among individuals on PI-based second-line ART 15/27 55.6 (30.0–78.5) 29/62 49.7 (35.3–64.2) 21/49 41.0 (26.0–57.8) Viral load suppression among women on ART 125/161 77.5 (59.4–89.0) 121/212 60.2 (51.2–68.6) 69/134 52.7 (43.1–62.0) Viral load suppression among men on ART 174/214 81.2 (61.7–92.1) 83/154 54.0 (44.2–63.5) 111/219 51.9 (45.8–57.9) 47HIV DRUG RESISTANCE REPORT 2019 Table 3.2h. Prevalence of viral load suppression for individuals on ART, late time point (≥48 months), national ADR surveys – Western Pacific Viet Nam (≥48 months) n Prevalence % (95% CI) Viral load <1000 copies/mL Viral load suppression among individuals on ART 691/723 96.1 (93.2–97.8) Viral load suppression among individuals on first-line ART 658/688 96.2 (93.6–97.8) Viral load suppression among individuals on first-line NNRTI-based ART 632/658 96.4 (93.6–98.0) Viral load suppression among individuals on TDF-based first-line NNRTI-based ART 431/443 97.7 (94.8–99.0) Viral load suppression among individuals on AZT-based first-line NNRTI-based ART 213/228 93.2 (87.9–96.3) Viral load suppression among individuals on PI-based second-line ART 33/35 94.6 (69.6–99.3) Viral load suppression among women on ART 257/267 96.8 (94.0–98.3) Viral load suppression among men on ART 434/456 95.7 (91.9–97.7) Viral load <400 copies/mL Viral load suppression among individuals on ART 688/723 95.7 (93.0–97.4) Viral load suppression among individuals on first-line ART 535/562 95.9 (93.6–97.4) Viral load suppression among individuals on first-line NNRTI-based ART 509/532 96.1 (93.6–97.7) Viral load suppression among individuals on TDF-based first-line NNRTI-based ART 428/443 97.1 (94.5–98.5) Viral load suppression among individuals on AZT-based first-line NNRTI-based ART 213/228 93.2 (87.9–96.3) Viral load suppression among individuals on PI-based second-line ART 33/35 94.6 (69.6–99.3) Viral load suppression among women on ART 256/267 96.6 (93.8–98.1) Viral load suppression among men on ART 432/456 95.2 (91.6–97.3) Viral load <50 copies/mL Viral load suppression among individuals on ART 646/723 89.8 (86.1–92.7) Viral load suppression among individuals on first-line ART 504/562 90.4 (86.0–93.6) Viral load suppression among individuals on first-line NNRTI-based ART 482/532 90.9 (86.3–94.1) Viral load suppression among individuals on TDF-based first-line NNRTI-based ART 409/443 92.5 (88.3–95.3) Viral load suppression among individuals on AZT-based first-line NNRTI-based ART 197/228 86.1 (79.1–91.0) Viral load suppression among individuals on PI-based second-line ART 28/35 80.8 (57.7–92.9) Viral load suppression among women on ART 242/267 91.0 (86.2–94.3) Viral load suppression among men on ART 404/456 89.1 (84.3–92.6) HIV DRUG RESISTANCE REPORT 201948 Table 3.3a. Prevalence of ADR among individuals on ART, early time point (12 months), national ADR surveys – Africa Cameroon (12–24 months) Eswatinia (12±3 months) Senegal (12±3 months) n/N Prevalence % (95% CI) n/N Prevalence % (95% CI) n/N Prevalence % (95% CI) HIVDR among individuals on ART Any 111/960 17.1 (14.0–20.7) 18/366 4.7 (2.5–8.6) 15/238 7.0 (3.9–12.4) NNRTI 109/960 16.7 (13.7–20.2) 17/366 4.5 (2.4–8.1) 15/238 7.0 (3.9–12.4) NRTI 97/960 14.7 (11.3–18.9) 18/366 4.7 (2.5–8.6) 8/238 2.4 (1.0–5.3) PI 1/960 0.3 (0.0–2.2) 0/366 0 0/238 0 NNRTI+NRTI 96/960 14.6 (11.3–18.7) 17/366 4.5 (2.4–8.1) 8/238 2.4 (1.0–5.3) HIVDR among individuals on ART with viral load ≥1000 copies/mL Any 111/164 61.1 (50.3–70.9) 18/26 51.8 (26.8–76.0) 15/27 62.5 (40.8–80.1) NNRTI 109/164 59.7 (49.3–69.4) 17/26 49.7 (26.4–73.2) 15/27 62.5 (40.8–80.1) NRTI 97/164 52.6 (41.2–63.7) 18/26 51.8 (26.8–76.0) 8/27 21.0 (6.9–49.1) PI 1/164 1.1 (0.1–7.5) 0/26 0 0/27 0 NNRTI+NRTI 96/164 52.3 (41.1–63.2) 17/26 49.7 (26.4–73.2) 8/27 21.0 (6.9–49.1) HIVDR among individuals on first-line ART with viral load ≥1000 copies/mL Any 110/162 61.2 (50.3–71.0) 17/25 50.8 (26.2–75.0) 15/27 62.5 (40.8–80.1) NNRTI 108/162 59.8 (49.3–69.5) 17/25 50.8 (26.2–75.0) 15/27 62.5 (40.8–80.1) NRTI 96/162 52.6 (41.2–63.7) 17/25 50.8 (26.2–75.0) 8/27 21.0 (6.9–49.1) PI 1/162 1.1 (0.1–7.5) 0/25 0 0/27 0 NNRTI+NRTI 95/162 52.3 (41.0–63.3) 17/25 50.8 (26.2–75.0) 8/27 21.0 (6.9–49.1) HIVDR among individuals on first-line NNRTI ART with viral load ≥1000 copies/mL Any 109/161 61.1 (50.2–70.9) 17/24 52.7 (2.71–76.9) 15/27 62.5 (40.8–80.1) NNRTI 107/161 59.7 (49.2–69.4) 17/24 52.7 (2.71–76.9) 15/27 62.5 (40.8–80.1) NRTI 95/161 52.5 (41.1–63.6) 17/24 52.7 (2.71–76.9) 8/27 21.0 (6.9–49.1) PI 1/161 1.1 (0.1–7.6) 0/24 0 0/27 0 NNRTI+NRTI 94/161 52.2 (40.9–63.2) 17/24 52.7 (2.71–76.9) 8/27 21.0 (6.9–49.1) HIVDR among individuals on first-line NNRTI and TDF-based ART with viral load ≥1000 copies/mL TDF resistance 42/115 28.8 (18.5–42.0) 15/24 48.9 (25.5–72.7) 7/26 19.1 (5.6–48.6) FTC or 3TC resistance 61/115 45.2 (34.1–56.8) 17/24 52.7 (27.3–76.7) 8/26 21.5 (6.9–50.5) TDF + XTC resistance 42/115 28.8 (18.5–42.0) 15/24 48.9 (25.5–72.7) 7/26 19.1 (5.6–48.6) TDF + XTC + AZT resistance 6/115 3.0 (1.1–8.1) 1/24 2.2 (0.3–15.4) 0/26 0 HIVDR among individuals on first-line NNRTI and AZT-based ART with viral load ≥1000 copies/mL AZT resistance 12/45 22.5 (13.6–34.7) NA NA NA NA FTC or 3TC resistance 32/45 68.4 (51.2–81.7) NA NA NA NA AZT + XTC resistance 12/45 22.5 (13.6–34.7) NA NA NA NA AZT + XTC + TDF resistance 11/45 21.0 (12.6–32.9) NA NA NA NA a Failure to suppress viral loads defined as ≥2005 copies/mL instead of ≥1000 copies/mL. This is due to the use of DBS with the Roche free viral elution platform, which has a limit of detection of 2005 copies/mL. Weight trimming approach used to adjust for excessively large sampling variances in the estimation of ADR prevalence. NNRTI resistance is defined as resistance to nevirapine (NVP) or efavirenz (EFV). NRTI resistance is defined as resistance to any NRTI, and any PI resistance is defined as resistance to atazanavir/ritonavir (ATV/r), lopinavir/ritonavir (LPV/r), or darunavir/ritonavir (DRV/r). Any HIVDR is defined as resistance to NVP/EFV, any NRTI, ATV/r, LPV/r or DRV/r. HIVDR is determined using the Stanford HIVdb algorithm: sequences classified as having low-, intermediate- or high-level resistance are considered resistant. 49HIV DRUG RESISTANCE REPORT 2019 Table 3.3b. Prevalence of ADR among individuals on ART, early time point (12 months), national ADR surveys – Africa Uganda (12±3 months) Zambiaa (12±3 months) n/N Prevalence % (95% CI) n/N Prevalence % (95% CI) HIVDR among individuals on ART Any 27/523 4.5 (3.6–5.6) 18/433 2.8 (0.8–9.4) NNRTI 27/523 4.5 (3.6–5.6) 18/433 2.8 (0.8–9.4) NRTI 23/523 4.2 (3.3–5.4) 17/433 2.6 (0.7–9.1) PI 0/523 0 0/433 0 NNRTI+NRTI 23/523 4.2 (3.3–5.4) 17/433 2.6 (0.7–9.1) HIVDR among individuals on ART with viral load ≥1000 copies/mL Any 27/30 96.6 (83.9–99.4) 18/24 75.8 (39.9–93.6) NNRTI 27/30 96.6 (83.9–99.4) 18/24 75.8 (39.9–93.6) NRTI 23/30 91.3 (65.0–98.3) 17/24 72.7 (39.3–91.6) PI 0/30 0 0/24 0 NNRTI+NRTI 23/30 91.3 (65.0–98.3) 17/24 72.7 (39.3–91.6) HIVDR among individuals on first-line ART with viral load ≥1000 copies/mL Any 27/30 96.6 (83.9–99.4) 18/24 75.8 (39.9–93.6) NNRTI 27/30 96.6 (83.9–99.4) 18/24 75.8 (39.9–93.6) NRTI 23/30 91.3 (65.0–98.3) 17/24 72.7 (39.3–91.6) PI 0/30 0 0/24 0 NNRTI+NRTI 23/30 91.3 (65.0–98.3) 17/24 72.7 (39.3–91.6) HIVDR among individuals on first-line NNRTI ART with viral load ≥1000 copies/mL Any 27/30 96.6 (83.9–99.4) 18/24 75.8 (39.9–93.6) NNRTI 27/30 96.6 (83.9–99.4) 18/24 75.8 (39.9–93.6) NRTI 23/30 91.3 (65.0–98.3) 17/24 72.7 (39.3–91.6) PI 0/30 0 0/24 0 NNRTI+NRTI 23/30 91.3 (65.0–98.3) 17/24 72.7 (39.3–91.6) HIVDR among individuals on first-line NNRTI and TDF-based ART with viral load ≥1000 copies/mL TDF resistance 14/30 84.1 (51.2–96.4) 13/24 54.2 (35.1-72.1) FTC/3TC resistance 23/30 91.3 (65.0–98.3) 16/24 66.7 (46.7-82.0) TDF+XTC resistance 14/30 84.1 (51.2–96.4) 12/24 50.0 (31.4-68.6) TDF+XTC+AZT resistance 5/30 15.6 (3.0–52.2) 0/24 0 HIVDR among individuals on first-line NNRTI and AZT-based ART with viral load ≥1000 copies/mL AZT resistance 1/3 16.8 (1.0–80.6) NA NA FTC or 3TC resistance 3/3 100 NA NA AZT + XTC resistance 1/3 16.8 (1.0–80.6) NA NA AZT + XTC + TDF resistance 1/3 16.8 (1.0–80.6) NA NA a Updated analysis from the 2017 HIVDR report using adjusted weights (weight trimming to adjust for excessively large sampling variances) NNRTI resistance is defined as resistance to nevirapine (NVP) or efavirenz (EFV). NRTI resistance is defined as resistance to any NRTI, and any PI resistance is defined as resistance to atazanavir/ritonavir (ATV/r), lopinavir/ritonavir (LPV/r), or darunavir/ritonavir (DRV/r). Any HIVDR is defined as resistance to NVP/EFV, any NRTI, ATV/r, LPV/r or DRV/r. HIVDR is determined using the Stanford HIVdb algorithm: sequences classified as having low-, intermediate- or high-level resistance are considered resistant. HIV DRUG RESISTANCE REPORT 201950 Table 3.3c. Prevalence of ADR among individuals on ART, early time point (12 months), national ADR surveys – the Americas Guatemala (12±3 months) Honduras (12±3 months) Nicaragua (12±3 months) n/N Prevalence % (95% CI) n/N Prevalence % (95% CI) n/N Prevalence % (95% CI) HIVDR among individuals on ART Any 16/216 9.5 (4.1–20.2) 14/166 7.6 (5.0–11.5) 22/113 18.3 (10.7–29.4) NNRTI 15/216 8.6 (4.1–17.1) 14/166 7.6 (5.0–11.5) 21/113 17.7 (10.2–28.9) NRTI 11/216 6.8 (2.6–16.7) 10/166 5.9 (3.5–9.9) 17/113 15.1 (8.0–26.7) PI 0/216 0 1/166 0.3 (0.2–0.6) 0/113 0 NNRTI+NRTI 10/216 5.9 (2.6–12.8) 10/166 5.9 (3.5–9.9) 16/113 14.5 (7.5–26.3) HIVDR among individuals on ART with viral load ≥1000 copies/mL Any 16/19 84.0 (57.4–95.3) 14/16 86.1 (48.9–97.6) 22/27 85.1 (66.1–94.4) NNRTI 15/19 76.0 (51.2–90.5) 14/16 86.1 (48.9–97.6) 21/27 82.4 (60.7–93.4) NRTI 11/19 60.0 (33.5–81.7) 10/16 67.1 (37.4–87.5) 17/27 70.2 (43.6–87.8) PI 0/19 0 1/16 3.8 (0.5–25.2) 0/27 0 NNRTI+NRTI 10/19 52.0 (32.9–70.5) 10/16 67.1 (37.4–87.5) 16/27 65.7 (40.0–86.6) HIVDR among individuals on first-line ART with viral load ≥1000 copies/mL Any 16/19 84.0 (57.4–95.3) 14/16 86.1 (48.9–97.6) 22/27 85.1 (66.1–94.4) NNRTI 15/19 76.0 (51.2–90.5) 14/16 86.1 (48.9–97.6) 21/27 82.4 (60.7–93.4) NRTI 11/19 60.0 (33.5–81.7) 10/16 67.1 (37.4–87.5) 17/27 70.2 (43.6–87.8) PI 0/19 0 1/16 3.8 (0.5–25.2) 0/27 0 NNRTI+NRTI 10/19 52.0 (32.9–70.5) 10/16 67.1 (37.4–87.5) 16/27 65.7 (40.0–86.6) HIVDR among individuals on first-line NNRTI ART with viral load ≥1000 copies/mL Any 15/17 88.9 (58.4–97.9) 14/16 86.1 (48.9–97.6) 21/25 84.9 (65.4–94.4) NNRTI 14/17 80.0 (51.0–93.9) 14/16 86.1 (48.9–97.6) 20/25 81.3 (58.2–93.2) NRTI 10/17 62.2 (37.5–81.9) 10/16 67.1 (37.4–87.5) 16/25 65.3 (42.2–82.9) PI 0/17 0 1/16 3.8 (0.5–25.2) 0/25 0 NNRTI+NRTI 9/17 53.3 (37.5–68.5) 10/16 67.1 (37.4–87.5) 15/25 61.7 (38.0–80.9) HIVDR among individuals on first-line NNRTI and TDF-based ART with viral load ≥1000 copies/mL TDF resistance 5/15 42.1 (18.3–70.3) 5/14 42.8 (15.1–75.8) 4/23 16.4 (4.7–44.2) FTC or 3TC resistance 8/15 57.9 (31.1–80.7) 9/14 72.8 (41.9–90.9) 13/23 56.2 (31.0–78.5) TDF + XTC resistance 5/15 42.1 (18.3–70.3) 5/14 42.8 (15.1–75.8) 4/23 16.4 (4.7–44.2) TDF + XTC + AZT resistance 0/15 0 3/14 21.5 (4.8–59.8) 1/23 4.1 (0.6–24.5) HIVDR among individuals on first-line NNRTI and AZT-based ART with viral load ≥1000 copies/mL AZT resistance 0/2 0 0/2 0 1/2 73.0 (0.0–100) FTC or 3TC resistance 1/2 57.1 (17.4–89.4) 0/2 0 1/2 73.0 (0.0–100) AZT + XTC resistance 0/2 0 0/2 0 1/2 73.0 (0.0–100) AZT + XTC + TDF resistance 0/2 0 0/2 0 1/2 73.0 (0.0–100) NNRTI resistance is defined as resistance to nevirapine (NVP) or efavirenz (EFV). NRTI resistance is defined as resistance to any NRTI, and any PI resistance is defined as resistance to atazanavir/ritonavir (ATV/r), lopinavir/ritonavir (LPV/r), or darunavir/ritonavir (DRV/r). Any HIVDR is defined as resistance to NVP/EFV, any NRTI, ATV/r, LPV/r or DRV/r. HIVDR is determined using the Stanford HIVdb algorithm: sequences classified as having low-, intermediate- or high-level resistance are considered resistant. 51HIV DRUG RESISTANCE REPORT 2019 Table 3.3d. Prevalence of ADR among individuals on ART, early time point (12 months), national ADR surveys – Western Pacific Viet Nam (2017) (12±3 months) n/N Prevalence % (95% CI) HIVDR among individuals on ART Any 11/425 3.0 (1.6–5.7) NNRTI 11/425 3.0 (1.6–5.7) NRTI 9/425 2.1 (1.0–4.2) PI 0/424 0 NNRTI+NRTI 9/425 2.1 (1.0–4.2) HIVDR among individuals on ART with viral load ≥1000 copies/mL Any 11/14 74.3 (42.8–91.8) NNRTI 11/14 74.3 (42.8–91.8) NRTI 9/14 50.5 (13.1–87.4) PI 0/14 0 NNRTI+NRTI 9/14 50.5 (13.1–87.4) HIVDR among individuals on first-line ART with viral load ≥1000 copies/mL Any 9/12 70.7 (39.1–90.0) NNRTI 9/12 70.7 (39.1–90.0) NRTI 8/12 51.1 (10.1–90.6) PI 0/11 0 NNRTI+NRTI 8/12 51.1 (10.1–90.6) HIVDR among individuals on first-line NNRTI ART with viral load ≥1000 copies/mL Any 9/12 70.7 (39.1–90.0) NNRTI 9/12 70.7 (39.1–90.0) NRTI 8/12 51.1 (10.1–90.6) PI 0/11 0 NNRTI+NRTI 8/12 51.1 (10.1–90.6) HIVDR among individuals on first-line NNRTI and TDF-based ART with viral load ≥1000 copies/mL TDF resistance 4/13 26.5 (4.8–72.2) FTC or 3TC resistance 8/13 47.5 (11.4–86.4) TDF + XTC resistance 4/13 26.5 (4.8–72.2) TDF + XTC + AZT resistance 0/13 0 HIVDR among individuals on first-line NNRTI and AZT-based ART with viral load ≥1000 copies/mL AZT resistance NA NA FTC or 3TC resistance NA NA AZT + XTC resistance NA NA AZT + XTC + TDF resistance NA NA NNRTI resistance is defined as resistance to nevirapine (NVP) or efavirenz (EFV). NRTI resistance is defined as resistance to any NRTI, and any PI resistance is defined as resistance to atazanavir/ritonavir (ATV/r), lopinavir/ritonavir (LPV/r), or darunavir/ritonavir (DRV/r). Any HIVDR is defined as resistance to NVP/EFV, any NRTI, ATV/r, LPV/r or DRV/r. HIVDR is determined using the Stanford HIVdb algorithm: sequences classified as having low-, intermediate- or high-level resistance are considered resistant. HIV DRUG RESISTANCE REPORT 201952 Table 3.3e. Prevalence of ADR among individuals on ART, late time point (≥48 months), national ADR surveys – Africa Cameroon (48–60 months) Eswatini (≥48 months) n/N Prevalence % (95% CI) n/N Prevalence % (95% CI) HIVDR among individuals on ART Any 59/334 28.3 (17.4–42.5) 15/488 4.9 (2.7–8.7) NNRTI 59/334 28.3 (17.4–42.5) 13/488 4.5 (2.3–8.4) NRTI 53/334 25.2 (14.0–40.9) 14/488 4.6 (2.4–8.5) PI 1/334 0.3 (0.0–3.7) 1/488 0.2 (0.0–1.2) NNRTI+NRTI 53/334 25.2 (14.0–40.9) 12/488 4.2 (2.1–8.2) HIVDR among individuals on ART with viral load ≥1000 copies/mL Any 59/67 87.7 (67.4–96.1) 15/20 79.0 (44.7–94.6) NNRTI 59/67 87.7 (67.4–96.1) 13/20 72.9 (41.6–91.1) NRTI 53/67 77.9 (50.2–92.5) 14/20 75.0 (40.2–93.1) PI 1/67 0.8 (0.1–9.4) 1/20 2.6 (0.3–20.6) NNRTI+NRTI 53/67 77.9 (50.2–92.5) 12/20 69.0 (36.9–89.5) HIVDR among individuals on first-line ART with viral load ≥1000 copies/mL Any 57/63 89.5 (71.0–96.7) 12/13 91.4 (48.0–99.2) NNRTI 57/63 89.5 (71.0–96.7) 12/13 91.4 (48.0–99.2) NRTI 51/63 79.3 (50.4–93.5) 11/13 85.7 (47.8–97.5) PI 1/63 0.8 (0.1–10.1) 0/13 0 NNRTI+NRTI 51/63 79.3 (50.4–93.5) 11/13 85.7 (47.8–97.5) HIVDR among individuals on first-line NNRTI ART with viral load ≥1000 copies/mL Any 57/63 89.5 (71.0–96.7) 11/12 90.6 (45.2–99.1) NNRTI 57/63 89.5 (71.0–96.7) 11/12 90.6 (45.2–99.1) NRTI 51/63 79.3 (50.4–93.5) 10/12 84.5 (44.6–97.4) PI 1/63 0.8 (0.1–10.1) 0/12 0 NNRTI+NRTI 51/63 79.3 (50.4–93.5) 10/12 84.5 (44.6–97.4) HIVDR among individuals on first-line NNRTI and TDF-based ART with viral load ≥1000 copies/mL TDF resistance 22/43 51.8 (25.9–76.8) 1/3 28.9 (2.5–86.4) FTC or 3TC resistance 33/43 77.4 (44.1–93.7) 1/3 28.9 (2.5–86.4) TDF + XTC resistance 22/43 51.8 (25.9–76.8) 1/3 28.9 (2.5–86.4) TDF + XTC + AZT resistance 7/43 21.3 (7.0–49.4) 0/3 0 HIVDR among individuals on first-line NNRTI and AZT-based ART with viral load ≥1000 copies/mL AZT resistance 10/20 50.1 (25.2–75.0) 2/5 29.7 (6.4–72.3) FTC or 3TC resistance 18/20 86.7 (50.1–97.7) 5/5 100.0 AZT + XTC resistance 10/20 50.1 (25.2–75.0) 2/5 29.7 (6.4–72.3) AZT + XTC + TDF resistance 10/20 50.1 (25.2–75.0) 2/5 29.7 (6.4–72.3) NNRTI resistance is defined as resistance to nevirapine (NVP) or efavirenz (EFV). NRTI resistance is defined as resistance to any NRTI, and any PI resistance is defined as resistance to atazanavir/ritonavir (ATV/r), lopinavir/ritonavir (LPV/r), or darunavir/ritonavir (DRV/r). Any HIVDR is defined as resistance to NVP/EFV, any NRTI, ATV/r, LPV/r or DRV/r. HIVDR is determined using the Stanford HIVdb algorithm: sequences classified as having low-, intermediate- or high-level resistance are considered resistant. 53HIV DRUG RESISTANCE REPORT 2019 Table 3.3f. Prevalence of ADR among individuals on ART, late time point (≥48 months), national ADR surveys – Africa Senegal (≥40 months) Uganda (≥48 months) n/N n/N Prevalence % (95% CI) n/N Prevalence % (95% CI) HIVDR among individuals on ART Any 28/302 9.6 (5.3–16.8) 87/1016 7.6 (5.9–9.7) NNRTI 28/302 9.6 (5.3–16.8) 85/1016 7.3 (5.5–9.6) NRTI 16/302 5.9 (2.9–11.1) 83/1016 7.2 (5.5–9.2) PI NA NA NA NA NNRTI+NRTI 16/302 5.9 (2.9–11.1) 81/1016 6.9 (5.2–9.1) HIVDR among individuals on ART with viral load ≥1000 copies/mL Any 28/32 92.1 (63.5–98.7) 87/93 92.2 (76.5–97.7) NNRTI 28/32 92.1 (63.5–98.7) 85/93 89.1 (73.4–96.0) NRTI 16/32 56.8 (30.0–80.1) 83/93 87.4 (73.6–94.5) PI NA NA NA NA NNRTI+NRTI 16/32 56.8 (30.0–80.1) 81/93 84.3 (70.4–92.4) HIVDR among individuals on first-line ART with viral load ≥1000 copies/mL Any 28/32 92.1 (63.5–98.7) 87/93 92.2 (76.5–97.7) NNRTI 28/32 92.1 (63.5–98.7) 85/93 89.1 (73.4–96.0) NRTI 16/32 56.8 (30.0–80.1) 83/93 87.4 (73.6–94.5) PI NA NA – – NNRTI+NRTI 16/32 56.8 (30.0–80.1) 81/93 84.3 (70.4–92.4) HIVDR among individuals on first-line NNRTI ART with viral load ≥1000 copies/mL Any 28/32 92.1 (63.5–98.7) 87/93 92.2 (76.5–97.7) NNRTI 28/32 92.1 (63.5–98.7) 85/93 89.1 (73.4–96.0) NRTI 16/32 56.8 (30.0–80.1) 83/93 87.4 (73.6–94.5) PI NA NA NA NA NNRTI+NRTI 16/32 56.8 (30.0–80.1) 81/93 84.3 (70.4–92.4) HIVDR among individuals on first-line NNRTI and TDF-based ART with viral load ≥1000 copies/mL TDF resistance 3/22 12.6 (4.0–33.0) 14/21 60.8 (31.4–84.0) FTC or 3TC resistance 8/22 38.3 (18.4–63.2) 16/21 68.5 (30.0–91.7) TDF + XTC resistance 3/22 12.6 (4.0–33.0) 14/21 60.8 (31.4–84.0) TDF + XTC + AZT resistance 1/22 8.0 (1.4–35.3) 3/21 12.6 (2.7–43.2) HIVDR among individuals on first-line NNRTI and AZT-based ART with viral load ≥1000 copies/mL AZT resistance 5/10 69.4 (23.5–94.4) 37/72 55.0 (42.2–67.1) FTC or 3TC resistance 7/10 83.2 (36.9–97.7) 66/72 89.8 (74.6–96.3) AZT + XTC resistance 4/10 63.6 (17.6–93.5) 36/72 51.8 (37.8–65.5) AZT + XTC + TDF resistance 2/10 11.9 (1.5–53.9) 26/72 40.0 (24.3–57.9) NNRTI resistance is defined as resistance to nevirapine (NVP) or efavirenz (EFV). NRTI resistance is defined as resistance to any NRTI, and any PI resistance is defined as resistance to atazanavir/ritonavir (ATV/r), lopinavir/ritonavir (LPV/r), or darunavir/ritonavir (DRV/r). Any HIVDR is defined as resistance to NVP/EFV, any NRTI, ATV/r, LPV/r or DRV/r. HIVDR is determined using the Stanford HIVdb algorithm: sequences classified as having low-, intermediate- or high-level resistance are considered resistant. HIV DRUG RESISTANCE REPORT 201954 Table 3.3g. Prevalence of ADR among individuals on ART, late time point (≥48 months), national ADR surveys – the Americas Guatemala (≥48 months) Honduras (≥48 months) Nicaragua (≥48 months) n/N Prevalence % (95% CI) n/N Prevalence % (95% CI) n/N Prevalence % (95% CI) HIVDR among individuals on ART Any 30/368 9.5 (3.0–26.2) 89/349 29.2 (23.3–36.0) 87/350 22.4 (18.5–26.8) NNRTI 29/368 9.2 (2.9–25.6) 86/349 27.3 (21.7–33.7) 82/350 21.0 (17.3–25.1) NRTI 25/368 7.8 (2.5–22.2) 79/349 26.7 (20.9–33.5) 68/350 17.6 (14.4–21.4) PI 1/368 0.3 (0.0–4.1) 3/349 2.3 (0.6–7.9) 6/350 1.4 (0.8–2.3) NNRTI+NRTI 24/368 7.5 (2.4–21.4) 76/349 24.8 (19.3–31.2) 63/350 16.2 (13.2–19.7) HIVDR among individuals on ART with viral load ≥1000 copies/mL Any 30/40 76.5 (55.6–89.4) 89/103 92.0 (86.8–95.3) 87/110 75.5 (63.5–84.5) NNRTI 29/40 74.2 (51.8–88.5) 86/103 86.0 (73.7–93.0) 82/110 70.7 (58.7–80.3) NRTI 25/40 63.0 (43.7–78.9) 79/103 84.1 (76.7–89.5) 68/110 59.4 (48.1–69.8) PI 1/40 2.6 (0.3–21.6) 3/103 7.3 (1.8–25.1) 6/110 4.6 (2.2–9.5) NNRTI+NRTI 24/40 60.7 (42.6–76.2) 76/103 78.1 (66.6–86.5) 63/110 54.6 (43.3–65.4) HIVDR among individuals on first-line ART with viral load ≥1000 copies/mL Any 29/35 83.8 (57.8–95.1) 75/80 96.6 (91.9–98.6) 75/93 77.3 (63.3–87.0) NNRTI 28/35 81.1 (59.3–92.6) 73/80 94.8 (89.1–97.6) 70/93 71.6 (57.7–82.3) NRTI 25/35 71.6 (42.4–89.6) 67/80 88.0 (79.7–93.2) 58/93 59.7 (46.8–71.4) PI 1/35 2.9 (0.3–23.4) 1/80 0.6 (0.1–3.8) 2/93 1.8 (0.5–6.0) NNRTI+NRTI 24/35 68.9 (44.3–86.1) 65/80 86.2 (77.6–91.9) 53/93 54.0 (41.3–66.2) HIVDR among individuals on first-line NNRTI ART with viral load ≥1000 copies/mL Any 27/31 87.3 (67.8–95.7) 74/79 96.6 (91.9–98.6) 69/80 82.4 (66.4–91.8) NNRTI 26/31 84.3 (69.4–92.7) 72/79 94.8 (89.0–97.6) 66/80 78.1 (62.3–88.4) NRTI 24/31 76.9 (47.1–92.5) 67/79 87.9 (79.4–93.1) 53/80 63.8 (49.5–76.0) PI 1/31 3.3 (0.3–26.5) 1/79 0.6 (0.1–3.9) 2/80 1.8 (0.4–7.3) NNRTI+NRTI 23/31 73.9 (49.6–89.0) 65/79 86.1 (77.3–91.8) 50/80 59.4 (45.3–72.2) HIVDR among individuals on first-line NNRTI and TDF-based ART with viral load ≥1000 copies/mL TDF resistance 11/21 48.2 (30.4–66.5) 10/20 53.6 (27.7–77.7) 11/35 33.9 (19.0–52.9) FTC or 3TC resistance 18/21 85.2 (63.2–95.1) 15/20 79.1 (53.8–92.5) 20/35 59.5 (39.6–76.7) TDF + XTC resistance 11/21 48.2 (30.4–66.5) 10/20 53.6 (27.7–77.7) 11/35 33.9 (19.0–52.9) TDF + XTC + AZT resistance 3/21 13.1 (5.0–30.4) 4/20 28.7 (8.4–63.7) 1/35 2.3 (0.4–13.8) HIVDR among individuals on first-line NNRTI and AZT-based ART with viral load ≥1000 copies/mL AZT resistance 4/9 46.0 (24.1–69.6) 30/56 66.2 (49.8–79.4) 8/42 15.9 (6.9–32.5) FTC or 3TC resistance 5/9 57.6 (35.4–77.1) 48/56 89.2 (78.1–95.0) 28/42 57.0 (35.4–76.3) AZT + XTC resistance 3/9 35.5 (16.4–60.7) 30/56 66.2 (49.8–79.4) 7/42 14.3 (5.8–31.2) AZT + XTC + TDF resistance 3/9 35.5 (16.4–60.7) 22/56 55.8 (37.9–72.2) 4/42 8.2 (2.7–22.3) NNRTI resistance is defined as resistance to nevirapine (NVP) or efavirenz (EFV). NRTI resistance is defined as resistance to any NRTI, and any PI resistance is defined as resistance to atazanavir/ritonavir (ATV/r), lopinavir/ritonavir (LPV/r), or darunavir/ritonavir (DRV/r). Any HIVDR is defined as resistance to NVP/EFV, any NRTI, ATV/r, LPV/r or DRV/r. HIVDR is determined using the Stanford HIVdb algorithm: sequences classified as having low-, intermediate- or high-level resistance are considered resistant. 55HIV DRUG RESISTANCE REPORT 2019 Table 3.3h. Prevalence of ADR among individuals on ART, late time point (≥48 months), national ADR surveys – Western Pacific Viet Nam (≥48 months) n/N Prevalence % (95% CI) HIVDR among individuals on ART Any 24/718 3.4 (1.9–6.1) NNRTI 23/718 3.3 (1.8–5.9) NRTI 23/718 3.3 (1.8–5.9) PI 1/716 0.1 (0.0–0.7) NNRTI+NRTI 22/718 3.1 (1.7–5.7) HIVDR among individuals on ART with viral load ≥1000 copies/mL Any 24/27 88.5 (70.7–96.1) NNRTI 23/27 84.3 (66.0–93.7) NRTI 23/27 84.4 (58.6–95.4) PI 1/25 2.5 (0.3–21.1) NNRTI+NRTI 22/27 80.2 (56.0–92.8) HIVDR among individuals on first-line ART with viral load ≥1000 copies/mL Any 22/25 87.6 (67.6–96.0) NNRTI 21/25 83.1 (63.1–93.4) NRTI 21/25 83.2 (55.6–95.2) PI 1/24 2.6 (0.3–21.6) NNRTI+NRTI 20/25 78.7 (53.2–92.3) HIVDR among individuals on first-line NNRTI ART with viral load ≥1000 copies/mL Any 20/22 90.9 (71.2–97.6) NNRTI 19/22 85.9 (66.1–95.0) NRTI 19/22 86.1 (55.0–96.9) PI 0/21 0 NNRTI+NRTI 18/22 81.1 (53.6–94.1) HIVDR among individuals on first-line NNRTI and TDF-based ART with viral load ≥1000 copies/mL TDF resistance 5/9 53.8 (20.4–84.1) FTC or 3TC resistance 7/9 76.1 (28.1–96.3) TDF + XTC resistance 5/9 53.8 (20.4–84.1) TDF + XTC + AZT resistance 0/9 0 HIVDR among individuals on first-line NNRTI and AZT-based ART with viral load ≥1000 copies/mL AZT resistance 7/13 55.8 (24.6–83.1) FTC or 3TC resistance 12/13 92.8 (61.5–99.1) AZT + XTC resistance 7/13 55.8 (24.6–83.1) AZT + XTC + TDF resistance 4/13 23.8 (5.7–61.6) NNRTI resistance is defined as resistance to nevirapine (NVP) or efavirenz (EFV). NRTI resistance is defined as resistance to any NRTI, and any PI resistance is defined as resistance to atazanavir/ritonavir (ATV/r), lopinavir/ritonavir (LPV/r), or darunavir/ritonavir (DRV/r). Any HIVDR is defined as resistance to NVP/EFV, any NRTI, ATV/r, LPV/r or DRV/r. HIVDR is determined using the Stanford HIVdb algorithm: sequences classified as having low-, intermediate- or high-level resistance are considered resistant. 56 HIV DRUG RESISTANCE REPORT 2019 Table. HIV subtype distribution for all sequences from HIVDR surveys conducted between 2014 and 2018 Subtype (%) Country n A B C D F F2 G C RF 01 _A E C RF 02 _A G C RF 06 _c px C RF 11 _c px C RF 12 _B F C RF 18 _c px C RF 20 _B G U RF , o th er Argentina 294 – 49.0 3.7 – 1.7 – – – – – – 22.8 – – 22.8 Brazil 1566 0.1 70.3 13.9 0.2 11.1 – – – 0.3 – – 0.6 – – 3.5 Cameroon 960 9.1 0.4 0.2 1.7 0.1 3.0 5.5 1.0 68.9 0.5 2.4 – 1.1 – 6.0 Colombia 196 – 98.5 – – 0.5 – – – 0.5 – – – – – 0.5 Cuba 141 0.7 35.5 2.1 19.1 – – 1.4 – – – – – 14.9 7.1 19.1 Eswatini 312 0.6 – 99.0 – – – – – – – – – – – 0.3 Ethiopia 240 – – 99.2 0.4 – – – – 0.4 – – – – – – Guatemala 310 – 99.0 – 0.3 – – – – – – – 0.3 0.3 – – Honduras 325 – 98.8 0.9 – – – – – 0.3 – – – – – – Malawi 288 0.3 – 99.7 – – – – – – – – – – – – Mexico 2270 – 99.0 – – – – – 0.2 0.1 – 0.1 0.0 0.1 0.1 0.2 Myanmar 352 3.7 15.1 29.0 – – – – 45.5 – – – – – – 6.8 Namibia 388 2.3 – 92.5 – – – 0.3 0.3 3.9 0.3 – – 0.3 – 0.3 Nepal 215 0.9 0.5 94.4 – – – – 1.9 1.9 – – – – – 0.5 Nicaragua 317 – 99.1 0.3 – – – – – 0.3 – – 0.3 – – – Nigeria 430 5.8 0.5 0.5 0.5 – 0.2 40.7 – 46.5 4.4 – – – – 0.9 Papua New Guinea 317 0.3 0.3 99.4 – – – – – – – – – – – – Senegal 63 14.3 3.2 6.3 – – – 1.6 – 68.3 1.6 – – – – 4.8 South Africa 402 – – 99.8 0.2 – – – – – – – – – – – Togo 201 6.0 – – – – – 11.9 – 60.7 18.4 – – – – 3.0 Uganda 506 62.1 3.4 2.8 29.1 – – 2.0 – 0.2 – – – 0.2 – 0.4 Viet Nam 403 0.2 0.2 0.7 – – – – 96.5 – – – – – – 2.2 Zambia 27 – – 100.0 – – – – – – – – – – – – Zimbabwe 361 – – 100.0 – – – – – – – – – – – – CRF: circulating recombinant forms; URF: unique recombinant forms; URF and other includes B+F (Cuba, Brazil), B+C (Brazil, Myanmar), B+G (Cuba).

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HIV DRUG RESISTANCE REPORT 2019

HIV DRUG RESISTANCE REPORT 2019 WHO/CDS/HIV/19.21 © World Health Organization 2019 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. If you create a translation of this work, you should add the following disclaimer along with the suggested citation: “This translation was not created by the World Health Organization (WHO). WHO is not responsible for the content or accuracy of this translation. The original English edition shall be the binding and authentic edition”. Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation rules of the World Intellectual Property Organization. Suggested citation. HIV Drug Resistance Report 2019. Geneva, Switzerland: World Health Organization; 2019 (WHO/CDS/HIV/19.21). Licence: CC BY-NC-SA 3.0 IGO. Cataloguing-in-Publication (CIP) data. CIP data are available at http://apps.who.int/iris. Sales, rights and licensing. To purchase WHO publications, see http://apps.who.int/bookorders. To submit requests for commercial use and queries on rights and licensing, see http://www.who.int/about/licensing. Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third-party- owned component in the work rests solely with the user. General disclaimers. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. Printed in Switzerland iii CONTENTS Definitions iv Acknowledgements iv Executive summary v Section 1. Pretreatment HIV drug resistance among adults initiating first-line antiretroviral therapy 1 Section 2. Pretreatment HIV drug resistance among treatment-naive infants newly diagnosed with HIV 7 Section 3. Acquired HIV drug resistance among adults receiving antiretroviral therapy 10 Section 4. Assessment of programmatic quality indicators associated with the emergence of HIV drug resistance 16 Tables Section 1. Tables of pretreatment HIV drug resistance among adults initiating first-line antiretroviral therapy 19 Population characteristics (Tables 1.1a–e) 19 Prevalence of pretreatment HIV drug resistance (Tables 1.2a–e) 24 Section 2. Tables of pretreatment HIV drug resistance among treatment-naive infants newly diagnosed with HIV 29 Population characteristics (Tables 2.1a–b) 29 Prevalence of pretreatment HIV drug resistance (Tables 2.2a–b) 31 Section 3. Tables of acquired HIV drug resistance among adults receiving antiretroviral therapy 33 Population characteristics (Tables 3.1a–g) 33 Prevalence of viral load suppression (Tables 3.2a–h) 40 Prevalence of acquired HIV drug resistance (Tables 3.3a–h) 40 Table: HIV subtype distribution 56 iv DEFINITIONS HIV drug resistance (HIVDR) is caused by one or more changes (mutation/s) in the genetic structure of HIV that affects the ability of a specific drug or combination of drugs to block replication of the virus. All current antiretroviral (ARV) drugs, including newer classes, are at risk of becoming partly or fully inactive because of the emergence of drug-resistant virus. People receiving ART can acquire HIVDR, and people can also be infected with HIV that is already drug resistant. WHO commonly classify HIVDR into three main categories. 1. Acquired HIV drug resistance (ADR) develops because of viral replication in the presence of ARV drugs. 2. Transmitted HIV drug resistance (TDR) is detected among ARV drug–naive people with no history of ARV drug exposure. TDR occurs when previously uninfected individuals are infected with virus that has drug resistance mutations. 3. Pretreatment HIV drug resistance (PDR) refers to resistance that is detected among ARV drug–naive people initiating ART or people with previous ARV drug exposure initiating or reinitiating first-line ART. PDR is either TDR or ADR or both. PDR may have been transmitted at the time of infection (TDR) or may be acquired through previous ARV drug exposure (such as among women exposed to ARV drugs for preventing mother-to-child transmission of HIV, among people who have received pre-exposure prophylaxis or among individuals reinitiating first-line ART after a period of treatment interruption). ARV drug–naive applies to people with no history of ARV drug exposure. ACKNOWLEDGEMENTS The report was written by Seth Inzaule and Silvia Bertagnolio (WHO, HIV Department), under the coordination of Meg Doherty (WHO, HIV Department). We are extremely grateful for the contributions of Amalia Girón for the statistical analysis. We also thank Neil Parkin, Michael R. Jordan, Natalie Exner and the HIVResNet steering group members for their guidance and support. We acknowledge the contributions of David Breuer for technical editing and Sue Hobbs for layout. This report would not have been possible without the collaboration of national HIV programme managers who supplied the surveillance data that underpin this report and staff from WHO regional and country offices, especially Fatim Cham, Giovanni Ravasi, Linh Le and B.B.Rewari. We thank the WHO HIVResNet Laboratory Network members, who have been essential in producing high-quality drug resistance surveillance data. Financial acknowledgements. This report has been supported in part by the Government of the Netherlands and the United States President’s Emergency Plan for AIDS Relief (PEPFAR) through the United States Centers for Disease Control and Prevention (CDC). We also acknowledge the support of Global Fund and PEPFAR to fund the HIVDR surveys. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the funders. vEXECUTIVE SUMMARY The rise in antimicrobial resistance (AMR) is one of the greatest threats to global health. If it is not urgently addressed, it may result in millions of deaths, an increase in new and hard-to-treat infections and increased health-care costs.1 As a result, combatting AMR, including the threat posed by drug-resistant HIV, is a major goal for the global community. Prevention, monitoring and timely response to population levels of HIV drug resistance (HIVDR) is critical to achieving the WHO/UNAIDS 90–90–90 targets for 2020 that 90% of people living with HIV know their HIV status, 90% of those who know their HIV-positive status are accessing treatment and 90% of the people receiving treatment having suppressed viral loads. These targets reflect the global community’s commitment to eliminating AIDS as a public health threat by 2030. In response to the threat of HIVDR to attaining these goals, the global health community launched a five-year Global Action Plan on HIVDR (2017–2021) that details a roadmap to prevent, monitor and respond to globally increasing levels of HIVDR. In response to the Global Action Plan, countries and funders are increasingly focusing on establishing robust and routine population-level monitoring of HIVDR to accompany the scaling up of antiretroviral therapy (ART) and supporting a safe transition to new antiretroviral (ARV) drugs in first- and second-line ART. 1 No time to wait: securing the future from drug-resistant infections: report to the Secretary-General of the United Nations. New York: Ad Hoc Interagency Coordination Group on Antimicrobial Resistance; 2019 (https://www.who.int/antimicrobial-resistance/interagency- coordination-group/IACG_final_report_EN.pdf?ua=1, accessed 5 July 2019). Substantial progress has been made in monitoring the population-level emergence and transmission of HIVDR. Between 2004 and 2018, 49 countries implemented surveys of HIVDR using WHO-recommended standard methods. A further 35 countries have plans to conduct surveys (Fig. 1). This report presents findings from 44 nationally representative HIVDR surveys implemented in 24 low- and middle-income countries using WHO standard survey methods.2 In 12 of 18 countries reporting survey data to WHO between 2014 and 2018, levels of pretreatment HIVDR (PDR) to efavirenz (EFV) and/or nevirapine (NVP) among adults initiating first-line ART exceeded 10% (Fig. 2). Overall, levels of NNRTI PDR are nearly twice as high among women as among men. These findings are important, since women comprise a larger proportion of the population living with HIV globally and especially in sub-Saharan Africa, the region with the highest burden of HIV infection. Another subpopulation at high risk of PDR is individuals reinitiating first-line ART and reporting previous exposure to ARV drugs (for example, for preventing the mother-to-child transmission of HIV, previous ART for treating HIV infection, post-exposure prophylaxis (PEP) and pre-exposure prophylaxis (PrEP) 2 HIV drug resistance surveillance guidance: 2015 update. Geneva: World Health Organization; 2015 (https://apps.who.int/iris/bitstream/handle/ 10665/204471/9789241510097_eng.pdf;jsessionid=42B6287D67B61D- 47BC29C36FD598DAA8?sequence=1, accessed 5 July 2019). Fig. 1. Implementation of national HIV drug resistance surveys, 2004–2018 0 1,700 3,400850 Kilometers The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. © WHO 2019. All rights reserved. Year of most recent survey 2004-2013 2014-2017 2018-2019 Planned Data Source: World Health Organization Map Production: Information Evidence and Research (IER) World Health Organization Data not available Not applicable HIV DRUG RESISTANCE REPORT 2019vi believed to have been taken since the person became HIV positive). Twelve of 18 surveys included both ARV drug– naive ART initiators and ART starters reporting previous exposure to ARV drugs. Among first-line ART initiators reporting prior ARV drug exposure, PDR to efavirenz and/or nevirapine is nearly three times higher than among ARV drug– naive individuals starting ART. These findings are relevant, since the proportion of people starting treatment reporting previous ARV drug exposure ranged from 1.2% to 26.3% in countries reporting data and is projected to increase with the continuing global scale-up of ART. Fig. 2. NNRTI pretreatment drug resistance in 18 countries reporting national survey data to WHO, 2014–2018 NNRTI resistance is defined as resistance to NVP or EFV. Previous ARV drug exposure: participants self-reporting being exposed to ARV drugs, such as women exposed to ARV drugs for preventing the mother-to-child transmission of HIV who interrupted ART after delivery and restarted care after a period of time; or defaulters restarting ART. Note that white (empty) cells represent lack of information because surveys excluded people with previous ARV drug exposure (Brazil, Colombia, Cuba and Zimbabwe) or no data on previous exposure were available (Nepal and South Africa). Fig. 2. In 12 of 18 countries the NNRTI PDR prevalence had exceeded 10%. Among women, NNRTI PDR was >10% in 14/18 countries, while among men PDR NNRTI prevalence was >10% in 10/18 countries. The NNRTI PDR prevalence among individuals starting first- line ART and reporting previous ARV drug exposure exceeded 10% in all reporting countries. A concerted global response to increasing levels of PDR is of paramount priority to WHO and its global partners. In 2017, WHO issued guidelines recommending using an alternative first-line regimen that does not contain efavirenz or nevirapine in countries in which resistance to these drugs exceeds 10%.1 In addition, 2018 WHO ARV guidelines recommended the rapid adoption of dolutegravir (DTG)-based regimens as the preferred first-line treatment for adults and children that, if implemented, will help avert the negative effects of resistance to non-nucleoside reverse-transcriptase inhibitors (NNRTIs). 1 Guidelines for the public heath response to pretreatment HIV drug resist- ance. Geneva: World Heath Organization; July 2017 (https://www.who. int/hiv/pub/guidelines/hivdr-guidelines-2017/en/) Fig 2: NNRTI pretreatment drug resistance in 18 countries reporting national survey data to WHO, 2014–2018 WHO region Country Survey year Prevalence of NNRTI PDR All (women and men) Women Men ART initiators reporting being ARV drug naive ART initiators reporting previous ARV drug exposure African region Cameroon 2015 Eswatini 2016 Namibia 2015 Uganda 2016 South Africa 2017 Zimbabwe 2015 Region of the Americas Argentina 2014 Brazil 2014 Colombia 2016 Cuba 2017 Guatemala 2016 Honduras 2016 Mexico 2017 Nicaragua 2016 Western Pacific Region and South-East Asia Region Myanmar 2016 Nepal 2016 Papua New Guinea 2017 Viet Nam 2017 Prevalence of PDR to EFV and/or NVP: <10% 10-30% >30% viiHIV DRUG RESISTANCE REPORT 2019 The prevalence of PDR among children ≤18 months diagnosed with HIV through national early infant diagnosis programmes is alarmingly high. Based on surveys conducted in nine countries in sub-Saharan Africa between 2012 and 2018, over half of the infants newly diagnosed with HIV carry a virus that is resistant to efavirenz and/or nevirapine. Levels of PDR to nucleoside reverse-transcriptase inhibitors (NRTIs) also exceed 10% in some countries. Since 2013, WHO has recommended using protease inhibitor (PI)-based ART regimens for children younger than three years old, and in 2018 WHO formally encouraged the phaseout of NNRTIs across age groups, with the introduction of DTG for children with approved dosing. However, in 2017, globally nearly 77% of young children were still receiving nevirapine in first-line ART because of limited supplies of child-friendly drug formulations.1 Continual efforts to expand the capacity of manufacturing lopinavir/ritonavir pellets formulations and to accelerate the investigation and introduction of DTG across lower weight bands are required since the very high levels of PDR make NNRTI-based ART highly suboptimal. Levels of PDR to NRTIs, including abacavir (ABC), are also high in some countries, underscoring the need to routinely monitor population levels of resistance, especially when ABC is given in combination with drugs with relatively low genetic barriers to selecting drug resistance such as NNRTIs or raltegravir (a first-generation integrase inhibitor). Achieving the third 90 target for maximal viral load suppression, thereby preventing the emergence and transmission of HIVDR, is critical for eliminating AIDS as a public health threat by 2030. Three of the nine countries reporting findings from acquired drug resistance (ADR) surveys among adults receiving HIV treatment between 2014 and 2018 showed levels of viral suppression exceeding 90%. Across all the surveys, the prevalence of ADR among people receiving ART ranged from 3% to 29%. Among populations receiving NNRTI-based ART with viral non-suppression, the levels of NNRTI and NRTI resistance ranged from 50% to 97% and from 21% to 91%, respectively. Estimates of dual class resistance (NNRTI and NRTI) ranged between 21% and 91% of individuals for whom NNRTI-based first-line ART failed. 1 ARV market report 2018: The state of the antiretroviral drug market in low- and middle-income countries, 2017–2022. Boston: Clinton Health Access Initiative; 2018 (https://clintonhealthaccess.org/content/uploads/ 2018/09/2018-HIV-Market-Report_FINAL.pdf, accessed 5 July 2019). The high level of HIVDR among people with viral non- suppression on NNRTI-based first-line ART demonstrates the degree to which NNRTI-based regimens are compromised for people with viral non-suppression detected by a single viral load test, indicating the need for rapid switch to second-line ART once failure to suppress viral loads is identified. Equally, the high levels of NRTI resistance at time of treatment failure, including dual-class NRTI resistance, support the need for optimizing the NRTI backbone during treatment switch, as recommended in WHO’s 2019 antiretroviral guidelines. In addition to routine population-level monitoring of HIVDR, preventing drug-resistant HIV is one of the strategic objectives of the Global Action Plan on HIVDR. WHO recommends monitoring and responding to gaps in quality indicators at the clinic or programme level that are associated with the emergence of HIVDR. These indicators include: appropriate prescribing practices, on-time ART pill pick-up (a proxy measure of adherence), retention on ART at 12 months, viral load testing coverage, viral load suppression, ARV drug stock-outs and timely switch to second-line ART. Between 2014 and 2018, 44 of 45 countries with a high burden of HIV reported these data to WHO. Overall data reporting across all the indicators was incomplete suggesting the need for strengthening systems for monitoring data indicating programme quality. Few countries are attaining the expected targets for quality-of-care indicators, suggesting the need for a proactive approach in addressing gaps in the quality of ART service delivery and minimizing the emergence and spread of HIVDR. Retention on ART at 12 months emerges as a programmatic area requiring significant attention and further improvement.

1SECTION 1: PRETREATMENT HIV DRUG RESISTANCE AMONG ADULTS INITIATING FIRST-LINE ANTIRETROVIRAL THERAPY Purpose and methods. PDR surveys provide evidence to inform the selection and effectiveness of first-line treatment, PEP and PrEP. The sample size estimation, sampling methods and statistical analysis are described in detail in the WHO concept note for PDR surveys among adults initiating first-line ART with and without previous ARV drug exposure.1 Goals. The overall goal of these surveys is to generate (1) nationally representative estimates for PDR among individuals initiating ART, regardless of previous ARV drug exposure, (2) nationally representative estimates of PDR among ARV drug–naive HIV treatment initiators and (3) estimates of the proportion of ART initiators reporting previous ARV drug exposure. Survey implementation progress. Between 2014 and 2018, 39 countries implemented surveys of PDR among adults starting or restarting first-line ART; of those, 25 surveys are completed, and 14 surveys are ongoing. Eighteen countries have plans to initiate surveys of PDR (Fig. 1.1). 1 Surveillance of HIV drug resistance in adults initiating anti retroviral therapy (pre-treatment HIV drug resistance). Geneva: World Health Organization; 2014 (https://apps.who.int/iris/bitstream/ handle/10665/112802/9789241507196_eng.pdf;jsessionid= CB4F92166CBA26A57EB421116A09658F? sequence=1, accessed 5 July 2019). Geographical representation. This report summarizes the results from 18 countries that have completed PDR surveys and have reported data to WHO: six from sub- Saharan Africa;2 nine from the WHO Region of the Americas, two from the Western Pacific Region and two from the South-East Asia Region (countries are listed in Fig. 2). In all countries, PDR surveys followed WHO standard methods, except in South Africa, where PDR estimates were generated from a national household survey. Survey populations. Most of the survey participants from sub-Saharan Africa, Nepal and Papua New Guinea were women (ranging from 51% to 73%). Men predominated in surveys from the Americas, Myanmar and Viet Nam (ranging from 59% to 89%). Twelve of the 18 surveys included ART initiators reporting being both ARV drug– naive or previously exposed to ARV drugs (including women with previous ARV drug exposure for preventing the mother-to-child transmission of HIV and individuals reinitiating first-line ART after initial disengagement from care). In these 12 surveys, the proportion of ART starters 2 Included a national household survey from South Africa. Participants in the PDR analysis were people with no detectable ARV drugs in blood and either self-reported not taking daily medication or this information was unknown (http://www.croiconference.org/sessions/ hiv-drug-resistance- south-africa- results-population-based-household-survey). Fig. 1.1 Implementation of national pretreatment drug resistance surveys among adults initiating or re-initiating first-line ART, 2014–2018 0 1,700 3,400850 Kilometers The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. © WHO 2019. All rights reserved. Survey completed and results reported Survey completed Survey ongoing Survey planned Data Source: World Health Organization Map Production: Information Evidence and Research (IER) World Health Organization Data not available Not applicable HIV DRUG RESISTANCE REPORT 20192 with self-reported previous exposure to ARV drugs ranged from 1.2% (95% confidence interval (CI) 0.4–3.7%) in Uganda to 26% (95% CI 20–34%) in Honduras. Previous use of ARV drugs for preventing the mother-to-child transmission of HIV was the most commonly reported type of previous ARV exposure in Cameroon, Eswatini and Uganda, while previous ART followed by treatment discontinuation and then ART re-initiation was more common in Argentina, Honduras, Mexico, Myanmar, Namibia, Papua New Guinea and Viet Nam. (Tables 1.1a–1.1e). Key findings. In 12 of 18 countries that reported survey findings to WHO, PDR to nevirapine/efavirenz in populations initiating first-line ART had reached levels above 10% (Argentina, Eswatini, Cuba, Guatemala, Honduras, Namibia, Nepal, Nicaragua, Papua New Guinea, South Africa,5 Uganda and Zimbabwe) (Fig. 1.2, Tables 1.2a–1.2e). Overall, in a pooled analysis of data from all countries, the prevalence of PDR to efavirenz and/or nevirapine was much higher in specific subpopulations, notably:    The prevalence of NNRTI PDR was nearly twice as high among women than men initiating ART: 11.8% (95%CI 9.4–14.8) versus 7.8% (95%CI 6.3-9.5) p=0.005. In addition, high levels of PDR to efavirenz and/or nevirapine were more common among women than among men across the surveys: 14 of 18 countries had NNRTI PDR ≥10% among women, and only 10 of 18 countries had NNRTI PDR ≥10% among men (Fig. 1.3).    The prevalence of NNRTI PDR was nearly three times higher among people reinitiating first-line ART reporting previous exposure to ARV drugs than among ARV drug–naive people: 21.1% (95%CI 15.0–28.9) versus 7.8 (6.3–9.6), p≤0.0001 (Fig. 1.4). The prevalence of PDR to NRTIs such as tenofovir (TDF) and XTC (emtricitabine (FTC) or lamivudine (3TC)) ranged from 0% to 4.5% and 0% to 5.7%, respectively (Fig. 1.5). 1 Guidelines for the public heath response to pretreatment HIV drug resistance. Geneva: World Heath Organization; July 2017 (https://www.who.int/hiv/pub/guidelines/hivdr-guidelines-2017/en/) Fig. 1.2 NNRTI (EFV/NVP) pretreatment drug resistance (PDR) among first-line ART initiators Viet  Nam Myanmar Colombia Brazil Cameroon Mexico Nepal Eswatini Zimbabwe Argentina Guatemala Namibia Uganda Papua  New  Guinea Nicaragua South  Africa Cuba Honduras 0 5 10 15 20 25 30 35 NNRTI  pretreatment  drug  resistance  prevalence  (95%  CI) NNRTI  PDR >  10% NNRTI  PDR <  10% Fig 1.2 shows NNRTI PDR point prevalence and 95% confidence intervals among the 18 countries reporting data to WHO between 2014 and 2018. The dotted line (10% prevalence) indicates the NNRTI PDR prevalence above which WHO recommends moving away from NNRTI-based ART in first-line.1 The prevalence of NNRTI PDR prevalence had exceeded 10% (vertical dotted line) in 12 countries. In all countries, PDR estimates are generated from nationally representative surveys using standard WHO survey methods, except in South Africa, where PDR estimates are generated from a national household survey. In 14 countries ART initiators regardless of previous ARV drug exposure were included in the PDR survey; in 4 countries (Brazil, Colombia, Cuba, Zimbabwe) only ARV drug- naive individuals starting ART were included in the PDR surveys. NNRTI PDR is defined as PDR to NVP and/or EFV. 3HIV DRUG RESISTANCE REPORT 2019 Drug resistance classification and analysis methods. HIVDR was assessed using the Stanford HIVdb algorithm Version 8.8. Sequences classified as low-, intermediate- or high-level resistance were designated as resistant. Data for all the outcomes were analysed in Stata software 14.0 (StataCorp LP, College Station, TX, USA)1 to generate weighted estimates based on the study design as described in the survey guidance.1 Implication of the findings. The high levels of observed PDR to NNRTIs highlight the need to fast-track the transition to dolutegravir-based first-line regimens in adults and to use PIs in circumstances where levels of PDR are high and the use of dolutegravir is not feasible as per WHO recommendations. The response to high levels of 1 StataCorp. 2015. Stata Statistical Software: Release 14. College Station, TX: StataCorp LP. Fig. 1.3 NNRTI (EFV/NVP) pretreatment drug resistance (by sex) among first-line ART initiators     r  figs Viet  Nam Myanmar Colombia Brazil Cameroon Nepal Argentina Eswatini Mexico Namibia Zimbabwe Uganda Guatemala South  Africa Papua  New  Guinea Nicaragua Honduras Cuba 0 5 10 15 20 25 30 35 40 45 50 55 60 NNRTI  pretreatment  drug  resistance  prevalence  (95%  CI) Men Women Fig. 1.3 shows the prevalence of NNRTI PDR by sex. In a pooled analysis of all surveys, women had significantly higher PDR prevalence than men: 11.8% (95%CI 9.4–14.8) versus 7.8% (95%CI 6.3–9.5) p=0.005. The dotted line (10% prevalence) indicates the NNRTI PDR prevalence above which WHO recommends moving away from NNRTI-based ART. The NNRTI PDR prevalence among women exceeded 10% in 14 of 18 countries versus 10 of 18 countries for men. NNRTI PDR is defined as PDR to NVP or EFV. PDR in countries is varied and is described in Fig. 1.6. In countries in Central and Latin America the levels of PDR to NNRTIs were particularly high, especially in women, suggesting the need to strengthening the health systems, and in particular, to increase access of women to continued and reliable ARV provision. The low prevalence of TDF/ XTC resistance provides reassurance for using this drug combination in PrEP; however, since these two drugs are used in combination as PrEP and as a component of ART first-line regimens, routine surveillance is required to provide continual assurance that these two ARV drugs can be effectively used as both treatment and prophylaxis when PrEP programmes are scaled up in low- and middle- income countries. HIV DRUG RESISTANCE REPORT 20194 Fig. 1.4 NNRTI (EFV and/or NVP) pretreatment drug resistance (by previous ARV drug exposure) among first-line ART initiators Viet  Nam Myanmar Eswatini Uganda Argentina Cameroon Mexico Guatemala Nambia Papua  New  Guinea Honduras Nicaragua 0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100 NNRTI  pretreatment  drug  resistance  prevalence  (95%  CI) ARV  drug  naive Prior  ARV  drug  exposed Fig. 1.4 shows the prevalence of NNRTI PDR among people initiating ART reporting previous ARV drug exposure and among ARV drug-naive people. The dotted line (10% prevalence) indicates the NNRTI PDR prevalence above which WHO recommends moving away from NNRTI-based ART. Compared with ARV drug naive-initiators, people reinitiating ART reporting previous exposure to ARV drugs had a significantly higher NNRTI PDR prevalence: 21.1% (95%CI 15.0–28.9) versus 7.8 (6.3–9.6), p≤0.0001 (pooled analysis form all surveys). Among people reporting previous ARV drug exposure, the prevalence of NNRTI PDR exceeded 10% in all 12 countries that included this group of people. 5HIV DRUG RESISTANCE REPORT 2019 Fig. 1.5 Pretreatment drug resistance among first-line ART initiators, by country and by drug 0% 5% 10% 15% 20% 25% 30% 35% Pr o p o rt io n  o f  A R T   in it ia to rs  w it h  d ru g   re si st an ce NVP EFV EFV/NVP  and  NRTI TDF XTC EFV: efavirenz; NVP: nevirapine; NRTI: nucleoside reverse-transcriptase inhibitors; TDF: tenofovir disoproxil fumarate; XTC: emtricitabine (FTC) or lamivudine (3TC). Fig. 1.5 shows the prevalence of PDR to the drugs used in first-line regimens. As expected, the prevalence of PDR is driven mainly by PDR to EFV and NVP. Across all countries, the prevalence of NRTI PDR was low and ranged from 0% to 6% for FTC/3TC and from 0% to 5% for TDF. HIV DRUG RESISTANCE REPORT 20196 Fig. 1.6 Country response to levels of pretreatment drug resistance (PDR) to efavirenz/nevirapine >10%, as of July 2019 0 1,700 3,400850 Kilometers The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. © WHO 2019. All rights reserved. Adults PDR response Data not available Not applicable Data Source: World Health Organization Map Production: Information Evidence and Research (IER) World Health Organization CUBA: PDR to EFV/NVP 22.8%. National guidelines revised to include the use of DTG as preferred first-line ART for adults and adolescents (and in women of child-bearing potential who are on reliable and consistent contraception GUATEMALA: PDR to EFV/NVP 13.2%. National guidelines revised to include the use of DTG as preferred first-line ART for adults and adolescents (and in women of child-bearing potential who are on reliable and consistent contraception HONDURAS: PDR to EFV/NVP 25.9%. Revision of national guidelines to use DTG as preferred first-line ART planned NAMIBIA: PDR to EFV/NVP 13.8%. National guidelines revised to include the use of DTG as preferred first-line ART for adults and adolescents (in women and girls of childbearing potential through informed choice). NEPAL: PDR to EFV/NVP 10.2%. Revision of national guidelines to use DTG as preferred first-line ART planned PAPUA NEW GUINEA: PDR to EFV/NVP 17.8%. National guidelines revised to include the use of DTG as preferred first- line ART SOUTH AFRICA: PDR to EFV/NVP 23.6%. National guidelines revised to include the use of DTG as preferred first-line ART for adults and adolescents (in women and girls of childbearing potential through informed choice). ESWATINI: PDR to EFV/NVP 10.5%. National guidelines revised to include the use of DTG as preferred first-line ART for adults and adolescents (in women and girls of childbearing potential through informed choice). UGANDA: PDR to EFV/NVP 15.4%. National guidelines revised to include the use of DTG as preferred first-line ART for adults and adolescents (in women and girls of childbearing potential through informed choice). ZIMBABWE: PDR to EFV/NVP 10.9%. National guidelines revised to include the use of DTG as preferred first-line ART for adults and adolescents (in women and girls of childbearing potential through informed choice). PDR to NNRTI>10% Not applicable ARGENTINA: PDR to EFV/NVP 10.9%. National guidelines revised to include the use of DTG as preferred first-line ART for adults and adolescents (and women of child-bearing potential who are on reliable and consistent contraception). Genotypic resistance testing used to guide treatment in women of child-bearing potential not eligible to use DTG NICARAGUA: PDR to EFV/NVP 19.3%. Revision of national guidelines to use DTG as preferred first-line ART planned 7SECTION 2. PRETREATMENT HIV DRUG RESISTANCE AMONG TREATMENT-NAIVE INFANTS NEWLY DIAGNOSED WITH HIV Purpose and methods. These surveys generate estimates of PDR among infants younger than 18 months who have been newly diagnosed with HIV through early infant diagnosis based on virological testing. Findings from these surveys inform the selection of standard first-line ART in children and accelerate the transition from NNRTI- to non-NNRTI-based first-line ART (dolutegravir or PI-based treatment, depending on the weight of the children). In addition, survey findings of NRTI resistance prevalence inform future optimal treatment strategies. The sample size estimation, sampling methods and statistical analysis are described in detail in the WHO guidance for PDR surveys for infants ≤18 months.1 Goal. The overall goal of these surveys for infants ≤18 months newly diagnosed with HIV through early infant diagnosis is to generate (1) nationally representative estimates of PDR among treatment-naive infants, regardless of exposure to prophylactic regimens used for preventing mother-to-child transmission of HIV, (2) nationally representative estimates of PDR among treatment-naive infants with known exposure to ARV drugs for preventing the mother-to-child transmission of HIV (maternal or neonatal portion), (3) nationally representative estimates of PDR among treatment- 1 Surveillance of HIV drug resistance in children newly diagnosed with HIV by early infant diagnosis. Geneva: World Health Organization; 2017 (https://apps.who.int/iris/bitstream/handle/ 10665/259732/9789241512541-eng.pdf?sequence=1, accessed 5 July 2019). naive infants with no or unknown exposure to drugs for preventing the mother-to-child transmission of HIV, and (4) estimates of the proportion of infants newly diagnosed with HIV through early infant diagnosis with reported exposure to ARV drugs for preventing the mother-to-child transmission of HIV. Progress in implementing the surveys and geographical representation. Between 2012 and 2018, 10 countries implemented surveys of PDR among treatment-naive infants ≤18 months. Nine countries have completed the survey, in one country the survey is still ongoing, and two countries are planning the survey. This report summarizes the findings from nine surveys conducted in sub-Saharan Africa (Fig. 2.1). Survey populations. Most infants surveyed had prior ARV drug exposure(s), either ARV drugs taken by the mother to prevent transmission to the infant or taken by the infant to prevent infection. Overall ARV drug exposures ranged from 40% in Cameroon to 85% in Mozambique. Many of the infants, however, had missing information on ARV drugs for preventing the mother-to-child transmission of HIV exposure, ranging from a low of 3% in Zimbabwe to 28% in Nigeria (Tables 2.1 a–b). Fig. 2.1 Implementation of WHO national pretreatment HIV drug resistance surveys among infants newly diagnosed with HIV and treatment naive, 2012–2018 0 1,700 3,400850 Kilometers The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. © WHO 2019. All rights reserved. Survey completed and results reported Survey ongoing Survey planned Data Source: World Health Organization Map Production: Information Evidence and Research (IER) World Health Organization Data not available Not applicable 0 1,700 3,400850 Kilometers The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. © WHO 2019. All rights reserved. Survey completed and results reported Survey ongoing Survey planned Data Source: World Health Organization Map Production: Information Evidence and Research (IER) World Health Organization Data not available Not applicable HIV DRUG RESISTANCE REPORT 20198 Key findings. Overall, prevalence estimates of PDR to efavirenz and nevirapine were very high, ranging from 34% (95% CI 27–41%) in Eswatini to 69% (95% CI 62–75%) in Malawi, indicating that about half of infants newly diagnosed with HIV carry drug-resistant HIV before initiating treatment (Fig. 2.2). PDR to abacavir and lamivudine (the preferred NRTIs for infants) was also high and exceeded 10% in three and four of the nine countries, respectively (Fig. 2.3). (Tables 2.2 a–b) Implications of the findings. Although more than half the infants newly diagnosed in these surveys carried NNRTI-resistant HIV, uptake of WHO recommendations for PI-based first-line regimens for young children is low. In 2017, nearly 77% of young children were receiving NNRTI- based regimens, because of limited supplies of appropriate child-friendly formulations.1 Fig. 2.4 shows the country responses to high levels of PDR among children ≤18 months. The results suggest the need to accelerate access to child-friendly non-NNRTI-based formulations in this vulnerable population to prevent poor treatment outcomes. Survey findings also highlight the increasing levels of PDR to NRTIs in some countries, suggesting the need for caution when using abacavir and lamivudine in combination with drugs that have a low genetic barrier for resistance (nevirapine (NVP) or raltegravir). 1 ARV market report 2018: The state of the antiretroviral drug market in low- and middle-income countries, 2017–2022. Boston: Clinton Health Access Initiative; 2018 (https://clintonhealth access.org/content/ uploads/2018/09/2018-HIV-Market-Report_ FINAL.pdf, accessed 5 July 2019). Fig. 2.2 NNRTI (EFV and/or NVP) pretreatment drug resistance among treatment-naive infants newly diagnosed with HIV, 2012–2018 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% Malawi           2016 Zimbabwe   2012 South  Africa   2014 Togo                 2012 Mozambique   2012 Nigeria           2016 Cameroon   2014 Uganda           2011 Eswatini       2011 Pr o p o rt io n  w it h  N N R TI  D R  (% ) All PMTCT  + PMTCT  -­‐/unk NNRTI PDR is defined as PDR to NVP or EFV. PMTCT: prevention of mother-to-child HIV transmission; PMTCT+: exposed to maternal and neonatal PMTCT-prophylactic ARV drugs; PMTCT -/unk: either PMTCT unexposed or with missing information on PMTCT exposure; unk: unknown. Fig. 2.2 shows the prevalence of NNRTI PDR among infants ≤18 months newly diagnosed with HIV and ARV naive. Overall, NNRTI PDR is alarmingly high with nearly half of young children having drug-resistant HIV before initiating treatment. Although the prevalence of NNRTI PDR is higher among those reporting exposure to PMTCT, children with unknown or no PMTCT exposure also have a high prevalence of NNRTI PDR. 9HIV DRUG RESISTANCE REPORT 2019 Fig. 2.3 Prevalence of NRTI HIV drug resistance among treatment-naive infants newly diagnosed with HIV, by drug and country 0% 5% 10% 15% 20% 25% 30% Nigeria         2016 Malawi         2016 Togo                 2012 South  Africa   2014 Cameroon   2014 Zimbabwe   2012 Uganda       2011 Mozambique   2012 Eswatini       2011 Pr o p o rt io n  w it h  D R  (% ) any  NRTI ABC XTC AZT TDF Legend: ABC: abacavir; AZT: zidovudine; NRTI: nucleoside reverse-transcriptase inhibitor; TDF: tenofovir disoproxil fumarate; XTC: emtricitabine (FTC) or lamivudine (3TC) Fig. 2.4 Country response to high levels of pretreatment drug resistance (PDR) among infants, as of July 2019 0 1,700 3,400850 Kilometers The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. © WHO 2019. All rights reserved. Infants PDR response Data not available Not applicable Data Source: World Health Organization Map Production: Information Evidence and Research (IER) World Health Organization ESWATINI: PDR to EFV/NVP 34.0%. LPV-r is the preferred and most-commonly used first-line ART for children <3 years. Discussions are ongoing to use DTG for children ≥20kg CAMEROON: PDR to EFV/NVP 47.0%. LPV-r is the preferred first-line ART for children <3 years in the national guidelines and discussions are ongoing to use DTG for children ≥20kg; however, NNRTIs are still the most commonly used first-line pediatric regimens MALAWI: PDR to EFV/NVP 68.8%. Adoption of LPV-r or INSTI as the preferred first-line ART in the national guidelines in process; NNRTIs are currently the first-line pediatric regimens MOZAMBIQUE: PDR to EFV/NVP 56%. LPV-r is the preferred first-line ART for children <3 years in the national guidelines and discussions are ongoing to use DTG for children ≥20kg ; however, NNRTIs are still the most commonly used first-line pediatric regimens NIGERIA: PDR to EFV/NVP 48.6%. LPV-r is the preferred first-line ART for children <3 years in the national guidelines and discussions are ongoing to use DTG for children ≥20kg ; however, NNRTIs are still the most commonly used first-line pediatric regimens (~91% of children) SOUTH AFRICA: PDR to EFV/NVP 63.7%. LPV-r is the preferred and most-commonly used first-line ART for children <3 years. Discussions are ongoing to use DTG for children ≥20kg TOGO: PDR to EFV/NVP 57.3%. LPV-r is the preferred first-line ART in the national guidelines UGANDA: PDR to EFV/NVP 35.7%. LPV-r is the preferred and most commonly used first-line ART for children <3 years. Discussions are ongoing to use DTG for children ≥20kg ZIMBABWE: PDR to EFV/NVP 63.9%. LPV-r is the preferred first-line ART for children <3 years in the national guidelines and discussions are ongoing to use DTG for children ≥20kg ; however, NNRTIs are still the most commonly used first-line pediatric regimens High levels of pretreatment HIV drug resistance (PDR) to efavirenz/nevirapine Data not available Not applicable Fig. 2.3 shows the prevalence of NRTI HIVDR among ARV-naive children ≤18 months newly diagnosed with HIV. The prevalence of NRTI resistance is also high, exceeding 10% for ABC, XTC and AZT in some countries. 10 SECTION 3. ACQUIRED HIV DRUG RESISTANCE AMONG ADULTS RECEIVING ANTIRETROVIRAL THERAPY Purpose and methods. Surveys of acquired HIV drug resistance (ADR) provide information needed to assess the performance of programmes in maximizing population- level viral suppression and inform the optimal selection of second- and third-line ART. The sample size estimation, sampling methods and statistical analysis are described in detail in the WHO guidance for ADR surveys of adults receiving ART.1 Goal. The overall goal of these cross-sectional surveys is to generate nationally representative estimates of (1) viral load suppression and (2) HIVDR in populations receiving ART for 12 (±3) months (referred to as early time point surveys) and ≥48 months (referred to as late time point surveys). Geographical representation. Between 2014 and 2018, 23 countries implemented 47 surveys of ADR among adults receiving ART; of these, 19 surveys have been completed and 26 are ongoing. Fifteen countries have plans to conduct ADR surveys (Fig. 3.1). This report summarizes the results from 17 surveys (nine surveys reporting data from the early time point and eight surveys from the late time point) conducted in nine countries: five from sub-Saharan Africa, three from the WHO Region of the Americas and one from the Western Pacific Region. Survey populations. Most of the participants from sub-Saharan Africa in surveys from both time points were women (ranging from 60% to 78%); men were predominant in the surveys from the early time point in the WHO Region of the Americas and in Viet Nam (ranging from 65% to 70%). However, there were fewer men in surveys assessing ADR at the late time point in the Region of the Americas (ranging from 41% to 62%), with most participants being women in Honduras (59%). 1 Surveillance of HIV drug resistance in adults receiving ART (acquired HIV drug resistance). Geneva: World Health Organization; 2014 (https:// apps.who.int/iris/bitstream/handle/10665/112801/9789241507073_eng. pdf?sequence=1, accessed 5 July 2019). The mean time on ART among participants enrolled in the early time point surveys ranged from 11.8 months in Viet Nam to 17.9 months in Cameroon;2 the mean time on ART ranged from 52.2 months in Senegal to 102.3 months in Honduras among people enrolled in the late time point survey. In all surveys, the most common regimen was TDF + 3TC or FTC + EFV. In surveys of people on ART for 12 months ±3 months, nearly all participants were receiving NNRTI-based first-line ART ranging from 88% in Nicaragua to 100% in Zambia. In late time point surveys, the proportion of participants receiving NNRTI-based first-line ART ranged from 75% in Nicaragua to 99% in Senegal. In the late time point survey, TDF + XTC + EFV was the most common regimen in Cameroon, Guatemala, Senegal and Viet Nam, but NVP and zidovudine (AZT) were also substantially used in all countries. In particular, AZT + XTC + EFV was the most common regimen in Honduras and Nicaragua, and AZT + XTC + NVP was the predominant regimen in Eswatini and Uganda. The proportion of people receiving second-line regimens was low across all surveys, ranging from 0.2% in Eswatini to 2% in Nicaragua in the early time point survey and from 1% in Senegal to 14% in Nicaragua for participants in the late time point survey (Tables 3.1 a–g). HIVDR classification and analysis methods. HIVDR was assessed using the Stanford HIVdb algorithm Version 8.8. Sequences classified as low-, intermediate- or high-level resistance were designated as resistant. Data for all the outcomes were analysed in Stata software 14.0 (StataCorp LP, College Station, TX, USA)3 to generate weighted estimates based on the study design as described in the WHO ADR survey concept guidance.4 2 In Cameroon, individuals receiving ART for 12–24 months were included in the 12-month ADR survey. 3 StataCorp. 2015. Stata Statistical Software: Release 14. College Station, TX: StataCorp LP. 4 HIV drug resistance surveillance guidance: 2015 update. Geneva: World Health Organization; 2015 (https://apps.who.int/iris/ bitstream/ handle/10665/204471/9789241510097_eng.pdf;jsessionid= 42B6287D67B61D47BC29C36FD598DAA8? sequence=1, accessed 5 July 2019). 11HIV DRUG RESISTANCE REPORT 2019 Fig. 3.1 Implementation of WHO acquired HIV drug resistance national surveys among adults receiving antiretroviral therapy, 2014–2018 0 1,700 3,400850 Kilometers The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. © WHO 2019. All rights reserved. Survey completed and results reported Survey completed Survey ongoing Survey planned Data Source: World Health Organization Map Production: Information Evidence and Research (IER) World Health Organization Data not available Not applicable Key findings. Overall, four of nine countries achieved the third 90–90–90 target for viral load suppression of ≥90% in the early time point survey and three of eight in the late time point survey. However, in three of nine countries, viral load suppression fell below the 90% target by 10–20 percentage points (Fig. 3.2). The prevalence of viral load suppression for early time point surveys ranged from 72% in Cameroon to 95% in Vietnam. In contrast, the prevalence of viral load suppression in the late time point survey was comparatively lower in five of eight countries that reported data from both time points; these differences were significant in two countries: Honduras and Uganda (Fig. 3.3 and 3.4 and Tables 3.2 a–h). Considering a conservative approach when people not retained in care are classified as not having suppressed viral loads, the prevalence of viral load suppression among the four countries reporting reliable retention data dropped by between 12 and 22 percentage points (Guatemala from 89% to 67%, Honduras from 90% to 73%, Nicaragua from 78% to 57% and Viet Nam from 96% to 84%), highlighting the need to account for retention when estimating viral load suppression (Tables 3.2 a–h). Overall, the prevalence of any HIVDR among all individuals receiving treatment ranged from 3% in Viet Nam to 29% in Honduras and was overall slightly higher in the late time point surveys (Tables 3.3 a–h). Among populations for whom NNRTI-based first-line treatment failed, the level of NNRTI resistance in the early time point survey ranged from 50% in Eswatini to 97% in Uganda, and the prevalence of dual-class NNRTI and NRTI resistance ranged from 21% in Senegal to 91% in Uganda. In most late time point surveys, the prevalence of NNRTI, NRTI and dual-class NNRTI and NRTI resistance was higher than the estimates observed at the early time point (Fig. 3.3–3.8). HIV DRUG RESISTANCE REPORT 201912 Implications of the findings. Although the observed high levels of viral load suppression are reassuring, some countries report much lower prevalence estimates of viral suppression especially among people on ART for a longer period of time. The heterogeneous levels of viral load suppression between countries demonstrate clear differences in programme performance between countries. Overall, the quality of service delivery needs to be strengthened, including addressing specific needs especially among long-term treated people to meet the 90% target for viral load suppression. The drop in viral load suppression estimates when people who were lost from care are considered as having viral non-suppression indicate the need to reinforce retention. The high levels of HIVDR to both NNRTI and NRTI among participants with viral non-suppression indicate the need to scale up viral load testing and promptly switch individuals with confirmed failure to second-line ART. The observed high levels of NRTI resistance, including dual-class TDF + XTC resistance, suggest the need to optimize the NRTI backbone when switch to second line ART is done among people with non-suppressed viral loads. Viral load monitoring before treatment substitutions including from TDF + XTC + NNRTI to TDF + XTC + DTG is encouraged and considered good practice, as a significant proportion of people failing NNRTI-based ART have resistance to both TDF and XTC. Fig. 3.2 Viral load suppression among adults receiving ART for 12 and ≥ 48 months (national ADR surveys), 2014–2018 All surveys followed WHO standard survey methods. Survey methods adaptations: in Cameroon, participants who had been receiving treatment for 12–24 months were included in the early time point survey (12 months) i. In Senegal, participants who had been receiving treatment for ≥40 months were included in the late time point survey (≥48 months). Weighted estimates. 0 10 20 30 40 50 60 70 80 90 100 Viet  Nam               2017 Uganda             2016 Eswatini             2016 Zambia                   2016 Honduras             2016 Guatemala             2016 Senegal             2017 Nicaragua             2016 Cameroon             2015 Pe rc en ta ge  w it h   vi ra l  l oa d   <1 00 0   co pi es /m L 12  months ≥48  months   Fig. 3.2 shows the prevalence of viral load suppression across the two survey time points. Overall, the prevalence of viral load suppression was higher at the early time point (12 months) than the late time point (≥48 months), but the difference was only statistically significant in Honduras and Uganda. 13HIV DRUG RESISTANCE REPORT 2019 Fig. 3.3 Prevalence of acquired HIV drug resistance by drug class and country (early time point survey, 12 months) EFV: efavirenz; NVP: nevirapine; NRTI: nucleoside reverse-transcriptase inhibitors; TDF: tenofovir disoproxil fumarate; XTC: emtricitabine (FTC) or lamivudine (3TC). The early time point survey in Cameroon included participants who had been receiving treatment for 12–24 months. Weighted estimates. Fig. 3.4 Prevalence of acquired HIV drug resistance by drug class and country (late time point survey, ≥48 months) EFV: efavirenz; NVP: nevirapine; NRTI: nucleoside reverse-transcriptase inhibitors; TDF: tenofovir disoproxil fumarate; XTC: emtricitabine (FTC) or lamivudine (3TC). The survey in Senegal included participants who had been receiving treatment for ≥40 months. Weighted estimates. VietNam36 2014 87.00% 79.90% 87.70% 87.00% 82.10% 84.80% 10.50% 14.90% 9.90% 10.50% 13.10% <-­‐  add  N  under  country  n 30 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Uganda         2016 Honduras   2016 Nicaragua   2016 Guatemala   2016 Zambia         2016 Vietnam     2017 Senegal         2017 Cameroon   2015 Eswatini   2016 Pr o p o rt io n  w it h  d ru g   re si st an ce ADR12 NVP EFV EFV/NVP  and  NRTI NRTI XTC TDF 93 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Uganda         2016 Honduras   2016 Nicaragua   2016 Guatemala   2016 Vietnam     2017 Senegal         2017 Cameroon   2015 Eswatini   2016 Pr o p o rt io n  w it h  d ru g   re si st an ce ADR48 NVP EFV EFV/NVP  and  NRTI NRTI XTC TDF Fig. 3.3 shows the prevalence of ADR for commonly used first-line drugs among participants for whom treatment failed in the early- time point survey. The prevalence of EFV and NVP ADR ranged from 50% in Eswatini to 97% in Uganda, and the prevalence of NRTI ADR ranged from 21% in Senegal to 91% in Uganda. Fig. 3.4 shows the prevalence of ADR for commonly used first-line drugs among participants for whom treatment failed in the late- time point survey. The prevalence of EFV and NVP ADR ranged from 71% in Nicaragua to 92% in Senegal, and the prevalence of NRTI ADR ranged from 57% in Senegal to 87% in Uganda. Overall HIVDR genotyping failure rates varied across the different surveys. It is therefore possible that HIVDR may be overestimated or underestimated if genotyping failures are correlated with the presence or absence of HIVDR. In addition, the small sample size for the ADR estimates may result in imprecise estimates necessitating caution in the interpretation. HIV DRUG RESISTANCE REPORT 201914 Fig. 3.6 NNRTI mutations associated with acquired drug resistance by country (late time point survey, ≥48 months) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% any  NNRTI   SDRM L100I K101EP K103NS V106AM E138A Y181  any Y188  any G190  any P225H M230L M ut at io n   Pr ev al en ce Cameroon  2015 Guatemala  2016 Nicaragua  2016 Uganda  2016 Viet  Nam  2017 Honduras  2016 Senegal  2017 Eswatini  2016 NNRTI: non-nucleoside reverse-transcriptase inhibitors; SDRM: surveillance drug resistance mutations. Unweighted estimates. The late time point survey in Senegal included participants who had been receiving treatment for ≥40 months. Fig. 3.6 shows the patterns of NNRTI ADR mutations among individuals for whom treatment failed in the late time point survey. K103N/S was the predominant mutation in all countries. Fig. 3.5 NNRTI mutations associated with acquired drug resistance by country (early time point survey, 12 months) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% any  NNRTI   SDRM L100I K101EP K103NS V106AM E138A Y181  any Y188  any G190  any P225H M230L M ut at io n   pr ev al en ce Cameroon  2015 Guatemala  2016 Nicaragua  2016 Uganda  2016 Viet  Nam  2017 Zambia  2016 Honduras  2016 Senegal  2017 Eswatini  2016 NNRTI: non-nucleoside reverse-transcriptase inhibitors; SDRM: surveillance drug resistance mutations. Unweighted estimates. The early-time point survey in Cameroon included participants who had been receiving treatment for 12–24 months. Fig. 3.5 shows the patterns of NNRTI ADR mutations among individuals for whom treatment failed in the early time point survey. K103N/S was the predominant mutation in all countries except for Eswatini and Zambia, where V106A/M predominated. 15HIV DRUG RESISTANCE REPORT 2019 Fig. 3.7 NRTI mutations associated with acquired drug resistance by country (early time point survey, 12 months) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% any  NRTI   SDRM M41L K65R D67EGN T69D K70ER L74IV V75AMST Y115F M184IV L210W T215  any K219  any M ut at io n   Pr ev al en ce Cameroon  2015 Guatemala  2016 Nicaragua  2016 Uganda  2016 Viet  Nam  2017 Zambia  2016 Honduras  2016 Senegal  2017 Eswatini  2016 NRTI: nucleoside reverse-transcriptase inhibitors; SDRM: surveillance drug resistance mutations. The early time point survey in Cameroon included participants who had been receiving treatment for 12–24 months. Unweighted estimates. Fig. 3.8 NRTI mutations associated with acquired drug resistance by country (late time point survey, ≥48 months) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% any  NRTI   SDRM M41L K65R D67EGN T69D K70ER L74IV V75AMST Y115F M184IV L210W T215  any K219  any M ut at io n   Pr ev al en ce Cameroon  2015 Guatemala  2016 Nicaragua  2016 Uganda  2016 Viet  Nam  2017 Honduras  2016 Senegal  2017 Eswatini  2016 NRTI: nucleoside reverse-transcriptase inhibitors; SDRM: surveillance drug resistance mutations. The late time point survey in Senegal included participants who had been receiving treatment for ≥40 months. Unweighted estimates. Fig. 3.7 shows the patterns of NRTI ADR mutations among individuals for whom treatment failed in the early time point survey. M184V was the most frequent NRTI mutation in all countries except for Senegal, where K65R predominated. Fig. 3.8 shows the patterns of NRTI ADR mutations among individuals for whom treatment failed in the early time point survey. M184V was the most frequent NRTI mutation in all countries. 16 SECTION 4. ASSESSMENT OF PROGRAMMATIC QUALITY INDICATORS ASSOCIATED WITH THE EMERGENCE OF HIVDR Preventing HIVDR is critical for the long-term success of ART programmes and is achieved by optimizing the quality of ART service delivery. Attaining high-quality ART service delivery involves routinely monitoring quality-of-care indicators associated with and predictive of the emergence of drug-resistant HIV. Identifying gaps in service delivery and, if found to be present, swift implementation of specific and evidence-informed actions to improve clinic and programme performance are critical. Key quality- of-care indicators associated with the prevention of HIVDR include: appropriate prescribing practices (use of internationally recommended triple drug regimens), on-time ART pill pick-up (a proxy measure of appropriate adherence to ART), retention on ART 12 months after initiation, viral load testing coverage (assesses adequate treatment monitoring for identification and switch of regimen in people for whom ART is failing), viral load suppression, ARV drug stock-outs and timely switch to second-line ART (proxy measure on how well a country uses viral load testing results to identify failure and switch people in a timely manner to the next line of treatment). Key findings Country-level assessment. Between 2015 and 2018, 44 of 45 WHO focus countries reported data on programmatic quality indicators through the UNAIDS Global AIDS Monitoring system.1 Where available, viral load suppression data from a PEPFAR (United States President’s Emergency Plan for AIDS Relief) population health indicator survey were used.2 The targets for the country-level programmatic quality indicators are classified based on the targets for clinic-level WHO early warning indicators of HIVDR.3 To provide as minimally biased estimates as possible, only data from countries reporting nationally representative data or data from ≥70% of all ART clinics in the country are summarized below (Fig. 4.1).    Retention 12 months after ART initiation. The proportions of countries with classifiable data were 1 of 45 (2%) in 2015, 15 of 45 (33%) in 2016 and 18 of 45 (40%) in 2017. The proportion of reporting countries meeting the 1 Global AIDS Monitoring [online database]. Geneva: UNAIDS; 2019 (https://www.unaids.org/en/dataanalysis/knowyour response/ globalaidsprogressreporting, accessed 5 July 2019). 2 https://phia.icap.columbia.edu 3 Consolidated guidelines on person-centred HIV patient monitoring and case surveillance guidelines (section 2.4.6) and Annex 2.4.6: HIVDR EWI sampling, abstraction and reporting guidance. Geneva: World Health Organization; 2017 (https://www. who.int/hiv/pub/guidelines/ WHO_Consolidated_Guidelines_Annexes_2.4.6.pdf?ua=1, accessed 5 July 2019). target of ≥85% retention was 100% (1 of 1) in 2015, 40% (6 of 15) in 2016 and 28% in 2017 (5 of 18).    Viral load testing coverage. The proportions of countries with data were 19 of 45 (42%) in 2015, 18 of 45 (40%) in 2016 and 29 of 45 (64%) in 2017. The proportions of reporting countries achieving the target of ≥70% were 16% (3 of 19) in 2015, 17% (3 of 18) in 2016 and 31% (9 of 29) in 2017.    Viral load suppression. The proportions of countries with classifiable data were 3 of 45 (6%) in 2015, 8 of 45 (18%) in 2016 and 15 of 45 (33%) in 2017. Among these countries, none met the target of ≥90% viral load suppression in 2015 (0 of 3), 50% (4 of 8) in 2016 and 13% (2 of 15) in 2017.    Drug stock-outs. The proportions of countries reporting were 28 of 45 (62%) in 2015, 32 of 45 (71%) in 2016 and 30 of 45 (67%) in 2017. The proportion of reporting countries meeting the target of zero drug stock- outs was 46% (13 of 28) in 2015, 50% in 2016 (16 of 32) and 53% in 2017 (16 of 30).    Proportion of people receiving second-line ART. The proportion of people switched to second-line ART is a proxy measure of how well a country identifies people failing treatment and switches them to a more effective regimen, thus preventing the accumulation of HIVDR. Programmatic and survey data show that about 5–30% of people receiving ART have viral non-suppression and thus may need to switch to second-line ART. The proportions of countries reporting the proportion of people receiving second-line ART were 17 of 45 (38%) in 2015, 16 of 45 (36%) in 2016 and 29 of 45 (64%) in 2017. The proportions of reporting countries that met the target of having at least 5% of people receiving a second-line regimen were 59% (10 of 17) in 2015, 56% (9 of 16) in 2016 and 45% (13 of 29) in 2017. Clinic-level retention assessment. Between 2015 and 2018, nine countries reported clinic-level data (early warning indicators of HIV drug resistance)3 to WHO: Benin, Burkina Faso, Dominican Republic, Egypt, Ethiopia, Ghana, Myanmar, Uganda, United Republic of Tanzania and Zimbabwe. All 10 countries reported data on adult populations; Myanmar and Zimbabwe reported separate data on adults and children. Data on most indicators were variedly reported since countries did not monitor all the indicators. Retention was widely reported and thus is included in this report. 17HIV DRUG RESISTANCE REPORT 2019 Fig. 4.1 Countries with a high burden of HIV infection meeting targets for the quality-of-care indicators associated with the emergence of HIVDR, 2015–2017 Figure 4.1 summarizes data on programmatic quality indicators associated with HIVDR from 45 WHO HIV focus countries. Overall data reporting was varied and not all countries met the reporting criteria for national-representativeness. Few countries attained the targets for quality of care indicators, but there was a signal of improvement for 2 of the 5 indicators: viral load testing coverage (number of countries meeting target improved from 16% in 2015 to 31% in 2017) and drug stock-outs (number of countries meeting target improved from 46% in 2015 to 53% in 2017). Of note, not all of the same countries reported the same indicators during the reporting period, limiting the ability to assess trends within and between countries over time. Source: UNAIDSInfo, UNAIDS/WHO Global AIDS Monitoring tool and WHO/AIDS Medicines and Diagnostics Survey on the use of ARV medicines and laboratory technologies and implementation of WHO related Guidelines. aViral load suppression data (from 11 countries) were obtained from PHIA (Population health impact survey supported by PEPFAR) b Countries’ datasets were included if they comprise ≥70% of the people newly initiating ART or <70% but reported to be nationally representative c The data originated from countries responding with the proportion of people receiving treatment who received a viral load test in the 12 months period. Countries’ datasets were included if data were collected from everyone receiving ART or from a nationally representative data set. However, the results may overestimate viral load testing coverage in countries in which viral load testing coverage is estimated based on the number of tests done and thus may not be able to account for multiple tests per patient e Countries’ datasets were included if viral load testing coverage was ≥70%; or <70% and reported to be nationally representative. Fig 4.1: Countries with a high burden of HIV infection meeting targets for the quality-of-care indicators associated with the emergence of HIVDR, 2015–2017 Retention on ART at 12 monthb Viral load testing coveragec Viral load suppression at 12 monthsd Drug Stock-out Proportion of people on second- line ART 2015 2016 2017 2015 2016 2017 2015 2016 2017 2015 2016 2017 2015 2016 2017 Angola Botswana Brazil Cambodia Cameroona Chad China Cote d’Ivoirea Democratic Republic of the Congo Dominican Republic Ethiopiaa Eswatinia Ghana Guatemala Haiti India Indonesia Iran (Islamic Republic of) Jamaica Kenya Lesothoa Malawia Malaysia Mali Mexico Morocco Mozambique Myanmar Namibiaa Nigeria Pakistan Papua New Guinea Philippines Russian Federation Somalia South Africa South Sudan Sudan Thailand Ugandaa Ukraine United Republic of Tanzaniaa Viet Nam Zambiaa Zimbabwea Data not available Data reported but not national representative or ≥70% of eligible population Excellent performance: targets for retention at 12 months (>85%), viral load testing coverage (≥70%), viral load suppression (≥90%), drug stock-outs (0%), proportion of people on second-line ART (≥5%) Fair performance: targets for retention at 12 months (75-85%), viral load suppression (80-<90%) Unsatisfactory performance: retention (<75%), viral load testing coverage (<70%), viral load suppression (<80%), drug stock-outs (>0%), proportion of people on second-line ART (<5%) HIV DRUG RESISTANCE REPORT 201918    All nine countries reported clinic-level data on 12-month retention1 on ART among people newly initiating ART. The proportion of clinics that met the target of ≥85% exceeded 60% in eight of the 10 countries and ranged from a low of 2% in Ghana to 100% in Benin (Fig. 4.2). Implication of the findings. Not all focus countries reported all quality of care indicators, and not all reported the same indicators over time; in addition, not all countries meet the reporting criteria for national representativeness. In general, data reporting was inadequate, suggesting the need for strengthening systems for collection and reporting data indicating programme quality. Few countries attained the targets for quality-of-care indicators, suggesting an 1 Retention is defined as % of patients retained on ART 12 months after ART initiation (numerator: number of people who are alive and on ART 12 months after initiating treatment; denominator: number of people who initiated ART and who were expected to achieve the 12-month outcomes within the reporting period, including those who have died since starting therapy, those who have stopped ART and those who have died since starting therapy, and those recorded as lost to follow-up at month 12). urgent need for a proactive approach in addressing clear gaps in the quality of ART service delivery and in promoting practices which minimize the emergence and transmission of drug-resistant HIV. In particular, both programme- and clinic-level data indicate low rates of retention on ART; this may undermine the global efforts towards attaining epidemic control, since participants lost to follow up may be at a high risk of fuelling the HIV epidemic, including an HIVDR epidemic. More efforts are needed to elucidate the causes of low retention and implement context-specific interventions, including differentiated service delivery approaches, among others. Fig. 4.2 Proportion of clinics achieving targets of quality of care indicators associated with the emergence of HIV drug resistance (Early Warning Indicators of HIVDR, EWI): focus on retention on ART at 12 months1 Fig. 4.2 shows 12-month retention on ART among people newly initiating ART in 10 countries reporting data to WHO. The data are reported by clinic, and the figure indicates the proportion of clinics with unsatisfactory, fair and excellent retention outcomes. Overall, the levels of retention were suboptimal in most clinics; the proportion of clinics that met the target of ≥85% of people retained in care (excellent outcome) ranged from 2% in Ghana to 63% in the Dominican Republic. Only Benin reported achieving this target for all the clinics. ĞŶŝŶ ;ϮϬϭϳͿ ƵƌŬŝŶĂ &ĂƐŽ ;ϮϬϭϱͿ ƚŚŝŽƉŝĂ ;ϮϬϭϲͿ 'ŚĂŶĂ ;ϮϬϭϲͿ hŶŝƚĞĚ ZĞƉƵďůŝĐ ŽĨ dĂŶnjĂŶŝĂ ;ϮϬϭϲͿ hŐĂŶĚĂ ;ϮϬϭϲͿ ŝŵďĂďǁĞ ;ĂĚƵůƚƐ ĂŶĚ ĐŚŝůĚƌĞŶ͕ ϮϬϭϳͿ ŽŵŝŶŝĐĂŶ ZĞƉƵďůŝĐ ;ϮϬϭϱͿ ŐLJƉƚ ;ϮϬϭϳͿ DLJĂŶŵĂƌ ;ĂĚƵůƚƐ ĂŶĚ ĐŚŝůĚƌĞŶ͕ ϮϬϭϰͿ DLJĂŶŵĂƌ ;ĂĚƵůƚƐ ĂŶĚ ĐŚŝůĚƌĞŶ͕ ϮϬϭϱͿ WƌŽƉŽƌƚŝŽŶŽĨĐůŝŶŝĐƐǁŝƚŚƵŶŬŶŽǁŶƌĞƐƵůƚƐ ϯ ϴ ϭϰ WƌŽƉŽƌƚŝŽŶŽĨĐůŝŶŝĐƐǁŝƚŚƵŶƐĂƚŝƐĨĂĐƚŽƌLJ;фϳϱйͿƌĞƐƵůƚƐ ϲϳ ϭϯ ϵϭ ϰϮ ϱϭ Ϯϵ Ϯϯ ϱϰ ϱ ϭϭ WƌŽƉŽƌƚŝŽŶŽĨĐůŝŶŝĐƐǁŝƚŚĨĂŝƌ;ϳϱ–ϴϱйͿƌĞƐƵůƚƐ ϭϳ ϯϱ ϳ ϯϲ Ϯϳ ϭϵ ϭϰ ϴ ϰϰ ϰϯ WƌŽƉŽƌƚŝŽŶŽĨĐůŝŶŝĐƐǁŝƚŚĞdžĐĞůůĞŶƚ;хϴϱйͿƌĞƐƵůƚƐ ϭϬϬ ϭϯ ϱϮ Ϯ ϭϰ ϮϮ ϯϴ ϲϯ ϯϴ ϱϭ ϰϲ EƵŵďĞƌŽĨĐůŝŶŝĐƐƉƌŽǀŝĚŝŶŐZd ϭϭϰ ϭϬϴ ϭϮϯϬ ϭϴϬϬ ϭϴϬϯ ϭϱϳϯ ϳϮ ϭϯ ϭϰϭ ϭϰϭ EƵŵďĞƌŽĨĐůŝŶŝĐƐƌĞƉŽƌƚŝŶŐĞĂƌůLJǁĂƌŶŝŶŐŝŶĚŝĐĂƚŽƌƐ ϳ ϯϬ ϵϰ ϮϬϯ ϯϲ ϯϬϰ ϰϯ ϮϮ ϭϯ ϰϭ ϰϭ Ϭ ϭϬ ϮϬ ϯϬ ϰϬ ϱϬ ϲϬ ϳϬ ϴϬ ϵϬ ϭϬϬ WƌŽƉŽƌƚŝŽŶŽĨĐůŝŶŝĐƐǁŝƚŚĞdžĐĞůůĞŶƚ;хϴϱйͿƌĞƐƵůƚƐ WƌŽƉŽƌƚŝŽŶŽĨĐůŝŶŝĐƐǁŝƚŚĨĂŝƌ;ϳϱ–ϴϱйͿƌĞƐƵůƚƐ WƌŽƉŽƌƚŝŽŶŽĨĐůŝŶŝĐƐǁŝƚŚƵŶƐĂƚŝƐĨĂĐƚŽƌLJ;фϳϱйͿƌĞƐƵůƚƐ WƌŽƉŽƌƚŝŽŶŽĨĐůŝŶŝĐƐǁŝƚŚƵŶŬŶŽǁŶƌĞƐƵůƚƐ 19 TABLES Section 1. Pretreatment HIV drug resistance among adults initiating first-line antiretroviral therapy Table 1.1a. Population characteristics of national PDR surveys – Africa Cameroon (start year 2015) Eswatini (start year 2016) Namibia (start year 2015) N = 321 N = 398 N = 383 n % (95% CI)a n % (95% CI)a n % (95% CI)a Gender Women 203 65.4 (60.0–70.6) 279 73.3 (63.2–81.5) 248 64.8 (59.3–69.8) Men 118 34.6 (29.4–40.1) 119 26.7 (18.5–36.8) 135 35.2 (30.1–40.7) Other 0 – 0 – 0 – Unknown 0 – 0 – 0 – Meanb age (95% CI), yearsb Initiated first-line 37.7 (36.5–38.9) 34.4 (31.6–37.2) 35.3 (33.5–37.1) NNRTI-basedc 320 100.0 (99.7–100.0) 0 – 379 99.7 (98.0–100.0) PI-basedd 1 <0.5 0 – 0 – DTG-based 0 – 0 – 0 – Unknown 0 – 398 100.0 1 <0.5 Backbone: TDF-based 276 87.7 (78.0–93.5) 0 – 360 94.7 (91.8–96.7) Backbone: AZT-based 45 12.3 (6.5–22.0) 0 – 15 3.9 (2.3–6.6) Backbone: d4T-based 0 – 0 – 0 – Previous ARV drug exposure Yes 29 7.8 (4.2–14.0) 40 10.7 (6.8–16.4) 69 18.0 (13.2–24.0) No 223 80.6 (72.2–86.9) 358 89.3 (83.6–93.2) 313 81.7 (75.6–86.6) Unknown 69 11.6 (6.2–20.9) 0 – 1 <0.5 Previous ARVdrug exposure (women) Yes 22 10.0 (5.1–18.7) 36 14.2 (8.7–22.5) 48 19.4 (14.7–24.5) No 137 77.3 (67.4–84.5) 243 85.8 (77.5–91.4) 199 80.2 (74.6–84.9) Unknown 44 12.7 (6.8–22.6) 0 – 1 <0.5 Previous ARV drug exposure (men) Yes 7 3.6 (1.1–11.0) 4 0.9 (0.2–3.2) 21 15.6 (10.1–23.1) No 86 86.8 (77.1–92.7) 115 99.1 (96.8–99.8) 114 84.4 (76.9–89.9) Unknown 25 9.6 (4.5–19.3) 0 – – – Type of ARV drug exposure PMTCT 14 47.4 (17.2–79.7) 25 60.6 (29.7–84.9) 16 23.2 (13.3–37.1) ART 9 24.0 (5.7–62.4) 11 16.1 (5.4–39.4) 53 76.8 (62.8–86.6) Other 6 28.6 (4.6–76.9) 0 – 0 – Unknown 0 – 4 23.3 (4.5–66.3) 0 – a Study design – weighted proportion and 95% confidence interval. b Study design – weighted mean and 95% confidence interval. c NNRTI-based first-line regimens include EFV or NVP. d PI-based first-line regimens include ATV/r, DRV/r or LPV/r. HIV DRUG RESISTANCE REPORT 201920 Table 1.1.b. Population characteristics of national PDR surveys – Africa Ugandaa (start year 2016) Zimbabweb (start year 2015) N = 342 N = 353 n % (95% CI)c n % (95% CI)c Gender Women 208 61.4 (51.8–70.2) 207 56.7 (50.1–63.0) Men 133 38.4 (29.7–48.0) 145 43.3 (36.9–49.8) Other 0 – – – Unknown 0 – 1 <0.5 Mean aged (95% CI), years Initiated first-line 34.1 (31.2–37.0) 34.7 (32.6–36.8) NNRTI-basede 321 100.0 353 100.0 PI-basedf 0 – 0 – DTG-based 0 – 0 – Unknown 0 – 0 – Backbone: TDF-based 305 94.5 (86.8–97.8) 353 100.0 Backbone: AZT-based 16 5.5 (2.2–13.2) 0 – Backbone: d4T-based 0 – 0 – Previous ARV drug exposure Yes 9 1.2 (0.4–3.7) NA NA No 296 88.9 (77.2–95.0) NA NA Unknown 37 9.9 (4.2–21.2) NA NA Previous ARV drug exposure (women) Yes 5 0.9 (0.2–3.8) NA NA No 177 89.6 (74.9–96.1) NA NA Unknown 26 9.5 (3.3–24.8) NA NA Previous ARV drug exposure (men) Yes 4 1.8 (0.5–6.4) NA NA No 118 87.8 (76.9–94.0) NA NA Unknown 11 10.4 (4.9–20.9) NA NA Type of ARV drug exposure PMTCT 14 47.4 (17.2–79.7) NA NA ART 9 24.0 (5.7–62.4) NA NA Other 6 28.6 (4.6–76.9) NA NA Unknown 0 – NA NA a One participant had missing data for gender and 21 participants had missing data for initiated first-line. b Previously ARV drug–exposed participants were not included in the survey. c Study design–weighted proportion and 95% confidence interval. d Study design–weighted mean and 95% confidence interval. e NNRTI-based first-line regimens include EFV or NVP. f PI-based first-line regimens include ATV/r, DRV/r or LPV/r. NA: not available, since individuals with previous ARV drug exposure were excluded from the survey. 21HIV DRUG RESISTANCE REPORT 2019 Table 1.1.c. Population characteristics of national PDR surveys – the Americas Argentina (start year 2014) Brazila (start year 2014)b Cubac (start year 2017) Colombiad (start year 2016) N = 294 N = 1390 N = 150 N = 192 n % (95% CI)e n % (95% CI)e n % (95% CI)e n % (95% CI)e Gender Women 97 33.3 (27.0–40.2) 380 30.3 (26.7–34.1) 30 20.3 (15.4–26.3) 22 11.5 (8.1–15.9) Men 195 65.9 (58.8–72.4) 874 69.7 (65.8–73.3) 120 79.7 (73.7–84.6) 170 88.5 (84.1–91.9) Other 2 0.8 (0.2–3.2) 0 – 0 – 0 – Unknown 0 – 0 – 0 – 0 – Meanf age (95% CI), years Initiated first-line 36.2 (34.8–37.7) 35.6 (35.0–36.2) 35.1 (31.8–38.5) 31.7 (30.5–32.9) NNRTI-basedg 202 68.4 (58.3–77.1) NA NA 94 62.1 (53.2–70.3) NA NA PI-basedh 89 30.1 (22.2–41.0) NA NA 26 17.2 (10.2–27.4) NA NA Others 3 0.7 (0.2–2.3) NA NA 2 1.0 (0.2–4.1) NA NA Backbone: TDF-based 219 71.0 (55.6–82.8) NA NA 96 62.3 (52.4–71.3) NA NA Backbone: AZT-based 52 18.9 (12.4–27.7) NA NA 43 31.4 (22.3–42.1) NA NA Backbone: d4T-based 0 – NA NA 0 – NA NA Backbone: others 23 10.1 (3.5–25.8) NA NA 0 – NA NA Previous ARV drug exposure Yes 54 18.6 (12.2–27.3) NA NA NA NA NA NA No 239 81.0 (72.4–87.4) NA NA NA NA NA NA Unknown 1 <0.5 NA NA NA NA NA NA Previous ARV drug exposure (women) Yes 27 29.0 (18.0–43.3) NA NA NA NA NA NA No 70 71.0 (56.7–82.1) NA NA NA NA NA NA Unknown 0 – NA NA NA NA NA NA Previous ARV drug exposure (men) Yes 27 13.6 (8.4–21.3) NA NA NA NA NA NA No 167 85.9 (78.3–91.1) NA NA NA NA NA NA Unknown 1 <0.5 NA NA NA NA NA NA Type of ARV drug exposure PMTCT 10 20.7 (10.2–37.6) NA NA NA NA NA NA ART 43 77.0 (62.1–87.3) NA NA NA NA NA NA Other 1 <0.5 NA NA NA NA NA NA Unknown 0 – NA NA NA NA NA NA a Previously ARV drug–exposed participants were not included in the survey; initiated first-line was not available; 137 participants had missing information for gender, and 185 had missing information for age. b Survey enrolment between 2013 and 2016, with the majority (~80%) of survey participants enrolled in 2014. c Previously exposed participants were not included in the survey. d Previously exposed participants were not included in the survey; initiated first-line was not available. e Study design–weighted proportion and 95% confidence interval. f Study design–weighted mean and 95% confidence interval. g NNRTI-based first-line regimens include EFV or NVP. h PI-based first-line regimens include ATV/r, DRV/r or LPV/r. NA: not available. HIV DRUG RESISTANCE REPORT 201922 Table 1.1d. Characteristics of the population for PDR surveys – the Americas Guatemalaa (start year 2016) Honduras (start year 2016) Mexicob (start year 2017) Nicaraguac (start year 2016) N = 241 N = 194 N = 2006 N = 171 n % (95% CI)d n % (95% CI)d n % (95% CI)d n % (95% CI)d Gender Women 66 32.7 (20.1–48.4) 61 36.1 (27.8–45.4) 328 15.2 (13.8–16.7) 48 28.1 (21.5–35.7) Men 173 66.7 (51.0–79.4) 126 59.1 (50.5–67.1) 1676 84.6 (83.1–86.0) 123 71.9 (64.3–78.5) Other 2 0.6 (0.2–2.3) 7 4.8 (2.1–13.0) 2 0.2 (0.1–0.7) 0 – Unknown 0 – 0 – 0 – 0 – Meane age (95% CI), years Initiated first-line 32.9 (31.8–34.1) 33.5 (31.7–35.2) 31.9 (31.4–32.3) 34.2 (32.5–35.9) NNRTI-basedf 220 96.7 (91.3–98.8) 172 86.3 (80.4–90.7) 415 19.3 (17.7–20.9) 165 97.1 (94.7–98.4) PI-basedg 5 2.9 (1.0–8.3) 2 0.5 (0.2–1.0) 64 3.1 (2.4–3.9) 5 2.9 (1.6–5.3) DTG-based 0 – 0 – 53 2.5 (1.9–3.2) 0 – Unknown 1 <0.5 19 13.0 (8.7–18.9) 1400 71.6 (69.7–73.4) 0 – Backbone: TDF-based 215 94.0 (89.8–96.7) 144 69.7 (61.5–76.8) 548 25.8 (24.1–27.7) 152 89.4 (83.8–93.3) Backbone: AZT-based 8 4.9 (2.5–9.3) 30 16.7 (11.7–23.3) 12 0.6 (0.4–1.1) 16 9.4 (5.8–15.0) Backbone: d4T-based 0 – 0 – 0 – 0 – Previous ARV drug exposure Yes 7 2.8 (0.7–11.1) 41 26.3 (20.1–33.5) 158 7.4 (6.3–8.7) 21 12.3 (5.8–24.3) No 229 93.9 (81.9–98.1) 134 61.3 (53.3–68.7) 1848 92.6 (91.3–93.7) 146 85.4 (75.4–91.7) Unknown 5 3.3 (0.8–12.9) 19 12.4 (8.1–18.7) 0 – 4 2.3 (1.0–5.4) Previous ARV drug exposure (women) Yes 3 5.7 (1.1–9.3) 19 36.0 (22.3–52.4) 55 16.8 (12.9–21.5) 13 27.1 (16.6–40.9) No 60 91.1 (79.3–96.4) 35 51.2 (34.1–68.1) 273 83.2 (78.5–87.1) 34 70.8 (56.5–82.0) Unknown 3 3.3 (1.5–19.5) 7 12.8 (5.8–16.1) 0 – 1 2.1 (0.2–15.8) Previous ARV drug exposure (men) Yes 4 2.6 (0.9–6.9) 22 22.5 (14.8–32.6) 103 5.7 (4.6–7.1) 8 6.5 (3.0–13.6) No 167 95.3 (88.9–98.1) 92 64.3 (54.5–73.1) 1573 94.3 (92.9–95.4) 112 91.2 (83.7–95.3) Unknown 2 2.1 (0.5–9.4) 12 13.2 (7.2–23.0) 0 – 3 2.4 (0.7–7.9) Previous ARV drug exposure (others) Yes NA NA 0 – 0 – NA NA No NA NA 7 100 2 100 NA NA Unknown NA NA 0 – 0 – NA NA Type of ARV drug exposure PMTCT 1 12.0 (0.1–94.0) 3 7.9 (2.1–25.1) 0 – 8 38.1 (18.3–62.8) ART 0 – 36 90.8 (74.7–97.1) 154 97.1 (91.6–99.0) 2 9.5 (1.2–47.6) Other 0 – 0 – 4 2.9 (1.0–8.4) 1 4.8 (0.3–41.9) Unknown 6 88.0 (6.0–99.9) 2 1.3 (0.3–6.8) 0 – 10 47.6 (34.9–60.6) a 15 participants had missing data for initiated first-line. b 23 participants had missing data for age. c One participant had missing data for initiated first-line. d Study design–weighted proportion and 95% confidence interval. e Study design–weighted mean and 95% confidence interval. f NNRTI-based first-line regimens include EFV or NVP. g PI-based first-line regimens include ATV/r, DRV/r or LPV/r. NA: not available, since individuals with previous ARV drug exposure were excluded from the survey. 23HIV DRUG RESISTANCE REPORT 2019 Table 1.1e. Characteristics of the population for PDR surveys – South-East Asia and the Western Pacific Myanmara (start year 2016) Nepal (start year 2016) Papua New Guineab (start year 2017) Viet Nam (start year 2017) N = 327 N = 274 N = 337 N = 409 n % (95% CI)c n % (95% CI)c n % (95% CI)c n % (95% CI)c Gender Women 115 36.6 (29.8–43.9) 143 50.8 (44.2–57.3) 207 62.5 (57.9–66.8) 122 29.9 (22.8–38.0) Men 206 63.4 (56.1–70.2) 123 46.4 (39.9–53.1) 128 37.0 (33.0–41.3) 287 70.1 (62.0–77.2) Other 0 – 1 0.2 (0.0–0.6) 0 – 0 – Unknown 0 – 7 2.7 (1.6–4.5) 2 0.5 (0.1–2.3) 0 – Meand age (95% CI), years Initiated first-line 35.6 (34.1–37.2) 34.7 (33.6–35.7) 31.4 (30.4–32.5) 34.2 (32.8–35.6) NNRTI-basede 263 100.0 0 – 312 100.0 (98.8–100.0) 0 – PI-basedf 0 – 0 – 0 0 – DTG-based 0 – 00 – 0 0 - Unknown 0 – 274 100.0 0 409 100.0 Backbone: TDF-based 250 93.9 (88.9–96.8) 0 – 267 84.0 (63.1–94.2) 0 – Backbone: AZT-based 7 3.7 (1.5–8.8) 0 – 43 15.4 (5.7–35.4) 0 – Backbone: d4T-based 3 0.8 (0.2–2.9) 0 – 2 0.5 (0.1–3.5) 0 – Others 3 0 – 0 – 0 – Previous ARV drug exposure Yes 32 8.4 (5.0–13.8) 0 – 69 20.9 (13.8–30.3) 28 7.0 (4.1–11.7) No 287 90.0 (83.7–94.0) 0 – 268 79.1 (69.7–86.2) 371 89.8 (82.7–94.2) Unknown 8 1.6 (0.5–5.6) 274 100.0 0 – 10 3.2 (0.8–12.6) Previous ARV drug exposure (women) Yes 19 9.0 (4.8–16.1) 0 – 51 25.4 (19.2–32.9) 14 12.3 (5.6–24.9) No 185 90.2 (82.2–94.8) 0 – 156 74.6 (67.1–80.8) 107 85.9 (72.9–93.2) Unknown 2 0.8 (0.2–4.4) 143 100.0 0 – 1 1.8 (0.8–12.6) Previous ARV drug exposure (men) Yes 13 7.6 (2.9–18.9) 0 – 17 12.8 (4.7–30.2) 14 4.7 (2.3–9.5) No 102 92.4 (81.1–97.1) 0 – 111 87.2 (69.8–95.3) 264 91.5 (83.2–95.9) Unknown 0 – 123 100.0 0 – 9 3.8 (1.0–13.8) Previous ARV drug exposure (others) Yes NA NA 0 1 51.8 (5.3–95.4) NA NA No NA NA 0 1 48.2 (4.6–94.7) NA NA Unknown NA NA 1 100.0 0 – NA NA Type of ARV drug exposure PMTCT 4 10.1 (2.9–29.7) NA 0 7 30.9 (9.7–65.1) ART 24 76.3 (41.2 –93.7) NA 68 100.0 (94.7–100.0) 21 69.1 (34.9–90.4) Other 3 13.2 (2.7–45.5) NA 0 0 – Unknown 1 <0.5 NA 0 0 – a Six participants had missing information for age and gender, and 64 participants had missing information for initiated first-line. b One participant had missing information on data for type of previous ARV drug exposure, and 25 participants had missing information for initiated first-line. c Study design–weighted proportion and 95% confidence interval. d Study design-weighted mean and 95% confidence interval. e NNRTI-based first-line regimens include EFV or NVP. f PI-based first-line regimens include ATV/r, DRV/r or LPV/r. NA: not available. HIV DRUG RESISTANCE REPORT 201924 Table 1.2a. National prevalence estimates of PDR – Africa Cameroon Eswatini Namibiab n/N Prevalence % (95% CI) n/N Prevalence % (95% CI) n/N Prevalence % (95% CI) Alla Any 24/321 8.3 (4.4–15.0) 34/266 11.6 (7.1–18.4) 56/383 14.6 (11.6–18.2) NNRTI 23/321 8.1 (4.3–14.7) 31/266 10.5 (6.3–17.0) 53/383 13.8 (11.1–17.1) NRTI 5/321 2.4 (0.4–12.9) 4/266 1.0 (0.3–3.3) 6/383 1.6 (0.6–3.8) PI 1/321 0.2 (0.0–1.7) 2/266 0.9 (0.2–4.2) 2/383 0.5 (0.1–2.2) NNRTI+NRTI 5/321 2.4 (0.4–12.9) 3/266 0.8 (0.2–3.2) 5/383 1.3 (0.5–3.6) Women Any 17/203 10.6 (5.2–20.3) 24/173 14.6 (9.1–22.6) 39/248 15.7 (11.3–21.5) NNRTI 16/203 10.2 (4.9–20.0) 21/173 12.8 (7.6–20.7) 37/248 14.9 (10.7–20.4) NRTI 4/203 3.6 (0.6–18.7) 4/173 1.7 (0.5–5.1) 4/248 1.6 (0.5–5.3) PI 1/203 0.3 (0.0–2.6) 2/173 1.5 (0.3–6.4) 2/248 0.8 (0.2–3.2) NNRTI+NRTI 4/203 3.6 (0.6–18.7) 3/173 1.3 (0.4–5.0) 4/248 1.6 (0.5–5.3) Men Any 7/118 4.0 (1.4–10.4) 10/93 6.9 (2.6–17.3) 17/135 12.6 (9.1–17.2) NNRTI 7/118 4.0 (1.4–10.4) 10/93 6.9 (2.6–17.3) 16/135 11.9 (8.2–16.8) NRTI 1/118 0.1 (0.0–0.8) 0/93 – 2/135 1.5 (0.3–6.2) PI 0/118 – 0/93 – 0/135 – NNRTI+NRTI 1/118 0.1 (0.0–0.8) 0/93 – 1/135 0.7 (0.1–6.0) Treatment naive Any 13/223 7.9 (3.8–15.9) 29/240 11.0 (6.6–17.6) 31/313 9.9 (6.5–14.9) NNRTI 12/223 7.7 (3.6–15.7) 26/240 9.7 (5.8–15.9) 29/313 9.3 (6.1–13.8) NRTI 2/223 2.8 (0.4–16.3) 3/240 0.8 (0.2–3.1) 1/313 0.3 (0.0–2.5) PI 1/223 0.3 (0.0–2.1) 2/240 1.0 (0.2–4.8) 2/313 0.6 (0.2–2.6) NNRTI+NRTI 2/223 2.8 (0.4–16.3) 2/240 0.5 (0.1–3.2) 1/313 0.3 (0.0–2.5) Treatment naive (women) Any 11/137 11.8 (5.5–23.3) 19/150 13.9 (8.5–21.8) 22/199 11.1 (7.3–16.5) NNRTI 10/137 11.3 (5.2–22.9) 16/150 11.7 (6.9–19.1) 20/199 10.1 (6.4–15.4) NRTI 2/137 4.5 (0.8–21.8) 3/150 1.3 (0.3–5.2) 1/199 0.5 (0–3.9) PI 1/137 0.4 (0–3.2) 2/150 1.8 (0.4–7.6) 2/199 1.0 (0.2–4.3) NNRTI+NRTI 2/137 4.5 (0.8–21.8) 2/150 0.9 (0.2–5.2) 1/199 0.5 (0–3.9) Treatment naive (men) Any 2/86 1.5 (0.4–5.9) 10/90 7.1 (2.6–18.2) 9/114 7.9 (4.0–15.0) NNRTI 2/86 1.5 (0.4–5.9) 10/90 7.1 (2.6–18.2) 9/114 7.9 (4.0–15.0) NRTI 0/86 – 0/90 – 0/114 – PI 0/86 – 0/90 – 0/114 – NNRTI+NRTI 0/86 – 0/90 – 0/114 – Previously exposed Any 8/29 20.5 (6.8–47.8) 5/26 16.1 (6.1–36.3) 25/69 36.2 (25.6–48.5) NNRTI 8/29 20.5 (6.8–47.8) 5/26 16.1 (6.1–36.3) 24/69 34.8 (25.2–45.8) NRTI 3/29 1.6 (0.2–9.9) 1/26 2.8 (0.4–17.3) 5/69 7.2 (2.7–18.2) PI 0/29 – 0/26 – 0/69 – NNRTI+NRTI 3/29 1.6 (0.2–9.9) 1/26 2.8 (0.4–17.3) 4/69 5.8 (1.7–17.9) Previously exposed (women) Any 4/22 12.9 (3.1–40.9) 5/23 17.7 (6.7–39.2) 17/48 35.4 (22.7–50.6) NNRTI 4/22 12.9 (3.1–40.9) 5/23 17.7 (6.7–39.2) 17/48 35.4 (22.7–50.6) NRTI 2/22 1.2 (0.2–7.1) 1/23 3.1 (0.4–18.8) 3/48 6.3 (2.0–18.3) PI 0/22 – 0/23 – 0/48 – NNRTI+NRTI 2/22 1.2 (0.2–7.1) 0/23 – 3/48 6.3 (2.0–18.3) Previously exposed (men) Any 4/7 60.6 (12.7–94.2) 0/3 – 8/21 38.1 (19.4–61.2) NNRTI 4/7 60.6 (12.7–94.2) 0/3 – 7/21 33.3 (15.9–56.9) NRTI 1/7 3.3 (0.4–21.1) 0/3 – 2/21 9.5 (2.2–32.9) PI 0/7 – 0/3 – 0/21 – NNRTI+NRTI 1/7 3.3 (0.4–21.1) 0/3 – 1/21 4.8 (0.6–29.5) a Estimates of HIVDR for all ART initiators include ARV-naive individuals, those with previous ARV drug exposure and those with unknown ARV drug exposure. b Unweighted estimates differs from the weighted estimate that has been reported elsewhere (doi: 10.1093/jac/dky278) NA: not available, since individuals with previous ARV drug exposure were excluded from the survey. NNRTI resistance is defined as resistance to nevirapine (NVP) efavirenz (EFV); NRTI resistance is defined as resistance to any NRTI and any PI resistance is defined as resistance to atazanavir/ritonavir (ATV/r), lopinavir/ritonavir (LPV/r) or darunavir/ritonavir (DRV/r). Any HIVDR is defined as resistance to NVP/EFV, any NRTI, ATV/r, LPV/r or DRV/r. HIVDR is determined using the Stanford HIVdb algorithm: sequences classified as having low-, intermediate- or high-level resistance are considered resistant. 25HIV DRUG RESISTANCE REPORT 2019 Table 1.2b. National prevalence estimates of PDR – Africa Uganda Zimbabwe n/N Prevalence % (95% CI) n/N Prevalence % (95% CI) Alla Any 48/342 17.4 (12.1–24.3) NA NA NNRTI 43/342 15.4 (10.3–22.5) NA NA NRTI 11/342 5.1 (2.4–10.3) NA NA PI 2/342 1.0 (0.2–4.6) NA NA NNRTI+NRTI 8/342 4.1 (1.8–9.0) NA NA Women Any 31/208 19.2 (11.8–29.8) NA NA NNRTI 28/208 16.5 (9.5–27.2) NA NA NRTI 9/208 7.3 (3.3–15.4) NA NA PI 1/208 1.3 (0.2–7.5) NA NA NNRTI+NRTI 7/208 5.9 (2.4–13.9) NA NA Men Any 17/133 14.5 (9.9–20.7) NA NA NNRTI 15/133 13.7 (9.1–20.3) NA NA NRTI 2/133 1.5 (0.3–7.1) NA NA PI 1/133 0.4 (0.0–3.6) NA NA NNRTI+NRTI 1/133 1.2 (0.2–8.1) NA NA Treatment naive Any 44/296 18.1 (12.7–25.2) 34/353 10.9 (7.1–16.4) NNRTI 39/296 15.9 (10.2–24.0) 34/353 10.9 (7.1–16.4) NRTI 11/296 5.7 (2.7–11.5) 3/353 0.8 (0.2–3.3) PI 2/296 1.1 (0.2–5.4) 0/353 – NNRTI+NRTI 8/296 4.6 (2.1–9.9) 3/353 0.8 (0.2–3.3) Treatment naive (women) Any 27/177 19.2 (11.5–30.3) 26/207 16.1 (10.9–23.0) NNRTI 24/177 16.1 (8.3–29.0) 26/207 16.1 (10.9–23.0) NRTI 9/177 8.2 (3.7–16.9) 3/207 1.4 (0.4–5.6) PI 1/177 1.4 (0.2–8.6) 0/207 – NNRTI+NRTI 7/177 6.6 (2.7–15.1) 3/207 1.4 (0.4–5.6) Treatment naive (men) Any 17/118 16.5 (11.4–23.2) 8/145 4.1 (1.1–14.3) NNRTI 15/118 15.7 (10.5–22.6) 8/145 4.1 (1.1–14.3) NRTI 2/118 1.7 (0.3–8.3) 0/145 – PI 1/118 <0.5 0/145 – NNRTI+NRTI 1/118 1.4 (0.2–9.4) 0/145 – Previously exposed Any 2/9 17.5 (2.3–65.2) NA NA NNRTI 2/9 17.5 (2.3–65.2) NA NA NRTI 0/9 – NA NA PI 0/9 – NA NA NNRTI+NRTI 0/9 – NA NA Previously exposed (women) Any 2/5 38.4 (9.4–79.0) NA NA NNRTI 2/5 38.4 (9.4–79.0) NA NA NRTI 0/5 – NA NA PI 0/5 – NA NA NNRTI+NRTI 0/5 – NA NA Previously exposed (men) Any 0/4 – NA NA NNRTI 0/4 – NA NA NRTI 0/4 – NA NA PI 0/4 – NA NA NNRTI+NRTI 0/4 – NA NA a Estimates of HIVDR in all ART initiators include ARV-naive individuals, those with previous ARV drug exposure and those with unknown ARV drug exposure. NA: not available, since individuals with previous ARV drug exposure were excluded from the survey. NNRTI resistance is defined as resistance to nevirapine (NVP) or efavirenz (EFV); NRTI resistance is defined as resistance to any NRTI and any PI resistance is defined as resistance to atazanavir/ritonavir (ATV/r), lopinavir/ritonavir (LPV/r), or darunavir/ritonavir (DRV/r). Any HIVDR is defined as resistance to NVP/EFV, any NRTI, ATV/r, LPV/r or DRV/r. HIVDR is determined using the Stanford HIVdb algorithm: sequences classified as having low-, intermediate- or high-level resistance are considered resistant. HIV DRUG RESISTANCE REPORT 201926 Table 1.2c. National prevalence estimates of PDR – the Americas Argentina Brazil Cuba Colombia n/N Prevalence % (95% CI) n/N Prevalence % (95% CI) n/N Prevalence % (95% CI) n/N Prevalence % (95% CI) Alla Any 41/294 13.8 (10.3–18.3) NA NA NA NA NA NA NNRTI 33/294 10.9 (8.2–14.3) NA NA NA NA NA NA NRTI 10/294 3.7 (1.9–7.0) NA NA NA NA NA NA PI 6/294 1.9 (0.7–4.8) NA NA NA NA NA NA NNRTI+NRTI 5/294 1.7 (0.6–4.6) NA NA NA NA NA NA Women Any 14/97 15.5 (9.7–24.0) NA NA NA NA NA NA NNRTI 12/97 11.9 (6.5–20.9) NA NA NA NA NA NA NRTI 5/97 6.2 (2.3–15.4) NA NA NA NA NA NA PI 1/97 1.2 (0.1–8.3) NA NA NA NA NA NA NNRTI+NRTI 4/97 3.7 (1.1–12.2) NA NA NA NA NA NA Men Any 27/195 13.1 (8.8–19.2) NA NA NA NA NA NA NNRTI 21/195 10.5 (6.9–15.8) NA NA NA NA NA NA NRTI 5/195 2.4 (0.9–6.4) NA NA NA NA NA NA PI 5/195 2.3 (0.9–5.4) NA NA NA NA NA NA NNRTI+NRTI 1/195 0.6 (0.1–4.4) NA NA NA NA NA NA Treatment naive Any 31/239 12.8 (9.2–17.4) 137/1391 9.8 (8.1–12.0) 42/141 29.1 (22.8–36.3) 19/192 9.9 (7.5–12.9) NNRTI 24/239 9.4 (6.4–13.4) 94/1391 6.8 (5.6–8.1) 33/141 22.8 (15.8–31.6) 12/192 6.3 (3.8–10.2) NRTI 8/239 3.6 (1.7–7.6) 50/1391 3.6 (2.8–4.7) 15/141 9.9 (6.2–15.6) 7/192 3.6 (1.7–7.6) PI 5/239 2.1 (0.7–5.9) 13/1391 0.9 (0.6–1.5) 2/141 1.4 (0.3–5.7) 0/192 – NNRTI+NRTI 3/239 1.1 (0.3–3.6) 17/1391 1.2 (0.8–1.9) 6/141 3.6 (1.8–7.3) 0/192 – Treatment naive (women) Any 11/70 17.1 (9.8–28.1) 26/380 6.8 (5.5–8.5) 10/27 39.5 (20.3–62.6) 2/22 9.1 (2.1–31.5) NNRTI 9/70 11.9 (6.0–22.3) 19/380 5.0 (3.8–6.6) 8/27 33.3 (14.9–58.7) 1/22 4.5 (0.6–26.9) NRTI 3/70 5.5 (1.5–18.2) 11/380 2.9 (1.7–4.9) 5/27 15.4 (5.9–34.6) 1/22 4.5 (0.5–30.5) PI 1/70 1.6 (0.2–11.4) 1/380 0.3 (0.0–2.1) 1/27 4.2 (0.5–27.0) 0/22 – NNRTI+NRTI 2/70 2.0 (0.5–8.2) 5/380 1.3 (0.7–2.5) 3/27 9.2 (2.6–27.7) 0/22 – Treatment naive (men) Any 20/167 11.2 (7.0–17.4) 100/874 11.4 (9.2–14.2) 32/114 26.5 (20.2–34.0) 17/170 10.0 (7.5–13.3) NNRTI 15/167 8.4 (5.0–14.0) 66/874 7.6 (6.0–9.5) 25/114 20.2 (14.2–27.9) 11/170 6.5 (4.0–10.4) NRTI 5/167 2.8 (1.0–7.5) 37/874 4.2 (3.2–5.6) 10/114 8.6 (4.4–16.2) 6/170 3.5 (1.5–7.9) PI 4/167 2.3 (0.9–6.1) 11/874 1.3 (0.7–2.3) 1/114 0.8 (0.1–6.1) 0/170 – NNRTI+NRTI 1/167 0.7 (0.1–5.3) 11/874 1.3 (0.7–2.3) 3/114 2.3 (0.7–6.9) 0/170 – Previously exposed (all) Any 10/54 18.6 (10.7–30.4) NA NA NA NA NA NA NNRTI 9/54 17.8 (10.0–29.5) NA NA NA NA NA NA NRTI 2/54 4.1 (0.7–20.7) NA NA NA NA NA NA PI 1/54 0.9 (0.1–4.9) NA NA NA NA NA NA NNRTI+NRTI 2/54 4.1 (0.7–20.7) NA NA NA NA NA NA Previously exposed (women) Any 3/27 11.8 (3.8–31.3) NA NA NA NA NA NA NNRTI 3/27 11.8 (3.8–31.3) NA NA NA NA NA NA NRTI 2/27 7.8 (1.5–32.3) NA NA NA NA NA NA PI 0/27 – NA NA NA NA NA NA NNRTI+NRTI 2/27 7.8 (1.5–32.3) NA NA NA NA NA NA Previously exposed (men) Any 7/27 26.0 (11.9–47.8) NA NA NA NA NA NA NNRTI 6/27 24.2 (10.7–46.1) NA NA NA NA NA NA NRTI 0 – NA NA NA NA NA NA PI 1/27 1.8 (0.3–9.5) NA NA NA NA NA NA NNRTI+NRTI 0 – NA NA NA NA NA NA a Estimates of HIVDR in all ART initiators include ARV-naive individuals, those with previous ARV drug exposure and those with unknown ARV drug exposure. NA: not available, since individuals with previous ARV drug exposure were excluded from the survey. NNRTI resistance is defined as resistance to nevirapine (NVP) or efavirenz (EFV); NRTI resistance is defined as resistance to any NRTI and any PI resistance is defined as resistance to atazanavir/ritonavir (ATV/r), lopinavir/ritonavir (LPV/r), or darunavir/ritonavir (DRV/r). Any HIVDR is defined as resistance to NVP/EFV, any NRTI, ATV/r, LPV/r or DRV/r. HIVDR is determined using the Stanford HIVdb algorithm: sequences classified as having low-, intermediate- or high-level resistance are considered resistant. 27HIV DRUG RESISTANCE REPORT 2019 Table 1.2d. National prevalence estimates of PDR – the Americas Guatemala Honduras Mexico Nicaragua n/N Prevalence % (95% CI) n/N Prevalence % (95% CI) n/N Prevalence % (95% CI) n/N Prevalence % (95% CI) Alla Any 34/241 15.1 (11.5–19.6) 48/161 26.9 (20.2–34.9) 261/2006 12.6 (11.2–14.0) 40/171 23.4 (14.4–35.6) NNRTI 29/241 13.2 (8.8–19.4) 45/161 25.9 (19.2–33.9) 205/2006 9.9 (8.7–11.2) 33/171 19.3 (12.2–29.1) NRTI 9/241 3.2 (1.5–6.8) 15/161 6.9 (4.0–11.7) 64/2006 3.2 (2.5–4.1) 18/171 10.5 (4.9–21.1) PI 2/241 0.6 (0.1–3.7) 0/161 – 29/2006 1.4 (1.0–2.0) 0/171 – NNRTI+NRTI 4/241 1.3 (0.4–3.9) 12/161 5.8 (3.1–10.7) 25/2006 1.3 (0.9–1.9) 11/171 6.4 (2.7–14.7) Women Any 10/66 19.2 (11.1–31.2) 18/50 32.4 (18.1–50.9) 56/328 17.5 (13.4–22.6) 18/48 37.5 (20.8–57.8) NNRTI 10/66 19.2 (11.1–31.2) 18/50 32.4 (18.1–50.9) 43/328 13.6 (10.0–18.2) 15/48 31.3 (19.6–45.8) NRTI 1/66 1.0 (0.1–9.1) 6/50 9.2 (3.1–24.1) 16/328 4.7 (2.8–7.9) 7/48 14.6 (5.0–35.5) PI 0/66 – 0/50 – 7/328 2.4 (1.1–5.2) 0/48 – NNRTI+NRTI 1/66 1.0 (0.1–9.1) 6/50 9.2 (3.1–24.1) 7/328 2.2 (1.0–4.6) 4/48 8.3 (2.8–22.4) Men Any 24/173 13.2 (9.6–17.9) 27/105 23.5 (15.7–33.7) 205/1676 11.7 (10.3–13.3) 22/123 17.9 (9.9–30.2) NNRTI 19/173 10.4 (6.4–16.4) 24/105 21.8 (14.2–32.0) 162/1676 9.2 (8.0–10.7) 18/123 14.6 (8.0–25.3) NRTI 8/173 4.3 (2.1–8.5) 8/105 5.5 (2.8–10.6) 48/1676 2.9 (2.2–3.9) 11/123 8.9 (4.0–18.8) PI 2/173 0.9 (0.1–5.1) 0/105 – 22/1676 1.2 (0.8–1.9) 0/123 – NNRTI+NRTI 3/173 1.4 (0.7–3.1) 5/105 3.8 (0.2–8.9) 18/1676 1.1 (0.7–1.8) 7/123 5.7 (2.4–13.1) Treatment naive Any 31/229 14.9 (11.0–19.9) 26/112 16.9 (11.2–24.6) 206/1848 11.1 (9.7–12.6) 23/146 15.8 (8.8–26.6) NNRTI 27/229 13.3 (8.5–20.1) 24/112 15.6 (10.2–23.1) 161/1848 8.6 (7.4–9.9) 16/146 11.0 (6.0–19.3) NRTI 8/229 3.0 (1.5–6.0) 10/112 6.4 (3.4–11.6) 39/1848 2.3 (1.7–3.1) 10/146 6.8 (2.7–16.1) PI 2/229 0.6 (0.1–3.8) 0/112 – 22/1848 1.2 (0.8–1.8) 0/146 – NNRTI+NRTI 4/229 1.4 (0.4–4.2) 8/112 5.1 (2.6–10.0) 9/1848 0.5 (0.3–1.1) 3/146 2.1 (0.6–7.0) Treatment naive (women) Any 9/60 19.9 (9.8–36.3) 7/28 13.5 (5.2–30.7) 37/273 13.9 (9.9–19.2) 7/34 20.6 (7.8–44.4) NNRTI 9/60 19.9 (9.8–36.3) 7/28 13.5 (5.2–30.7) 28/273 10.4 (7.0–15.2) 4/34 11.8 (5.7–22.7) NRTI 1/60 1.1 (0.4–3.0) 3/28 6.1 (1.4–22.6) 7/273 2.3 (1.0–5.2) 3/34 8.8 (1.7–35.2) PI 0/60 – 0/28 – 4/273 1.6 (0.6–4.6) 0/34 – NNRTI+NRTI 1/60 1.1 (0.4–3.0) 3/28 6.1 (1.4–22.6) 2/273 0.4 (0.1–1.7) 0/34 – Treatment naive (men) Any 22/167 12.7 (9.3–17.3) 16/78 16.9 (9.6–27.9) 169/1573 10.7 (9.2–12.3) 16/112 14.3 (7.6–25.3) NNRTI 18/167 10.3 (7.1–14.7) 14/78 14.9 (8.3–25.3) 133/1573 8.3 (7.0–9.8) 12/112 10.7 (5.3–20.5) NRTI 7/167 4.0 (2.5–6.3) 6/78 6.5 (2.7–14.7) 32/1573 2.3 (1.6–3.2) 7/112 6.3 (2.4–15.2) PI 2/167 0.9 (0.4–2.0) 0/78 – 18/1573 1.1 (0.7–1.8) 0/112 – NNRTI+NRTI 3/167 1.5 (0.8–2.8) 4/78 4.5 (1.6–12.0) 7/1573 0.6 (0.3–1.2) 3/112 2.7 (0.8–9.1) Previously exposed Any 3/7 38.7 (12.6–73.4) 18/33 54.8 (33.3–74.6) 55/158 31.3 (24.1–39.7) 16/21 76.2 (52.9–90.1) NNRTI 2/7 26.7 (3.2–80.1) 17/33 53.8 (32.4–73.8) 44/158 26.2 (19.5–34.3) 16/21 76.2 (52.9–90.1) NRTI 1/7 12.0 (1.6–53.8) 4/33 10.6 (2.8–33.3) 25/158 15.0 (10.1–21.8) 7/21 33.3 (13.9–60.8) PI 0/7 – 0/33 – 7/158 4.0 (1.8–8.5) 0/21 – NNRTI+NRTI 0/7 – 3/33 9.6 (2.2–33.4) 16/158 10.8 (6.6–17.2) 7/21 33.3 (13.9–60.8) Previously exposed (women) Any 1/3 34.5 (6.3–80.6) 10/16 64.8 (29.7–88.9) 19/55 35.5 (22.4–51.2) 10/13 76.9 (54.8–90.2) NNRTI 1/3 34.5 (6.3–80.6) 10/16 64.8 (29.7–88.9) 15/55 29.5 (17.4–45.6) 10/13 76.9 (54.8–90.2) NRTI 0/3 – 2/16 14.5 (2.5–52.7) 9/55 16.8 (8.5–30.5) 3/13 23.1 (8.3–49.8) PI 0/3 – 0/16 – 3/55 6.2 (1.8–19.2) 0/13 – NNRTI+NRTI 0/3 – 2/16 14.5 (2.5–52.7) 5/55 10.8 (4.3–24.3) 3/13 23.1 (8.3–49.8) Previously exposed (men) Any 2/4 41.4 (12.2–78.2) 8/17 43.6 (17.2–74.3) 36/103 29.1 (20.5–39.5) 6/8 75 (37.5–93.8) NNRTI 1/4 21.8 (36.9–66.9) 7/17 41.5 (15.7–72.9) 29/103 24.5 (16.8–34.2) 6/8 75 (37.5–93.8) NRTI 1/4 19.6 (5.6–50.0) 2/17 6.3 (1.2–27.4) 16/103 14.1 (8.5–22.4) 4/8 50 (17.9–82.2) PI 0/4 – 0/17 – 4/103 2.8 (1.1–7.3) 0/8 – NNRTI+NRTI 0/4 – 1/17 4.2 (0.5–29.1) 11/103 10.8 (6.0–18.8) 4/8 50 (17.9–82.2) a Estimates of HIVDR in all ART initiators include ARV-naive individuals, those with previous ARV drug exposure, and those with unknown ARV drug exposure; NNRTI resistance is defined as resistance to nevirapine (NVP) efavirenz (EFV); NRTI resistance is defined as resistance to any NRTI, and any PI resistance is defined as resistance to atazanavir/ ritonavir, lopinavir/ritonavir (LPV/r), or darunavir/ritonavir (DRV/r); Any HIVDR is defined as resistance to NVP/EFV, any NRTI, ATV/r, LPV/r or DRV/r. HIVDR is determined using the Stanford HIVdb algorithm: sequences classified as having low-, intermediate- or high-level resistance are considered “resistant”. HIV DRUG RESISTANCE REPORT 201928 Table 1.2e. National prevalence estimates of PDR – South-East Asia and the Western Pacific Myanmar Nepal Papua New Guinea Viet Nam n/N Prevalence % (95% CI) n/N Prevalence % (95% CI) n/N Prevalence % (95% CI) n/N Prevalence % (95% CI) Alla Any 21/327 5.4 (3.1–9.2) 26/184 12.9 (8.8–18.5) 51/315 18.4 (13.8–24.3) 22/340 5.8 (3.4–9.5) NNRTI 16/327 3.9 (2.1–7.4) 21/184 10.2 (6.7–15.4) 49/315 17.8 (13.6–23.0) 15/340 3.4 (1.8–6.2) NRTI 5/327 1.4 (0.5–3.7) 14/184 7.8 (4.7–12.6) 13/315 5.6 (1.6–17.1) 13/340 3.5 (1.8–6.8) PI 1/326 0.2 (0.0–1.8) 0/184 – 0/315 – 0/333 – NNRTI+NRTI 1/327 0.2 (0.0–1.3) 9/184 5.1 (2.7–9.5) 11/315 4.9 (1.5–14.5) 6/340 1.2 (0.5–2.8) Women Any 7/115 5.2 (2.1–12.2) 12/84 13.4 (7.5–22.8) 36/193 21.7 (16.7–27.7) 2/95 2.5 (0.5–11.5) NNRTI 5/115 3.6 (1.2–10.3) 10/84 11.1 (5.8–20.2) 36/193 21.7 (16.7–27.7) 0/95 – NRTI 2/115 1.6 (0.3–7.4) 7/84 9.4 (4.4–18.8) 7/193 5.0 (1.2–18.3) 2/95 2.5 (0.5–11.5) PI 0/115 – 0/84 – 0/193 – 0/93 – NNRTI+NRTI 0/115 – 5/84 7.1 (2.9–16.4) 7/193 5.0 (1.2–18.3) 0/95 – Men Any 13/206 5.3 (2.9–9.7) 13/94 12.1 (7.2–19.7) 14/120 12.3 (5.3–26.0) 20/245 7.0 (3.9–12.3) NNRTI 10/206 3.9 (1.9–7.9) 11/94 10.2 (5.8–17.5) 12/120 10.5 (4.5–22.6) 15/245 4.7 (2.5–8.6) NRTI 3/206 1.3 (0.4–4.5) 6/94 5.7 (2.7–11.3) 6/120 6.5 (2.1–18.3) 11/245 3.9 (1.7–8.5) PI 1/205 0.4 (0.0–2.9) – – 0/120 – 0/240 – NNRTI+NRTI 1/206 0.3 (0.0–2.1) 4/94 3.8 (1.6–8.9) 4/120 4.8 (1.7–12.3) 6/245 1.6 (0.6–4.0) Treatment naive Any 14/287 4.3 (2.3–8.0) NA NA 30/254 12.3 (7.8–18.9) 16/310 4.6 (2.5–8.4) NNRTI 9/287 2.7 (1.2–6.0) NA NA 28/254 11.5 (7.0–18.5) 10/310 2.7 (1.3–5.5) NRTI 5/287 1.5 (0.6–4.2) NA NA 6/254 2.7 (1.0–7.1) 10/310 2.7 (1.2–6.1) PI 1/286 0.3 (0.0–2.0) NA NA 0/254 – 0/305 – NNRTI+NRTI 1/287 0.2 (0.0–1.4) NA NA 4/254 1.8 (0.6–5.9) 4/310 0.9 (0.3–2.8) Treatment naive (women) Any 6/102 5.5 (2.2–13.1) NA NA 17/145 12.7 (7.8–20.2) 2/87 2.7 (0.6–12.3) NNRTI 4/102 3.8 (1.2–11.1) NA NA 17/145 12.7 (7.8–20.2) 0/87 – NRTI 2/102 1.7 (0.4–8.0) NA NA 1/145 0.7 (0.1–5.5) 2/87 2.7 (0.6–12.3) PI 0/102 – NA NA 0/145 – 0/87 – NNRTI+NRTI 0/102 – NA NA 1/145 0.7 (0.1–5.5) 0/87 – Treatment naive (men) Any 8/185 3.6 (1.6–8.0) NA NA 12/108 11.0 (4.3–25.3) 14/223 5.3 (2.6–10.6) NNRTI 5/185 2.1 (0.8–5.7) NA NA 10/108 9.1 (3.2–23.4) 10/223 3.8 (1.9–7.5) NRTI 3/185 1.4 (0.4–5.0) NA NA 5/108 5.4 (1.9–14.2) 8/223 2.7 (1.0–7.5) PI 1/185 <0.05 NA NA 0/108 – 0/218 – NNRTI+NRTI 1/185 <0.05 NA NA 3/108 3.5 (1.1–10.3) 4/223 1.2 (0.4–4.0) Previously exposed Any 6/32 15.7 (5.5–37.4) NA NA 21/61 42.4 (29.1–56.9) 4/20 11.1 (2.9–33.9) NNRTI 6/32 15.7 (5.5–37.4) NA NA 21/61 42.4 (29.1–56.9) 4/20 11.1 (2.9–33.9) NRTI 0/32 – NA NA 7/61 16.9 (4.1–49.1) 2/20 6.5 (1.4–24.7) PI 0/32 – NA NA 0/61 – 0/18 – NNRTI+NRTI 0/32 – NA NA 7/61 16.9 (4.1–49.1) 2/20 6.5 (1.4–24.7) Previously exposed (women) Any 1/13 1.1 (0.2–7.5) NA NA 19/48 46.8 (33.4–60.7) 0/7 – NNRTI 1/13 1.1 (0.2–7.5) NA NA 19/48 46.8 (33.4–60.7) 0/7 – NRTI 0/13 – NA NA 6/48 17.1 (4.2–49.5) 0/7 – PI 0/13 – NA NA 0/48 – 0/5 – NNRTI+NRTI 0/13 – NA NA 6/48 17.1 (4.2–49.5) 0/7 – Previously exposed (men) Any 5/19 22.8 (8.3–49.1) NA NA 2/12 24.6 (7.2–57.7) 4/13 16.6 (3.9–49.1) NNRTI 5/19 22.8 (8.3–49.1) NA NA 2/12 24.6 (7.2–57.7) 4/13 16.6 (3.9–49.1) NRTI 0/19 – NA NA 1/12 17.2 (2.8–60.0) 2/13 9.7 (2.2–33.9) PI 0/19 – NA NA 0/12 – 0/13 – NNRTI+NRTI 0/19 – NA NA 1/12 17.2 (2.8–60.0) 2/13 9.7 (2.2–33.9) a Estimates of HIVDR in all ART initiators include ARV-naive individuals, those with previous ARV drug exposure and those with unknown ARV drug exposure. NA: not available, since individuals with previous ARV drug exposure were excluded from the survey. NNRTI resistance is defined as resistance to nevirapine (NVP) efavirenz (EFV). NRTI resistance is defined as resistance to any NRTI, and any PI resistance is defined as resistance to atazanavir/ritonavir (ATV/r), lopinavir/ritonavir (LPV/r), or darunavir/ritonavir (DRV/r). Any HIVDR is defined as resistance to NVP/EFV, any NRTI, ATV/r, LPV/r or DRV/r. HIVDR is determined using the Stanford HIVdb algorithm: sequences classified as having low-, intermediate- or high-level resistance are considered resistant. 29HIV DRUG RESISTANCE REPORT 2019 Section 2. Pretreatment HIV drug resistance among treatment-naive infants newly diagnosed with HIV Table 2.1a. Population characteristics of PDR surveys in infants – Africa Cameroon (start year 2014)a Eswatini (start year 2011) Malawi (start year 2016)b Mozambique (start year 2012) N = 380 N = 197 N = 405 N = 400 n Prevalence % (95% CI)c n Prevalence % (95% CI) n Prevalence % (95% CI) n Prevalence % (95% CI) Gender Female – – 96 48.7 (41.7–55.8) 176 38.2 (32.8–43.8) 195 48.8 (43.8–53.7) Male – – 91 46.2 (39.2–53.2) 167 47.2 (41.5–53.0) 170 42.5 (37.6–47.4) Unknown – – 10 5.1 (2.0–8.2) 62 14.6 (11.0–19.2) 35 8.8 (6.0–11.5) Mean age (95% CI), years 5.8 (5.3–6.3)d 5.87 (5.28–6.45) 5.1 (4.6–5.6)d 4.55 (4.20–4.90) ≤6 months 136 38.9 (34.0–44.1) 82 41.6 (34.7–48.6) 147 37.7 (32.0–43.8) 97 24.3 (20.0–28.5) >6 months 226 61.1 (55.9–66.0) 115 58.4 (51.4–65.3) 252 62.3 (56.2–68.0) 300 75.8 (71.5–80.0) PMTCT exposure status Yes 158 40.3 (35.4–45.3) 148 75.1 (69.0–81.2) 308 77.3 (71.9–81.9) 338 84.5 (80.9–88.1) No 148 41.0 (36.2–46.1) 22 11.2 (6.7–15.6) 3 1.6 (0.5–5.3) 16 4.0 (2.1–5.9) Unknown 74 18.7 (15.1–22.9) 27 13.7 (8.9–18.6) 94 21.1 (16.7–26.3) 46 11.5 (8.4–14.6) Breastfeeding status Yes 270 71.1 (66.3–75.5) 123 62.4 (55.6–69.3) 265 66.2 (60.2–71.8) 0 – No 18 4.8 (3.0–7.5) 66 33.5 (26.9–40.2) 140 33.8 (28.2–39.8) 0 – Unknown 92 24.1 (20.0–28.8) 8 4.1 (1.3–6.8) 0 – 400 100 Type of PMTCT exposure status Maternal prophylaxis 101 24.3 (20.4–28.5) 125 63.5 (56.7–70.2) 302 76.0 (70.5–80.7) 260 65.0 (60.3–69.7) Infant prophylaxis 119 30.9 (26.4–35.8) 128 65.0 (58.3–71.7) 141 31.5 (26.5–37.0) 304 76.0 (71.8–80.2) Both maternal ART and infant prophylaxis 62 17.7 (14.1–22.1) 105 53.3 (46.3–60.3) 135 30.4 (25.4–35.8) 226 56.5 (51.6–61.4) a All participants had missing data for gender and 18 participants had missing data for age. b Six infants missing data on age. c Study design–weighted proportion and 95% confidence interval. d Study design–weighted mean and 95% confidence interval. HIV DRUG RESISTANCE REPORT 201930 Table 2.1b. Population characteristics of PDR surveys in infants – Africa Nigeria (start year 2016)a Togo (start year 2012) Uganda (start year 2011) Zimbabwe (start year 2012) N = 547 N = 201 N = 224 N = 201 n/N Prevalence % (95% CI)b n/N Prevalence % (95% CI)b n/N Prevalence % (95% CI)b n/N Prevalence % (95% CI)b Gender Female 242 43.7 (39.0–48.4) 105 52.2 (45.3–59.1) 121 54.0 (47.4–60.6) 116 51.1 (44.5–57.7) Male 252 44.9 (40.1–49.8) 95 47.3 (40.4–54.2) 103 46.0 (39.4–52.6) 105 46.3 (39.7–52.8) Unknown 53 11.4 (8.8–14.8) 1 <0.5 0 6 2.6 (0.05–4.75) Mean age (95% CI), years 6.04 (5.60–6.47) c 6.03 (5.40–6.66)c 6.70 (6.07–7.34) 5.99 (5.38–6.61) ≤6 months 200 40.4 (35.4–45.6) 81 40.3 (33.7–47.3) 99 44.2 (37.6–50.8) 99 43.6 (37.1–50.1) >6 months 288 59.6 (54.4–64.6) 120 59.7 (52.7–66.3) 125 55.8 (49.2–62.4) 128 56.4 (49.9–62.9) PMTCT exposure status Yes 259 52.1 (47.7–56.5) 131 65.2 (58.3–71.5) 178 79.5 (74.1–84.8) 174 76.7 (71.1–82.2) No 117 20.3 (16.7–24.4) 41 20.4 (15.3–26.6) 35 15.6 (10.8–20.4) 46 20.3 (15.0–25.5) Unknown 171 27.6 (24.1–31.5) 29 14.4 (10.2–20.0) 11 4.9 (2.1–7.8) 7 3.1 (0.8–5.3) Breastfeeding status Yes 414 79.2 (75.4–82.5) 156 77.6 (71.3–82.9) 162 72.3 (66.4–78.2) 172 75.8 (70.2–81.4) No 44 5.2 (3.8–7.0) 18 9.0 (5.7–13.8) 41 18.3 (13.2–23.4) 35 15.4 (10.7–20.2) Unknown 89 15.7 (12.7–19.2) 27 13.4 (9.3–18.9) 21 9.4 (5.5–13.2) 20 8.8 (5.1–12.5) Type of PMTCT exposure status Maternal prophylaxis 209 41.2 (36.9–45.6) 90 44.8 (38.0–51.8) 164 73.2 (67.3–79.1) 134 60.8 (54.4–67.2) Infant prophylaxis 183 37.3 (33.1–41.7) 111 55.2 (48.2–62.0) 142 63.4 (57.0–69.8) 151 66.5 (60.3–72.7) Both maternal ART and infant prophylaxis 133 28.3 (24.3–32.6) 70 44.8 (38.0–51.8) 128 57.1 (50.6–63.7) 115 50.7 (44.1–57.2) a 59 infants missing data on age. b Study design–weighted proportion and 95% confidence interval. c Study design–weighted mean and 95% confidence interval. 31HIV DRUG RESISTANCE REPORT 2019 Table 2.2a. Prevalence estimates of PDR in infants – Africa Cameroon Eswatini Malawi Mozambique n/N Prevalence % (95% CI) n/N Prevalence % (95% CI) n/N Prevalence % (95% CI) n/N Prevalence % (95% CI) All Any 189/380 48.8 (43.9–53.8) 69/197 35.0 (28.3–41.7) 146/232 69.2 (62.1–75.5) 229/400 57.3 (52.4–62.1) NNRTI 182/380 47.0 (42.1–52.0) 67/197 34.0 (27.4–40.6) 145/232 68.8 (61.7–75.1) 224/400 56.0 (51.1–60.9) NRTI 40/380 10.3 (7.6–13.8) 4/197 2.0 (0.04–4.0) 47/232 25.8 (17.5–36.4) 26/400 6.5 (4.1–8.9) PI 0/380 – NA NA 0/232 – NA NA NNRTI+NRTI 33/380 8.5 (6.1–11.7) 2/197 1.0 (0.04–2.4) 46/232 25.4 (17.1–36.0) 21/400 5.3 (3.1–7.4) PMTCT exposed Any 101/158 63.8 (55.9–71.0) 63/148 41.9 (34.5–50.6) 133/199 73.9 (66.7–80.0) 205/338 60.7 (55.4–65.9) NNRTI 100/158 63.2 (55.3–70.4) 61/148 41.2 (33.2–49.2) 132/199 73.4 (66.3–79.6) 200/338 59.2 (53.9–64.4) NRTI 21/158 13.1 (8.7–19.4) 4/148 2.7 (0.1–5.3) 42/199 27.8 (18.7–39.3) 21/338 6.2 (3.6–8.8) PI 0/158 – NA NA 0/199 – NA NA NNRTI+NRTI 20/158 12.5 (8.2–18.7) 2/148 1.4 (–0.1–3.2) 41/199 27.4 (18.3–38.9) 16/338 4.7 (2.5–7.0) PMTCT unexposed or unknown Any 88/222 38.5 (32.4–45.0) 6/49 12.2 (2.7–21.8) 13/30 35.4 (16.6–60.1) 24/62 38.7 (26.2–51.2) NNRTI 82/222 35.8 (29.9–42.3) 6/49 12.2 (2.7–21.8) 13/30 35.4 (16.6–60.1) 24/62 38.7 (26.2–51.2) NRTI 19/222 8.3 (5.4–12.8) 0/49 – 5/30 10.1 (2.4–33.7) 5/62 8.1 (1.09–15.0) PI 0/222 – NA NA 0/30 – NA NA NNRTI+NRTI 13/222 5.7 (3.3–9.6) 0/49 – 5/30 10.1 (2.4–33.7) 5/62 8.1 (1.09–15.0) NNRTI resistance is defined as resistance to nevirapine (NVP) or efavirenz (EFV). NRTI resistance is defined as resistance to any NRTI, and any PI resistance is defined as resistance to atazanavir/ritonavir (ATV/r), lopinavir/ritonavir (LPV/r), or darunavir/ritonavir (DRV/r). Any HIVDR is defined as resistance to NVP/EFV, any NRTI, ATV/r, LPV/r or DRV/r. HIVDR is determined using the Stanford HIVdb algorithm: sequences classified as having low-, intermediate- or high-level resistance are considered resistant. HIV DRUG RESISTANCE REPORT 201932 Table 2.2b. Prevalence estimates of PDR among infants – Africa Nigeria Togo Uganda Zimbabwe n/N Prevalence % (95% CI) n/N Prevalence % (95% CI) n/N Prevalence % (95% CI) n/N Prevalence % (95% CI) All Any 198/423 50.1 (44.6–55.6) 123/199 61.8 (54.8–68.3) 86/224 38.4 (32.0–44.8) 145/227 63.9 (57.6–70.2) NNRTI 192/423 48.6 (43.1–54.0) 114/199 57.3 (50.3–64.0) 80/224 35.7 (29.4–42.0) 145/227 63.9 (57.6–70.2) NRTI 91/423 22.9 (18.4–28.0) 33/199 16.6 (12.0–22.5) 19/224 8.5 (4.8–12.2) 22/227 9.7 (5.8–13.6) PI 0/423 – NA NA NA NA NA NA NNRTI+NRTI 85/423 21.3 (17.0–26.4) 24/199 12.1 (8.2–17.4) 13/224 5.8 (2.7–8.9) 22/227 9.7 (5.8–13.6) PMTCT exposed Any 110/194 57.2 (49.7–64.4) 97/130 74.6 (66.4–81.4) 73/178 41.0 (33.7–48.3) 130/174 74.7 (68.2–81.2) NNRTI 107/194 55.4 (48.0–62.6) 94/130 72.3 (63.9–79.4) 69/178 38.8 (31.5–46.0) 130/174 74.7 (68.2–81.2) NRTI 61/194 30.5 (23.9–38.0) 21/130 16.2 (10.7–23.6) 15/178 8.4 (4.3–12.5) 21/174 12.1 (7.2–16.9) PI 0/286 – NA NA NA NA NA NA NNRTI+NRTI 58/194 28.6 (22.2–36.0) 18/130 13.8 (8.9–21.0) 11/178 6.2 (2.6–9.7) 21/174 12.1 (7.2–16.9) PMTCT unexposed or unknown Any 88/229 42.6 (34.9–50.6) 26/69 37.7 (27.0–49.7) 13/46 28.3 (14.7–41.8) 15/53 28.3 (15.8–40.8) NNRTI 85/229 41.4 (33.8–49.5) 20/69 29.0 (19.5–40.8) 11/46 23.9 (11.1–36.7) 15/53 28.3 (15.8–40.8) NRTI 30/229 14.8 (9.6–22.2) 12/69 17.4 (10.1–28.3) 4/46 8.7 (0.2–17.2) 1/53 1.9 (0–5.7) PI 0/229 – NA NA NA NA NA NA NNRTI+NRTI 27/229 13.7 (8.6–21) 6/69 8.7 (3.9–18.1) 2/46 4.3 (0–10.5) 1/53 1.9 (0–5.7) NNRTI resistance is defined as resistance to nevirapine (NVP) efavirenz (EFV). NRTI resistance is defined as resistance to any NRTI, and any PI resistance is defined as resistance to atazanavir/ritonavir (ATV/r), lopinavir/ritonavir (LPV/r), or darunavir/ritonavir (DRV/r). Any HIVDR is defined as resistance to NVP/EFV, any NRTI, ATV/r, LPV/r or DRV/r. HIVDR is determined using the Stanford HIVdb algorithm: sequences classified as having low-, intermediate- or high-level resistance are considered “resistant”. 33HIV DRUG RESISTANCE REPORT 2019 Section 3. Acquired HIV Drug Resistance among adults receiving antiretroviral treatment Table 3.1a. Population characteristics of early time point (12 months) for ADR surveys – Africa Cameroon (12–24 months) Eswatini (12 ±3 months) Senegal (12 ±3 months) N = 1064 (start year 2015) N = 375 (start year 2016) N = 255 (start year 2017) n % (95% CI)a n % (95% CI)a n % (95% CI)a Gender Women 808 77.9 (75.4–80.2) 270 72.1 (65.4–77.9) 184 72.7 (63.6–80.3) Men 256 22.1 (19.8–24.6) 105 27.9 (22.1–34.6) 71 27.3 (19.7–36.4) Meanb age (95% CI), years 40.0 (39.4–40.7) 36.0 (34.5–37.6) 42.1 (38.8–45.4) Individuals on first-line ART 1050 99.0 (98.1–99.5) 374 99.8 (98.8–100.0) 252 99.3 (96.7–99.9) Individuals on NNRTI- based first-line ART 1048 98.9 (97.8–99.4) 368 98.1 (95.7–99.1) 249 95.4 (86.6–98.5) Individuals on second- line ART 14 1.0 (0.6–1.9) 1 0.2 (0.0–1.2) 1 0.5 (0.1–3.7) Current ART TDF + XTC + EFV 758 71.4 (63.3–78.4) 330 87.4 (81.8–91.5) 236 88.9 (80.1–94.1) TDF + XTC + NVP 109 9.0 (6.1–13.0) 7 1.6 (0.7–3.5) 2 0.6 (0.1–2.9) AZT + XTC + EFV 32 3.6 (2.1–6.3) 12 3.9 (2.1–7.3) 0 0 AZT + XTC + NVP 148 14.8 (10.5–20.4) 5 1.7 (0.6–4.6) 0 0 D4T + XTC + EFV 0 0 2 0.5 (0.1–2.1) 0 0 D4T + XTC + NVP 0 0 0 0 0 0 PI-based regimen 16 1.1 (0.6–2.2) 1 0.2 (0.0–1.2) 1 0.5 (0.1–3.7) INI-based regimen 0 0 0 0 0 0 Other 1 <0.5 12 2.9 (1.3–6.6) 14 8.8 (4.0–18.2) Unknown 0 0 6 1.8 (0.7–4.2) 2 1.2 (0.2–5.5) Mean time on ART (95% CI), months 17.9 (17.4–18.4) 12.5 (12.3–12.7) 12.3 (11.9–12.7) a Study design–weighted proportion and 95% confidence interval. b Study design–weighted mean and 95% confidence interval. HIV DRUG RESISTANCE REPORT 201934 Table 3.1b. Population characteristics of early time point (12 months) for ADR surveys – Africa Ugandaa (12 ±3 months) Zambiab (12 ±3 months) N = 533 (start year 2016) N = 454 (start year 2016) n % (95% CI)c n % (95% CI)c Gender Women 351 65.9 (59.3–72.0) 257 60.0 (56.3–63.4) Men 182 34.1 (28.0–40.7) 197 40.1 (36.6–43.7) Meand age (95% CI), years 33.2 (31.1–35.2) 37.9 (36.4–39.4) Individuals on first-line ART 533 100.0 453 100.0 (99.6–100) Individuals on NNRTI-based first-line ART 533 100.0 453 100.0 (99.6–100) Individuals on second-line ART 0 1 <0.5 Current ART TDF + XTC + EFV 473 96.4 (86.7–99.1) 450 99.8 (99.3–100.0) TDF + XTC + NVP 0 0 3 <0.5 AZT + XTC + EFV 25 2.3 (0.5–9.8) 0 0 AZT + XTC + NVP 33 1.3 (0.4–4.5) 0 0 D4T + XTC + EFV 0 0 0 0 D4T + XTC + NVP 0 0 0 0 PI-based regimen 0 0 1 <0.5 INI-based regimen 0 0 0 0 Other 2 0.1 (0.0–0.6) 0 0 Unknown 0 0 0 0 Mean time on ART (95% CI), months 12.6 (12.2–12.9) 12.2 (11.8–12.6) a Included only participants on first-line ART. b Three participants had missing data for age. c Study design–weighted proportion and 95% confidence interval. d Study design–weighted mean and 95% confidence interval. 35HIV DRUG RESISTANCE REPORT 2019 Table 3.1c. Population characteristics of early time point (12 months) for ADR surveys – the Americas Guatemala (12 ± 3 months) Honduras (12 ± 3 months) Nicaragua (12 ± 3 months) N = 222 (start year 2016) N = 168 (start year 2016) N = 114 (start year 2016) n % (95% CI)a n % (95% CI)a n % (95% CI)a Gender Women 66 29.7 (21.1–40.1) 61 35.0 (28.6–42.1) 38 33.5 (24.3–44.0) Men 156 70.3 (59.9–78.9) 107 65.0 (57.9–71.4) 76 66.6 (56.0–75.7) Meanb age (95% CI), years 35.7 (33.8–37.6) 34.9 (34.9–36.3) 32.3 (30.9–33.8) Individuals on first-line ART 220 99.1 (96.4–99.8) 167 99.1 (95.3–99.8) 110 97.8 (97.7–97.9) Individuals on NNRTI-based first-line ART 216 97.3 (93.8–98.9) 166 98.5 (95.2–99.5) 104 88.4 (76.2–94.8) Individuals on second-line ART 2 0.9 (0.4–2.1) 1 0.9 (0.2–4.7) 4 2.2 (2.1–2.3) Current ART TDF + XTC + EFV 199 89.6 (74.5–96.2) 157 93.0 (89.5–95.5) 91 75.2 (64.7–83.3) TDF + XTC + NVP 0 – 1 0.8 (0.2–4.3) 0 AZT + XTC + EFV 3 1.4 (0.4–4.8) 4 1.9 (1.0–3.5) 13 13.3 (10.6–16.4) AZT + XTC + NVP 3 1.4 (0.3–5.2) 0 – 0 – D4T + XTC + EFV 0 – 0 – 0 – D4T + XTC + NVP 0 – 0 – 0 – PI-based regimen 6 2.7 (1.1–6.2) 1 0.6 (0.1–2.8) 8 10.5 (4.3–23.2) INI-based regimen 0 – 1 0.6 (0.1–2.8) 0 – Other 11 5.0 (1.2–17.7) 4 3.0 (1.3–6.6) 2 1.1 (1.0–1.1) Unknown 0 – 0 – 0 – Mean time on ART (95% CI), months 12.2 (12.0–12.4) 12.1 (11.8–12.4) 12.1 (11.7–12.4) a Study design–weighted proportion and 95% confidence interval. b Study design–weighted mean and 95% confidence interval. HIV DRUG RESISTANCE REPORT 201936 Table 3.1d. Population characteristics of early time point (12 months) for ADR surveys – Western Pacific Viet Nam (12 ± 3 months) N = 429 (start year 2017) n % (95% CI)a Gender Women 139 31.4 (23.9–40.0) Men 290 68.6 (60.0–76.1) Mean ageb (95% CI), years 35.7 (33.8–37.6) Individuals on first-line ART 423 98.4 (95.5–99.4) Individuals on NNRTI-based first-line ART 423 98.4 (95.5–99.4) Individuals on second-line ART 6 1.6 (0.6–4.5) Current ART TDF + XTC + EFV 419 97.5 (94.7–98.9) TDF + XTC + NVP 2 0.2 (0.1–1.0) AZT + XTC + EFV 2 0.7 (0.2–2.6) AZT + XTC + NVP 3 0.7 (0.2–2.3) D4T + XTC + EFV 0 0 D4T + XTC + NVP 1 0.3 (0.0–2.4) PI-based regimen 1 0.3 (0.0–2.0) INI-based regimen 0 0 Other 1 0.3 (0.0–2.0) Unknown 0 0 Mean time on ART (95% CI), months 11.8 (11.4–12.2) a Study design–weighted proportion and 95% confidence interval. b Study design–weighted mean and 95% confidence interval 37HIV DRUG RESISTANCE REPORT 2019 Table 3.1e. Population characteristics of late time point (≥48 months) for ADR surveys – Africa Cameroon (48–60 months) Eswatini (≥48 months) Senegal (≥40 months) Ugandaa (≥48 months) N = 388 (start year 2015) N = 500 (start year 2016) N = 315 (start year 2017) N = 1062 (start year 2017) n % (95% CI)b n % (95% CI)b n % (95% CI)b n % (95% CI)b Gender Women 287 75.3 (66.6–82.3) 359 70.3 (65.4–74.7) 239 76.5 (69.2–82.4) 693 65.6 (62.2–68.9) Men 101 24.7 (17.7–33.4) 141 29.8 (25.3–34.7) 76 23.5 (17.6–30.8) 369 44.4 (31.1–37.8) Meanc age (95% CI), years 43.1 (42.0–44.3) 43.4 (41.3–45.6) 43.8 (42.0–45.6) 44.6 (43.7–45.5) Individuals on first-line ART 364 94.4 (83.9–98.2) 468 93.6 (90.4–95.8) 311 98.8 (96.4–99.6) 1062 100.0 (99.6–100.0) Individuals on NNRTI-based first- line ART 364 94.4 (83.9–98.2) 464 92.7 (89.4–95.0) 311 98.8 (96.4–99.6) 1061 99.9 (99.2–100.0) Individuals on second-line ART 24 5.6 (2.0–15.1) 32 6.4 (4.2–9.6) 3 1.1 (0.3–3.6) 0 0 Current ART TDF + XTC + EFV 229 58.8 (46.2–70.3) 148 29.4 (23.7–35.9) 235 75.1 (64.6–83.2) 244 23.0 (18.3–28.5) TDF + XTC + NVP 58 16.0 (7.9–29.8) 23 5.1 (3.2–7.8) 1 0.4 (0.1–2.5) 122 10.4 (7.7–13.8) AZT + XTC + EFV 4 1.0 (0.1–6.5) 50 11.1 (7.6–16.0) 13 7.1 (2.1–20.8) 106 9.7 (7.2–12.9) AZT + XTC + NVP 73 18.6 (9.1–34.3) 178 33.4 (27.8–39.4) 62 16.2 (11.2–23.0) 586 56.6 (49.6–63.4) D4T + XTC + EFV 0 0 24 5.2 (3.4–7.9) 0 0 0 0 D4T + XTC + NVP 0 0 31 6.6 (4.6–9.2) 0 0 0 0 PI-based regimen 23 5.4 (1.8–15.4) 25 5.0 (3.0–8.2) 4 1.2 (0.4–3.6) 1 0.1 (0–0.8) Other 1 <0.5 10 2.0 (1.1–3.6) 0 0 3 0 Unknown 0 0 11 2.3 (1.2–4.3) 0 0 0 0 Mean time on ART (95% CI), months 53.3 (52.1–54.6) 85.2 (81.5–88.9) 52.2 (48.4–56.0) 88.5 (80.3–96.6) a Included only participants on first-line ART. b Study design–weighted proportion and 95% confidence interval. c Study design–weighted mean and 95% confidence interval. HIV DRUG RESISTANCE REPORT 201938 Table 3.1f. Population characteristics of late time point (≥48 months) for ADR surveys – the Americas Guatemala (≥48 months) Honduras (≥48 months) Nicaragua (≥48 months) N = 377 (start year 2016) N = 367 (start year 2016) N = 350 (start year 2016) n % (95% CI)a n % (95% CI)a n % (95% CI)a Gender Women 161 42.7 (35.0–50.7) 212 58.8 (51.8–65.5) 134 43.0 (35.8–50.5) Men 214 56.8 (48.5–64.7) 154 41.0 (34.3–48.1) 219 57.0 (49.5–64.2) Others 2 0.5 (0.1–2.1) 1 0.1 (0.1–0.1) 0 0 Meanb age (95% CI), years 42.7 (41.4–43.9) 43.4 (41.7–45.0) 38.7 (37.2–39.0) Individuals on first-line ART 350 92.9 (81.8–97.4) 298 86.0 (81.8–89.4) 303 84.8 (79.2–89.1) Individuals on NNRTI- based first-line ART 323 85.7 (78.3–90.9) 290 84.2 (79.9–87.6) 264 74.9 (69.2–79.9) Individuals on second- line ART 27 7.1 (5.4–9.4) 62 12.5 (9.3–16.7) 49 14.4 (10.4–19.5) Current ART TDF + XTC + EFV 185 49.0 (43.5–54.6) 57 12.3 (9.7–15.5) 117 32.4 (26.8–38.6) TDF + XTC + NVP 27 7.2 (4.1–12.3) 9 1.7 (1.2–2.4) 2 0.8 (0.2–3.0) AZT + XTC + EFV 70 18.5 (14.7–23.1) 210 65.3 (60.1–70.3) 130 36.6 (30.3–43.4) AZT + XTC + NVP 14 3.7 (1.8–7.7) 1 0.4 (0.1–2.0) 3 1.5 (0.5–4.8) D4T + XTC + EFV 0 0 0 0 0 0 D4T + XTC + NVP 0 0 0 0 0 0 PI-based regimen 52 13.8 (8.5–21.6) 67 13.6 (10.3–17.8) 59 18.6 (14.1–24.1) Other 29 7.7 (3.6–15.9) 23 6.7 (4.5–10.0) 42 10.0 (7.3–13.6) Unknown 0 0 0 0 0 0 Mean time on ART (95% CI), months 91.8 (84.5–99.1) 102.3 (97.5–107.0) 82.1 (76.8–87.4) a Study design–weighted proportion and 95% confidence interval. b Study design–weighted mean and 95% confidence interval. 39HIV DRUG RESISTANCE REPORT 2019 Table 3.1g. Population characteristics of late time point (≥48 months) for ADR surveys – Western Pacific Viet Nam (≥48 months) N = 723 (start year 2017) n % (95% CI)a Gender Women 267 37.6 (33.2–42.1) Men 456 62.4 (57.9–66.8) Meanb age (95% CI), years 41.0 (40.1–41.8) Individuals on first-line ART 688 94.8 (92.1–96.7) Individuals on NNRTI-based first-line ART 658 91.7 (88.1–94.2) Individuals on second-line ART 35 5.2 (3.3–7.9) Current ART TDF + XTC + EFV 436 62.6 (55.6–69.1) TDF + XTC + NVP 6 0.9 (0.4–1.9) AZT + XTC + EFV 81 11.0 (7.8–15.2) AZT + XTC + NVP 134 17.1 (13.0–22.1) D4T + XTC + EFV 1 0.1 (0.0–1.0) D4T + XTC + NVP 0 0 PI-based regimen 58 7.2 (5.0–10.3) Other 7 1.1 (0.4–3.1) Unknown 0 0 Mean time on ART (95% CI), months 87.8 (83.1–92.5) a Study design–weighted proportion and 95% confidence interval. b Study design–weighted mean and 95% confidence interval. HIV DRUG RESISTANCE REPORT 201940 Table 3.2a. Prevalence of viral load suppression for individuals on ART, early time point (12 months), ADR surveys – Africa Cameroon (12–24 months) Eswatinia (12±3 months) Senegal (12±3 months) n Prevalence % (95% CI) n Prevalence % (95% CI) n Prevalence % (95% CI) Cut-off viral load <1000 copies/mL Viral load suppression among individuals on ART 796/1064 72.1 (66.2–77.2) 340/375 90.5 (86.3–93.5) 211/255 86.5 (79.4–91.5) Viral load suppression among individuals on first-line ART 786/1050 72.1 (66.5–77.2) 340/375 90.6 (86.5–93.6) 208/252 86.4 (79.2–91.4) Viral load suppression among individuals on first-line NNRTI-based ART 785/1048 72.1 (66.4–77.2) 335/368 90.8 (86.6–93.8) 206/249 86.0 (78.8–91.0) Viral load suppression among individuals on TDF-based first- line NNRTI-based ART 668/887 74.9 (70.2–79.1) 303/334 90.7 (86.4–93.7) 196/238 85.4 (78.0–90.6) Viral load suppression among individuals on AZT-based first-line NNRTI-based ART 117/180 60.2 (49.1–70.4) 15/17 85.9 (58.4–96.3) 0/238 0 Viral load suppression among individuals on PI-based second-line ART 10/14 65.5 (34.9–87.1) 0/1 0 1/1 100.0 Viral load suppression among women on ART 624/808 75.0 (69.4–79.9) 249/270 92.0 (88.2–94.7) 154/184 86.8 (78.9–92.0) Viral load suppression among men on ART 172/256 61.6 (51.7–70.6) 91/105 86.5 (74.1–93.5) 57/71 85.8 (72.0–93.5) a Viral suppression defined as viral load ≤2005 copies/mL based on DBS, lower limit of detection by the Roche free viral elution platform. 41HIV DRUG RESISTANCE REPORT 2019 Table 3.2b. Prevalence of viral load suppression for individuals on ART, early time point (12 months), ADR surveys – Africa Uganda (12±3 months) Zambia (12±3 months) n/N Prevalence % (95% CI) n/N Prevalence % (95% CI) Cut-off viral load <1000 copies/mL Viral load suppression among individuals on ART 493/533 94.6 (92.8–96.0) 409/454 90.0 (80.1–94.2) Viral load suppression among individuals on first-line ART 493/533 94.6 (92.8–96.0) 408/453 88.9 (80.2–94.1) Viral load suppression among individuals on first-line NNRTI-based ART 493/533 94.6 (92.8–96.0) 408/453 88.9 (80.2–94.1) Viral load suppression among individuals on TDF-based first-line NNRTI-based ART 493/533 94.6 (92.8–96.0) 408/453 88.9 (80.2–94.1) Viral load suppression among individuals on AZT-based first-line NNRTI-based ART 53/58 94.9 (86.9–98.1) 0/453 0 Viral load suppression among individuals on PI-based second-line ART NA NA 1/1 100.0 Viral load suppression among women on ART 324/351 93.1 (91.4–94.5) 228/257 86.3 (74.1–93.3) Viral load suppression among women on men 169/182 97.6 (90.8–99.4) 181/197 92.9 (83.5–97.1) Cut-off viral load <400 copies/mL Viral load suppression among individuals on ART NA NA 397/454 85.3 (68.1–94.0) Viral load suppression among individuals on first-line ART NA NA 396/453 85.3 (68.1–94.0) Viral load suppression among individuals on first-line NNRTI-based ART NA NA 396/453 85.3 (68.1–94.0) Viral load suppression among individuals on TDF-based first-line NNRTI-based ART NA NA 396/453 85.3 (68.1–94.0) Viral load suppression among individuals on AZT-based first-line NNRTI-based ART NA NA 0 0 Viral load suppression among individuals on PI-based second-line ART NA NA 1/1 100 Viral load suppression among women on ART NA NA 223/257 83.4 (64.7–93.2) Viral load suppression among men on ART NA NA 174/197 88.1 (70.2–95.9) Cut-off viral load <50 copies/mL Viral load suppression among individuals on ART NA NA 350/454 75.3 (56.1–87.9) Viral load suppression among individuals on first-line ART NA NA 350/453 75.3 (56.0–87.9) Viral load suppression among individuals on first-line NNRTI-based ART NA NA 349/453 75.2 (56.0–87.9) Viral load suppression among individuals on TDF-based first-line NNRTI-based ART NA NA 349/453 75.2 (56.0–87.9) Viral load suppression among individuals on AZT-based first-line NNRTI-based ART NA NA 0 0 Viral load suppression among individuals on PI-based second-line ART NA NA 1/1 100 Viral load suppression among women on ART NA NA 196/257 76.3 (58.2–88.1) Viral load suppression among men on ART NA NA 154/197 73.7 (49.2–89.1) HIV DRUG RESISTANCE REPORT 201942 Table 3.2c. Prevalence of viral load suppression for individuals on ART, early time point (12 months), ADR surveys – the Americas Guatemalaa (12±3 months) Hondurasb (12±3 months) Nicaraguac (12±3 months) n/N Prevalence % (95% CI) n/N Prevalence % (95% CI) n/N Prevalence % (95% CI) Cut-off viral load <1000copies/mL Viral load suppression among individuals on ART (on treatment analysis)d 197/222 88.7 (77.4–94.8) 150/168 89.7 (85.1–93.0) 86/114 77.8 (67.1–85.8) Viral load suppression among individuals on ART (intention-to-treat analysis)e 197/222 66.9 (60.2–73.6) 150/168 72.7 (68.6–76.7) 86/114 57.1 (49.2–65.1) Viral load suppression among individuals on first-line ART 195/220 88.6 (77.1–94.7) 149/167 89.6 (85.0–93.0) 82/110 77.3 (66.4–85.5) Viral load suppression among individuals on first-line NNRTI-based ART 193/216 89.3 (79.2–94.9) 148/166 89.6 (84.9–92.9) 78/104 80.7 (76.1–84.7) Viral load suppression among individuals on TDF- based first-line NNRTI-based ART 181/199 91.0 (81.6–95.8) 142/158 90.4 (85.8–93.6) 67/91 80.0 (75.9–83.6) Viral load suppression among individuals on AZT- based first-line NNRTI-based ART 4/6 66.7 (13.8–96.2) 5/7 66.1 (35.0–87.7) 15/19 68.3 (37.7–88.5) Viral load suppression among individuals on PI-based second-line ART 2/2 100 1/1 100.0 4/4 100.0 Viral load suppression among women on ART 56/66 84.8 (73.0–92.0) 52/61 87.0 (77.4–92.9) 28/38 66.4 (42.7–84.0) Viral load suppression among men on ART 141/156 90.4 (76.0–96.5) 98/107 91.2 (83.6–95.5) 58/76 83.5 (73.8–90.2) Cut-off viral load <400 copies/mL Viral load suppression among individuals on ART 196/222 88.3 (76.1–94.7) 149/168 89.4 (84.5–92.7) 81/114 74.8 (64.4–83.0) Viral load suppression among individuals on first-line ART 194/220 88.2 (75.9–94.7) 148/167 89.3 (84.7–92.6) 79/110 75.4 (64.6–83.7) Viral load suppression among individuals on first-line NNRTI-based ART 192/216 88.9 (77.9–94.8) 147/166 89.2 (84.6–92.6) 75/104 78.6 (73.8–82.7) Viral load suppression among individuals on TDF- based first-line NNRTI-based ART 180/199 90.5 (80.0–95.7) 141/158 90.0 (85.5–93.3) 65/91 78.5 (74.2–82.2) Viral load suppression among individuals on AZT- based first-line NNRTI-based ART 4/6 66.7 (13.8–96.2) 5/7 66.1 (35.0–87.7) 14/19 65.1 (36.8–85.6) Viral load suppression among individuals on PI-based second-line ART 2/2 100 1/1 100.0 2/4 50 (50–50) Viral load suppression among women on ART 56/66 84.8 (73.0–92.0) 51/61 86.0 (78.3–91.3) 26/38 63.0 (42.9–79.4) Viral load suppression among men on ART 140/156 89.7 (73.7–96.5) 98/107 91.2 (83.6–95.5) 55/76 80.8 (76.7–84.3) Cut-off viral load <50 copies/mL Viral load suppression among individuals on ART 178/222 80.2 (70.2–87.4) 125/168 73.1 (65.9–79.3) 71/114 67.9 (57.8–76.6) Viral load suppression among individuals on first-line ART 177/220 80.5 (71.0–87.4) 125/167 73.8 (66.5–80.0) 69/110 68.3 (57.9–77.1) Viral load suppression among individuals on first-line NNRTI-based ART 175/216 81.0 (72.7–87.2) 124/166 73.6 (66.3–79.8) 65/104 70.7 (65.4–75.6) Viral load suppression among individuals on TDF- based first-line NNRTI-based ART 165/199 82.9 (75.5–88.5) 119/158 74.1 (66.6–80.5) 56/91 70.2 (64.9–75.0) Viral load suppression among individuals on AZT- based first-line NNRTI-based ART 4/6 66.7 (13.8–96.2) 4/7 55.2 (28.5–79.2) 13/19 61.9 (35.7–82.6) Viral load suppression among individuals on PI-based second-line ART 1/1 50.0 (33.2–96.7) 0/1 <0.5 2/4 50 (50–50) Viral load suppression among women on ART 53/66 80.3 (61.8–91.1) 41/61 67.4 (56.2–76.9) 23/38 57.4 (39.2–73.8) Viral load suppression among men on ART 125/156 80.1 (70.1–87.4) 84/107 76.2 (66.5–83.6) 48/76 73.2 (67.5–78.1) National retention prevalence for adults ≥15 years old: a75%, b81% and c73%. Source: UNAIDS/WHO Global AIDS Monitoring tool. d Prevalence of viral load suppression assessed from participants in the survey. e Prevalence of viral load suppression extrapolated to the 12-month cohort that initiated treatment together with the individuals participating in the survey: adjusting for loss to follow-up and accounting for deaths and transfers out. 43HIV DRUG RESISTANCE REPORT 2019 Table 3.2d. Prevalence of viral load suppression for individuals on ART, early time point (12 months), ADR surveys – Western Pacific Viet Nama (12±3 months) n Prevalence % (95% CI) Cut-off viral load <1000 copies/mL Viral load suppression among individuals on ART (on treatment analysis)b 411/429 95.5 (91.3–97.8) Viral load suppression among individuals on ART (intention-to-treat analysis)c 411/429 84.0 (78.4–88.4) Viral load suppression among individuals on first-line ART 407/423 96.0 (91.7–98.1) Viral load suppression among individuals on first-line NNRTI-based ART 407/423 96.0 (91.7–98.1) Viral load suppression among individuals on TDF-based first-line NNRTI-based ART 404/421 95.7 (91.4–97.9) Viral load suppression among individuals on AZT-based first-line NNRTI-based ART 6/7 87.7 (42.3–98.6) Viral load suppression among individuals on PI-based second-line ART 4/6 69.0 (30.8–91.7) Viral load suppression among women on ART 133/139 94.2 (83.7–98.1) Viral load suppression among men on ART 278/290 96.2 (92.9–98.0) Cut-off viral load <400 copies/mL Viral load suppression among individuals on ART 406/429 94.0 (89.4–96.5) Viral load suppression among individuals on first-line ART 402/423 94.3 (89.7–96.9) Viral load suppression among individuals on first-line NNRTI-based ART 402/423 94.3 (89.7–96.9) Viral load suppression among individuals on TDF-based first-line NNRTI-based ART 399/421 94.0 (89.4–96.6) Viral load suppression among individuals on AZT-based first-line NNRTI-based ART 6/7 87.7 (42.3–98.6) Viral load suppression among individuals on PI-based second-line ART 4/6 69.0 (30.8–91.7) Viral load suppression among women on ART 130/139 91.0 (81.1–95.9) Viral load suppression among men on ART 276/290 95.2 (91.6–97.3) Cut-off viral load <50 copies/mL Viral load suppression among individuals on ART 369/429 84.6 (78.7–89.1) Viral load suppression among individuals on first-line ART 366/423 85.1 (78.8–90.0) Viral load suppression among individuals on first-line NNRTI-based ART 366/423 85.1 (78.8–90.0) Viral load suppression among individuals on TDF-based first-line NNRTI-based ART 363/421 84.7 (78.5–89.4) Viral load suppression among individuals on AZT-based first-line NNRTI-based ART 5/7 74.2 (38.3–93.0) Viral load suppression among individuals on PI-based second-line ART 3/6 53.0 (27.6–76.9) Viral load suppression among women on ART 120/139 85.5 (75.6–91.7) Viral load suppression among men on ART 249/290 84.2 (73.3–91.1) a National retention prevalence 89% (95% CI: 85–92%) estimated from sites participating in the survey. b Prevalence of viral load suppression assessed from participants in the survey. c Prevalence of viral load suppression extrapolated to the 12-month cohort that initiated treatment together with the individuals participating in the survey: adjusting for loss to follow-up and accounting for deaths and transfers out. HIV DRUG RESISTANCE REPORT 201944 Table 3.2e. Prevalence of viral load suppression for individuals on ART, late time point (≥48 months), national ADR surveys – Africa Cameroon (48–60 months) Eswatinia (≥48 months) Senegal (≥40 months) n/N Prevalence % (95% CI) n/N Prevalence % (95% CI) n/N Prevalence % (95% CI) Cut-off viral load <1000 copies/mL Viral load suppression among individuals on ART 267/388 67.8 (55.8–77.7) 468/500 93.7 (90.4–95.9) 270/315 88.1 (81.2–92.7) Viral load suppression among individuals on first-line ART 255/364 68.7 (56.0–79.1) 443/468 94.7 (91.3–96.8) 267/311 88.2 (81.2–92.8) Viral load suppression among individuals on first-line NNRTI-based ART 255/364 68.7 (56.0–79.1) 441/464 95.1 (91.6–97.2) 267/311 88.2 (81.2–92.8) Viral load suppression among individuals on TDF-based first-line NNRTI-based ART 210/287 70.8 (57.4–81.4) 164/171 96.0 (90.6–98.3) 206/236 88.5 (80.6–93.5) Viral load suppression among individuals on AZT-based first-line NNRTI-based ART 45/77 60.6 (42.7–76.1) 217/228 95.1 (90.6–97.5) 61/75 87.1 (73.6–94.2) Viral load suppression among individuals on PI-based second-line ART 12/24 51.1 (34.6–67.5) 25/32 78.8 (62.1–89.4) 2/3 83.2 (32.4–98.1) Viral load suppression among women on ART 202/287 69.4 (57.2–79.3) 339/359 94.1 (89.6–96.7) 208/239 89.3 (81.9–93.8) Viral load suppression among men on ART 65/101 62.7 (41.8–79.7) 129/141 92.6 (86.9–96.0) 62/76 84.4 (69.7–92.8) a Viral suppression defined as viral load ≤2005 copies/mL based on DBS, lower limit of detection by the Roche free viral elution platform. 45HIV DRUG RESISTANCE REPORT 2019 Table 3.2f. Prevalence of viral load suppression for individuals on ART, late time point (≥48 months), national ADR surveys – Africa Uganda (≥48 months) n/N Prevalence % (95% CI) Cut-off viral load <1000 copies/mL Viral load suppression among individuals on ART 923/1062 88.0 (84.6–90.7) Viral load suppression among individuals on first-line ART 923/1062 88.0 (84.6–90.7) Viral load suppression among individuals on first-line NNRTI-based ART 922/1061 88.0 (84.6–90.7) Viral load suppression among individuals on TDF-based first-line NNRTI-based ART 328/366 90.7 (84.9–94.4) Viral load suppression among individuals on AZT-based first-line NNRTI-based ART 591/692 86.6 (82.4–89.9) Viral load suppression among individuals on PI-based second-line ART 0/0 0 Viral load suppression among women on ART 606/693 88.3 (85.2–90.8) Viral load suppression among men on ART 317/369 87.4 (81.6–91.6) HIV DRUG RESISTANCE REPORT 201946 Table 3.2g. Prevalence of viral load suppression for individuals on ART, late time point (≥48 months), national ADR surveys – the Americas Guatemala (≥48 months) Honduras (≥48 months) Nicaragua (≥48 months) n/N Prevalence % (95% CI) n/N Prevalence % (95% CI) n/N Prevalence % (95% CI) Viral load <1000 copies/mL Viral load suppression among individuals on ART 328/377 86.9 (70.4–94.8) 246/367 67.9 (61.7–73.6) 240/353 70.3 (66.7–73.8) Viral load suppression among individuals on first-line ART 308/350 87.9 (71.5–95.4) 203/298 68.9 (61.7–75.3) 208/303 70.9 (66.8–74.6) Viral load suppression among individuals on first-line NNRTI-based ART 286/323 88.4 (71.8–95.8) 198/290 69.2 (61.8–75.7) 182/264 70.3 (65.7–74.4) Viral load suppression among individuals on TDF- based first-line NNRTI-based ART 188/212 88.6 (72.8–95.7) 38/60 64.6 (54.0–73.9) 77/113 70.4 (64.8–75.6) Viral load suppression among individuals on AZT- based first-line NNRTI-based ART 72/84 85.5 (59.2–96.0) 161/227 71.9 (63.2–79.2) 112/159 71.9 (65.8–77.3) Viral load suppression among individuals on PI-based second-line ART 20/27 74.1 (54.0–87.4) 41/62 66.5 (54.4–76.8) 31/49 65.3 (53.9–75.2) Viral load suppression among women on ART 137/161 85.0 (67.2–94.0) 141/212 69.4 (61.3–76.5) 92/134 72.5 (65.2–78.8) Viral load suppression among men on ART 189/214 88.2 (71.8–95.7) 105/154 66.1 (54.9–75.7) 148/219 68.7 (62.2–74.5) Viral load <400 copies/mL Viral load suppression among individuals on ART 323/377 85.6 (69.5–93.9) 233/367 63.9 (57.1–70.1) 229/353 66.9 (61.7–71.8) Viral load suppression among individuals on first-line ART 304/350 86.7 (70.9–94.6) 194/298 65.0 (57.4–72.0) 199/303 67.8 (62.6–72.4) Viral load suppression among individuals on first-line NNRTI-based ART 283/323 87.5 (70.7–95.3) 189/290 65.2 (57.4–72.3) 174/264 66.9 (61.3–72.1) Viral load suppression among individuals on TDF- based first-line NNRTI-based ART 185/212 87.1 (70.7–95.0) 38/60 64.6 (54.0–73.9) 75/113 69.1 (61.0–76.2) Viral load suppression among individuals on AZT- based first-line NNRTI-based ART 72/84 85.5 (59.2–96.0) 152/227 67.1 (57.9–75.1) 106/159 67.4 (60.4–73.6) Viral load suppression among individuals on PI-based second-line ART 19/27 70.4 (51.2–84.3) 37/62 60.8 (47.8–72.4) 29/49 60.6 (44.9–74.3) Viral load suppression among women on ART 134/161 83.1 (67.0–92.2) 133/212 64.1 (55.0–72.3) 89/134 69.1 (60.0–77.0) Viral load suppression among men on ART 187/214 87.3 (69.6–95.4) 100/154 63.8 (53.8–72.8) 140/219 65.2 (59.4–70.7) Viral load <50 copies/mL Viral load suppression among individuals on ART 301/377 79.7 (61.4–90.7) 204/367 57.6 (50.9–64.0) 180/353 52.2 (46.9–57.5) Viral load suppression among individuals on first-line ART 286/350 81.6 (63.3–91.9) 174/298 59.5 (51.9–66.7) 158/303 53.6 (48.3–58.9) Viral load suppression among individuals on first-line NNRTI-based ART 266/323 82.2 (63.1–92.6) 170/290 59.8 (52.0–67.1) 139/264 53.8 (48.2–59.4) Viral load suppression among individuals on TDF- based first-line NNRTI-based ART 174/212 82.0 (64.0–92.1) 34/60 58.6 (47.7–68.7) 63/113 59.2 (50.6–67.3) Viral load suppression among individuals on AZT- based first-line NNRTI-based ART 68/84 80.8 (52.8–94.0) 139/227 62.3 (53.2–70.6) 81/159 52.1 (44.7–59.4) Viral load suppression among individuals on PI-based second-line ART 15/27 55.6 (30.0–78.5) 29/62 49.7 (35.3–64.2) 21/49 41.0 (26.0–57.8) Viral load suppression among women on ART 125/161 77.5 (59.4–89.0) 121/212 60.2 (51.2–68.6) 69/134 52.7 (43.1–62.0) Viral load suppression among men on ART 174/214 81.2 (61.7–92.1) 83/154 54.0 (44.2–63.5) 111/219 51.9 (45.8–57.9) 47HIV DRUG RESISTANCE REPORT 2019 Table 3.2h. Prevalence of viral load suppression for individuals on ART, late time point (≥48 months), national ADR surveys – Western Pacific Viet Nam (≥48 months) n Prevalence % (95% CI) Viral load <1000 copies/mL Viral load suppression among individuals on ART 691/723 96.1 (93.2–97.8) Viral load suppression among individuals on first-line ART 658/688 96.2 (93.6–97.8) Viral load suppression among individuals on first-line NNRTI-based ART 632/658 96.4 (93.6–98.0) Viral load suppression among individuals on TDF-based first-line NNRTI-based ART 431/443 97.7 (94.8–99.0) Viral load suppression among individuals on AZT-based first-line NNRTI-based ART 213/228 93.2 (87.9–96.3) Viral load suppression among individuals on PI-based second-line ART 33/35 94.6 (69.6–99.3) Viral load suppression among women on ART 257/267 96.8 (94.0–98.3) Viral load suppression among men on ART 434/456 95.7 (91.9–97.7) Viral load <400 copies/mL Viral load suppression among individuals on ART 688/723 95.7 (93.0–97.4) Viral load suppression among individuals on first-line ART 535/562 95.9 (93.6–97.4) Viral load suppression among individuals on first-line NNRTI-based ART 509/532 96.1 (93.6–97.7) Viral load suppression among individuals on TDF-based first-line NNRTI-based ART 428/443 97.1 (94.5–98.5) Viral load suppression among individuals on AZT-based first-line NNRTI-based ART 213/228 93.2 (87.9–96.3) Viral load suppression among individuals on PI-based second-line ART 33/35 94.6 (69.6–99.3) Viral load suppression among women on ART 256/267 96.6 (93.8–98.1) Viral load suppression among men on ART 432/456 95.2 (91.6–97.3) Viral load <50 copies/mL Viral load suppression among individuals on ART 646/723 89.8 (86.1–92.7) Viral load suppression among individuals on first-line ART 504/562 90.4 (86.0–93.6) Viral load suppression among individuals on first-line NNRTI-based ART 482/532 90.9 (86.3–94.1) Viral load suppression among individuals on TDF-based first-line NNRTI-based ART 409/443 92.5 (88.3–95.3) Viral load suppression among individuals on AZT-based first-line NNRTI-based ART 197/228 86.1 (79.1–91.0) Viral load suppression among individuals on PI-based second-line ART 28/35 80.8 (57.7–92.9) Viral load suppression among women on ART 242/267 91.0 (86.2–94.3) Viral load suppression among men on ART 404/456 89.1 (84.3–92.6) HIV DRUG RESISTANCE REPORT 201948 Table 3.3a. Prevalence of ADR among individuals on ART, early time point (12 months), national ADR surveys – Africa Cameroon (12–24 months) Eswatinia (12±3 months) Senegal (12±3 months) n/N Prevalence % (95% CI) n/N Prevalence % (95% CI) n/N Prevalence % (95% CI) HIVDR among individuals on ART Any 111/960 17.1 (14.0–20.7) 18/366 4.7 (2.5–8.6) 15/238 7.0 (3.9–12.4) NNRTI 109/960 16.7 (13.7–20.2) 17/366 4.5 (2.4–8.1) 15/238 7.0 (3.9–12.4) NRTI 97/960 14.7 (11.3–18.9) 18/366 4.7 (2.5–8.6) 8/238 2.4 (1.0–5.3) PI 1/960 0.3 (0.0–2.2) 0/366 0 0/238 0 NNRTI+NRTI 96/960 14.6 (11.3–18.7) 17/366 4.5 (2.4–8.1) 8/238 2.4 (1.0–5.3) HIVDR among individuals on ART with viral load ≥1000 copies/mL Any 111/164 61.1 (50.3–70.9) 18/26 51.8 (26.8–76.0) 15/27 62.5 (40.8–80.1) NNRTI 109/164 59.7 (49.3–69.4) 17/26 49.7 (26.4–73.2) 15/27 62.5 (40.8–80.1) NRTI 97/164 52.6 (41.2–63.7) 18/26 51.8 (26.8–76.0) 8/27 21.0 (6.9–49.1) PI 1/164 1.1 (0.1–7.5) 0/26 0 0/27 0 NNRTI+NRTI 96/164 52.3 (41.1–63.2) 17/26 49.7 (26.4–73.2) 8/27 21.0 (6.9–49.1) HIVDR among individuals on first-line ART with viral load ≥1000 copies/mL Any 110/162 61.2 (50.3–71.0) 17/25 50.8 (26.2–75.0) 15/27 62.5 (40.8–80.1) NNRTI 108/162 59.8 (49.3–69.5) 17/25 50.8 (26.2–75.0) 15/27 62.5 (40.8–80.1) NRTI 96/162 52.6 (41.2–63.7) 17/25 50.8 (26.2–75.0) 8/27 21.0 (6.9–49.1) PI 1/162 1.1 (0.1–7.5) 0/25 0 0/27 0 NNRTI+NRTI 95/162 52.3 (41.0–63.3) 17/25 50.8 (26.2–75.0) 8/27 21.0 (6.9–49.1) HIVDR among individuals on first-line NNRTI ART with viral load ≥1000 copies/mL Any 109/161 61.1 (50.2–70.9) 17/24 52.7 (2.71–76.9) 15/27 62.5 (40.8–80.1) NNRTI 107/161 59.7 (49.2–69.4) 17/24 52.7 (2.71–76.9) 15/27 62.5 (40.8–80.1) NRTI 95/161 52.5 (41.1–63.6) 17/24 52.7 (2.71–76.9) 8/27 21.0 (6.9–49.1) PI 1/161 1.1 (0.1–7.6) 0/24 0 0/27 0 NNRTI+NRTI 94/161 52.2 (40.9–63.2) 17/24 52.7 (2.71–76.9) 8/27 21.0 (6.9–49.1) HIVDR among individuals on first-line NNRTI and TDF-based ART with viral load ≥1000 copies/mL TDF resistance 42/115 28.8 (18.5–42.0) 15/24 48.9 (25.5–72.7) 7/26 19.1 (5.6–48.6) FTC or 3TC resistance 61/115 45.2 (34.1–56.8) 17/24 52.7 (27.3–76.7) 8/26 21.5 (6.9–50.5) TDF + XTC resistance 42/115 28.8 (18.5–42.0) 15/24 48.9 (25.5–72.7) 7/26 19.1 (5.6–48.6) TDF + XTC + AZT resistance 6/115 3.0 (1.1–8.1) 1/24 2.2 (0.3–15.4) 0/26 0 HIVDR among individuals on first-line NNRTI and AZT-based ART with viral load ≥1000 copies/mL AZT resistance 12/45 22.5 (13.6–34.7) NA NA NA NA FTC or 3TC resistance 32/45 68.4 (51.2–81.7) NA NA NA NA AZT + XTC resistance 12/45 22.5 (13.6–34.7) NA NA NA NA AZT + XTC + TDF resistance 11/45 21.0 (12.6–32.9) NA NA NA NA a Failure to suppress viral loads defined as ≥2005 copies/mL instead of ≥1000 copies/mL. This is due to the use of DBS with the Roche free viral elution platform, which has a limit of detection of 2005 copies/mL. Weight trimming approach used to adjust for excessively large sampling variances in the estimation of ADR prevalence. NNRTI resistance is defined as resistance to nevirapine (NVP) or efavirenz (EFV). NRTI resistance is defined as resistance to any NRTI, and any PI resistance is defined as resistance to atazanavir/ritonavir (ATV/r), lopinavir/ritonavir (LPV/r), or darunavir/ritonavir (DRV/r). Any HIVDR is defined as resistance to NVP/EFV, any NRTI, ATV/r, LPV/r or DRV/r. HIVDR is determined using the Stanford HIVdb algorithm: sequences classified as having low-, intermediate- or high-level resistance are considered resistant. 49HIV DRUG RESISTANCE REPORT 2019 Table 3.3b. Prevalence of ADR among individuals on ART, early time point (12 months), national ADR surveys – Africa Uganda (12±3 months) Zambiaa (12±3 months) n/N Prevalence % (95% CI) n/N Prevalence % (95% CI) HIVDR among individuals on ART Any 27/523 4.5 (3.6–5.6) 18/433 2.8 (0.8–9.4) NNRTI 27/523 4.5 (3.6–5.6) 18/433 2.8 (0.8–9.4) NRTI 23/523 4.2 (3.3–5.4) 17/433 2.6 (0.7–9.1) PI 0/523 0 0/433 0 NNRTI+NRTI 23/523 4.2 (3.3–5.4) 17/433 2.6 (0.7–9.1) HIVDR among individuals on ART with viral load ≥1000 copies/mL Any 27/30 96.6 (83.9–99.4) 18/24 75.8 (39.9–93.6) NNRTI 27/30 96.6 (83.9–99.4) 18/24 75.8 (39.9–93.6) NRTI 23/30 91.3 (65.0–98.3) 17/24 72.7 (39.3–91.6) PI 0/30 0 0/24 0 NNRTI+NRTI 23/30 91.3 (65.0–98.3) 17/24 72.7 (39.3–91.6) HIVDR among individuals on first-line ART with viral load ≥1000 copies/mL Any 27/30 96.6 (83.9–99.4) 18/24 75.8 (39.9–93.6) NNRTI 27/30 96.6 (83.9–99.4) 18/24 75.8 (39.9–93.6) NRTI 23/30 91.3 (65.0–98.3) 17/24 72.7 (39.3–91.6) PI 0/30 0 0/24 0 NNRTI+NRTI 23/30 91.3 (65.0–98.3) 17/24 72.7 (39.3–91.6) HIVDR among individuals on first-line NNRTI ART with viral load ≥1000 copies/mL Any 27/30 96.6 (83.9–99.4) 18/24 75.8 (39.9–93.6) NNRTI 27/30 96.6 (83.9–99.4) 18/24 75.8 (39.9–93.6) NRTI 23/30 91.3 (65.0–98.3) 17/24 72.7 (39.3–91.6) PI 0/30 0 0/24 0 NNRTI+NRTI 23/30 91.3 (65.0–98.3) 17/24 72.7 (39.3–91.6) HIVDR among individuals on first-line NNRTI and TDF-based ART with viral load ≥1000 copies/mL TDF resistance 14/30 84.1 (51.2–96.4) 13/24 54.2 (35.1-72.1) FTC/3TC resistance 23/30 91.3 (65.0–98.3) 16/24 66.7 (46.7-82.0) TDF+XTC resistance 14/30 84.1 (51.2–96.4) 12/24 50.0 (31.4-68.6) TDF+XTC+AZT resistance 5/30 15.6 (3.0–52.2) 0/24 0 HIVDR among individuals on first-line NNRTI and AZT-based ART with viral load ≥1000 copies/mL AZT resistance 1/3 16.8 (1.0–80.6) NA NA FTC or 3TC resistance 3/3 100 NA NA AZT + XTC resistance 1/3 16.8 (1.0–80.6) NA NA AZT + XTC + TDF resistance 1/3 16.8 (1.0–80.6) NA NA a Updated analysis from the 2017 HIVDR report using adjusted weights (weight trimming to adjust for excessively large sampling variances) NNRTI resistance is defined as resistance to nevirapine (NVP) or efavirenz (EFV). NRTI resistance is defined as resistance to any NRTI, and any PI resistance is defined as resistance to atazanavir/ritonavir (ATV/r), lopinavir/ritonavir (LPV/r), or darunavir/ritonavir (DRV/r). Any HIVDR is defined as resistance to NVP/EFV, any NRTI, ATV/r, LPV/r or DRV/r. HIVDR is determined using the Stanford HIVdb algorithm: sequences classified as having low-, intermediate- or high-level resistance are considered resistant. HIV DRUG RESISTANCE REPORT 201950 Table 3.3c. Prevalence of ADR among individuals on ART, early time point (12 months), national ADR surveys – the Americas Guatemala (12±3 months) Honduras (12±3 months) Nicaragua (12±3 months) n/N Prevalence % (95% CI) n/N Prevalence % (95% CI) n/N Prevalence % (95% CI) HIVDR among individuals on ART Any 16/216 9.5 (4.1–20.2) 14/166 7.6 (5.0–11.5) 22/113 18.3 (10.7–29.4) NNRTI 15/216 8.6 (4.1–17.1) 14/166 7.6 (5.0–11.5) 21/113 17.7 (10.2–28.9) NRTI 11/216 6.8 (2.6–16.7) 10/166 5.9 (3.5–9.9) 17/113 15.1 (8.0–26.7) PI 0/216 0 1/166 0.3 (0.2–0.6) 0/113 0 NNRTI+NRTI 10/216 5.9 (2.6–12.8) 10/166 5.9 (3.5–9.9) 16/113 14.5 (7.5–26.3) HIVDR among individuals on ART with viral load ≥1000 copies/mL Any 16/19 84.0 (57.4–95.3) 14/16 86.1 (48.9–97.6) 22/27 85.1 (66.1–94.4) NNRTI 15/19 76.0 (51.2–90.5) 14/16 86.1 (48.9–97.6) 21/27 82.4 (60.7–93.4) NRTI 11/19 60.0 (33.5–81.7) 10/16 67.1 (37.4–87.5) 17/27 70.2 (43.6–87.8) PI 0/19 0 1/16 3.8 (0.5–25.2) 0/27 0 NNRTI+NRTI 10/19 52.0 (32.9–70.5) 10/16 67.1 (37.4–87.5) 16/27 65.7 (40.0–86.6) HIVDR among individuals on first-line ART with viral load ≥1000 copies/mL Any 16/19 84.0 (57.4–95.3) 14/16 86.1 (48.9–97.6) 22/27 85.1 (66.1–94.4) NNRTI 15/19 76.0 (51.2–90.5) 14/16 86.1 (48.9–97.6) 21/27 82.4 (60.7–93.4) NRTI 11/19 60.0 (33.5–81.7) 10/16 67.1 (37.4–87.5) 17/27 70.2 (43.6–87.8) PI 0/19 0 1/16 3.8 (0.5–25.2) 0/27 0 NNRTI+NRTI 10/19 52.0 (32.9–70.5) 10/16 67.1 (37.4–87.5) 16/27 65.7 (40.0–86.6) HIVDR among individuals on first-line NNRTI ART with viral load ≥1000 copies/mL Any 15/17 88.9 (58.4–97.9) 14/16 86.1 (48.9–97.6) 21/25 84.9 (65.4–94.4) NNRTI 14/17 80.0 (51.0–93.9) 14/16 86.1 (48.9–97.6) 20/25 81.3 (58.2–93.2) NRTI 10/17 62.2 (37.5–81.9) 10/16 67.1 (37.4–87.5) 16/25 65.3 (42.2–82.9) PI 0/17 0 1/16 3.8 (0.5–25.2) 0/25 0 NNRTI+NRTI 9/17 53.3 (37.5–68.5) 10/16 67.1 (37.4–87.5) 15/25 61.7 (38.0–80.9) HIVDR among individuals on first-line NNRTI and TDF-based ART with viral load ≥1000 copies/mL TDF resistance 5/15 42.1 (18.3–70.3) 5/14 42.8 (15.1–75.8) 4/23 16.4 (4.7–44.2) FTC or 3TC resistance 8/15 57.9 (31.1–80.7) 9/14 72.8 (41.9–90.9) 13/23 56.2 (31.0–78.5) TDF + XTC resistance 5/15 42.1 (18.3–70.3) 5/14 42.8 (15.1–75.8) 4/23 16.4 (4.7–44.2) TDF + XTC + AZT resistance 0/15 0 3/14 21.5 (4.8–59.8) 1/23 4.1 (0.6–24.5) HIVDR among individuals on first-line NNRTI and AZT-based ART with viral load ≥1000 copies/mL AZT resistance 0/2 0 0/2 0 1/2 73.0 (0.0–100) FTC or 3TC resistance 1/2 57.1 (17.4–89.4) 0/2 0 1/2 73.0 (0.0–100) AZT + XTC resistance 0/2 0 0/2 0 1/2 73.0 (0.0–100) AZT + XTC + TDF resistance 0/2 0 0/2 0 1/2 73.0 (0.0–100) NNRTI resistance is defined as resistance to nevirapine (NVP) or efavirenz (EFV). NRTI resistance is defined as resistance to any NRTI, and any PI resistance is defined as resistance to atazanavir/ritonavir (ATV/r), lopinavir/ritonavir (LPV/r), or darunavir/ritonavir (DRV/r). Any HIVDR is defined as resistance to NVP/EFV, any NRTI, ATV/r, LPV/r or DRV/r. HIVDR is determined using the Stanford HIVdb algorithm: sequences classified as having low-, intermediate- or high-level resistance are considered resistant. 51HIV DRUG RESISTANCE REPORT 2019 Table 3.3d. Prevalence of ADR among individuals on ART, early time point (12 months), national ADR surveys – Western Pacific Viet Nam (2017) (12±3 months) n/N Prevalence % (95% CI) HIVDR among individuals on ART Any 11/425 3.0 (1.6–5.7) NNRTI 11/425 3.0 (1.6–5.7) NRTI 9/425 2.1 (1.0–4.2) PI 0/424 0 NNRTI+NRTI 9/425 2.1 (1.0–4.2) HIVDR among individuals on ART with viral load ≥1000 copies/mL Any 11/14 74.3 (42.8–91.8) NNRTI 11/14 74.3 (42.8–91.8) NRTI 9/14 50.5 (13.1–87.4) PI 0/14 0 NNRTI+NRTI 9/14 50.5 (13.1–87.4) HIVDR among individuals on first-line ART with viral load ≥1000 copies/mL Any 9/12 70.7 (39.1–90.0) NNRTI 9/12 70.7 (39.1–90.0) NRTI 8/12 51.1 (10.1–90.6) PI 0/11 0 NNRTI+NRTI 8/12 51.1 (10.1–90.6) HIVDR among individuals on first-line NNRTI ART with viral load ≥1000 copies/mL Any 9/12 70.7 (39.1–90.0) NNRTI 9/12 70.7 (39.1–90.0) NRTI 8/12 51.1 (10.1–90.6) PI 0/11 0 NNRTI+NRTI 8/12 51.1 (10.1–90.6) HIVDR among individuals on first-line NNRTI and TDF-based ART with viral load ≥1000 copies/mL TDF resistance 4/13 26.5 (4.8–72.2) FTC or 3TC resistance 8/13 47.5 (11.4–86.4) TDF + XTC resistance 4/13 26.5 (4.8–72.2) TDF + XTC + AZT resistance 0/13 0 HIVDR among individuals on first-line NNRTI and AZT-based ART with viral load ≥1000 copies/mL AZT resistance NA NA FTC or 3TC resistance NA NA AZT + XTC resistance NA NA AZT + XTC + TDF resistance NA NA NNRTI resistance is defined as resistance to nevirapine (NVP) or efavirenz (EFV). NRTI resistance is defined as resistance to any NRTI, and any PI resistance is defined as resistance to atazanavir/ritonavir (ATV/r), lopinavir/ritonavir (LPV/r), or darunavir/ritonavir (DRV/r). Any HIVDR is defined as resistance to NVP/EFV, any NRTI, ATV/r, LPV/r or DRV/r. HIVDR is determined using the Stanford HIVdb algorithm: sequences classified as having low-, intermediate- or high-level resistance are considered resistant. HIV DRUG RESISTANCE REPORT 201952 Table 3.3e. Prevalence of ADR among individuals on ART, late time point (≥48 months), national ADR surveys – Africa Cameroon (48–60 months) Eswatini (≥48 months) n/N Prevalence % (95% CI) n/N Prevalence % (95% CI) HIVDR among individuals on ART Any 59/334 28.3 (17.4–42.5) 15/488 4.9 (2.7–8.7) NNRTI 59/334 28.3 (17.4–42.5) 13/488 4.5 (2.3–8.4) NRTI 53/334 25.2 (14.0–40.9) 14/488 4.6 (2.4–8.5) PI 1/334 0.3 (0.0–3.7) 1/488 0.2 (0.0–1.2) NNRTI+NRTI 53/334 25.2 (14.0–40.9) 12/488 4.2 (2.1–8.2) HIVDR among individuals on ART with viral load ≥1000 copies/mL Any 59/67 87.7 (67.4–96.1) 15/20 79.0 (44.7–94.6) NNRTI 59/67 87.7 (67.4–96.1) 13/20 72.9 (41.6–91.1) NRTI 53/67 77.9 (50.2–92.5) 14/20 75.0 (40.2–93.1) PI 1/67 0.8 (0.1–9.4) 1/20 2.6 (0.3–20.6) NNRTI+NRTI 53/67 77.9 (50.2–92.5) 12/20 69.0 (36.9–89.5) HIVDR among individuals on first-line ART with viral load ≥1000 copies/mL Any 57/63 89.5 (71.0–96.7) 12/13 91.4 (48.0–99.2) NNRTI 57/63 89.5 (71.0–96.7) 12/13 91.4 (48.0–99.2) NRTI 51/63 79.3 (50.4–93.5) 11/13 85.7 (47.8–97.5) PI 1/63 0.8 (0.1–10.1) 0/13 0 NNRTI+NRTI 51/63 79.3 (50.4–93.5) 11/13 85.7 (47.8–97.5) HIVDR among individuals on first-line NNRTI ART with viral load ≥1000 copies/mL Any 57/63 89.5 (71.0–96.7) 11/12 90.6 (45.2–99.1) NNRTI 57/63 89.5 (71.0–96.7) 11/12 90.6 (45.2–99.1) NRTI 51/63 79.3 (50.4–93.5) 10/12 84.5 (44.6–97.4) PI 1/63 0.8 (0.1–10.1) 0/12 0 NNRTI+NRTI 51/63 79.3 (50.4–93.5) 10/12 84.5 (44.6–97.4) HIVDR among individuals on first-line NNRTI and TDF-based ART with viral load ≥1000 copies/mL TDF resistance 22/43 51.8 (25.9–76.8) 1/3 28.9 (2.5–86.4) FTC or 3TC resistance 33/43 77.4 (44.1–93.7) 1/3 28.9 (2.5–86.4) TDF + XTC resistance 22/43 51.8 (25.9–76.8) 1/3 28.9 (2.5–86.4) TDF + XTC + AZT resistance 7/43 21.3 (7.0–49.4) 0/3 0 HIVDR among individuals on first-line NNRTI and AZT-based ART with viral load ≥1000 copies/mL AZT resistance 10/20 50.1 (25.2–75.0) 2/5 29.7 (6.4–72.3) FTC or 3TC resistance 18/20 86.7 (50.1–97.7) 5/5 100.0 AZT + XTC resistance 10/20 50.1 (25.2–75.0) 2/5 29.7 (6.4–72.3) AZT + XTC + TDF resistance 10/20 50.1 (25.2–75.0) 2/5 29.7 (6.4–72.3) NNRTI resistance is defined as resistance to nevirapine (NVP) or efavirenz (EFV). NRTI resistance is defined as resistance to any NRTI, and any PI resistance is defined as resistance to atazanavir/ritonavir (ATV/r), lopinavir/ritonavir (LPV/r), or darunavir/ritonavir (DRV/r). Any HIVDR is defined as resistance to NVP/EFV, any NRTI, ATV/r, LPV/r or DRV/r. HIVDR is determined using the Stanford HIVdb algorithm: sequences classified as having low-, intermediate- or high-level resistance are considered resistant. 53HIV DRUG RESISTANCE REPORT 2019 Table 3.3f. Prevalence of ADR among individuals on ART, late time point (≥48 months), national ADR surveys – Africa Senegal (≥40 months) Uganda (≥48 months) n/N n/N Prevalence % (95% CI) n/N Prevalence % (95% CI) HIVDR among individuals on ART Any 28/302 9.6 (5.3–16.8) 87/1016 7.6 (5.9–9.7) NNRTI 28/302 9.6 (5.3–16.8) 85/1016 7.3 (5.5–9.6) NRTI 16/302 5.9 (2.9–11.1) 83/1016 7.2 (5.5–9.2) PI NA NA NA NA NNRTI+NRTI 16/302 5.9 (2.9–11.1) 81/1016 6.9 (5.2–9.1) HIVDR among individuals on ART with viral load ≥1000 copies/mL Any 28/32 92.1 (63.5–98.7) 87/93 92.2 (76.5–97.7) NNRTI 28/32 92.1 (63.5–98.7) 85/93 89.1 (73.4–96.0) NRTI 16/32 56.8 (30.0–80.1) 83/93 87.4 (73.6–94.5) PI NA NA NA NA NNRTI+NRTI 16/32 56.8 (30.0–80.1) 81/93 84.3 (70.4–92.4) HIVDR among individuals on first-line ART with viral load ≥1000 copies/mL Any 28/32 92.1 (63.5–98.7) 87/93 92.2 (76.5–97.7) NNRTI 28/32 92.1 (63.5–98.7) 85/93 89.1 (73.4–96.0) NRTI 16/32 56.8 (30.0–80.1) 83/93 87.4 (73.6–94.5) PI NA NA – – NNRTI+NRTI 16/32 56.8 (30.0–80.1) 81/93 84.3 (70.4–92.4) HIVDR among individuals on first-line NNRTI ART with viral load ≥1000 copies/mL Any 28/32 92.1 (63.5–98.7) 87/93 92.2 (76.5–97.7) NNRTI 28/32 92.1 (63.5–98.7) 85/93 89.1 (73.4–96.0) NRTI 16/32 56.8 (30.0–80.1) 83/93 87.4 (73.6–94.5) PI NA NA NA NA NNRTI+NRTI 16/32 56.8 (30.0–80.1) 81/93 84.3 (70.4–92.4) HIVDR among individuals on first-line NNRTI and TDF-based ART with viral load ≥1000 copies/mL TDF resistance 3/22 12.6 (4.0–33.0) 14/21 60.8 (31.4–84.0) FTC or 3TC resistance 8/22 38.3 (18.4–63.2) 16/21 68.5 (30.0–91.7) TDF + XTC resistance 3/22 12.6 (4.0–33.0) 14/21 60.8 (31.4–84.0) TDF + XTC + AZT resistance 1/22 8.0 (1.4–35.3) 3/21 12.6 (2.7–43.2) HIVDR among individuals on first-line NNRTI and AZT-based ART with viral load ≥1000 copies/mL AZT resistance 5/10 69.4 (23.5–94.4) 37/72 55.0 (42.2–67.1) FTC or 3TC resistance 7/10 83.2 (36.9–97.7) 66/72 89.8 (74.6–96.3) AZT + XTC resistance 4/10 63.6 (17.6–93.5) 36/72 51.8 (37.8–65.5) AZT + XTC + TDF resistance 2/10 11.9 (1.5–53.9) 26/72 40.0 (24.3–57.9) NNRTI resistance is defined as resistance to nevirapine (NVP) or efavirenz (EFV). NRTI resistance is defined as resistance to any NRTI, and any PI resistance is defined as resistance to atazanavir/ritonavir (ATV/r), lopinavir/ritonavir (LPV/r), or darunavir/ritonavir (DRV/r). Any HIVDR is defined as resistance to NVP/EFV, any NRTI, ATV/r, LPV/r or DRV/r. HIVDR is determined using the Stanford HIVdb algorithm: sequences classified as having low-, intermediate- or high-level resistance are considered resistant. HIV DRUG RESISTANCE REPORT 201954 Table 3.3g. Prevalence of ADR among individuals on ART, late time point (≥48 months), national ADR surveys – the Americas Guatemala (≥48 months) Honduras (≥48 months) Nicaragua (≥48 months) n/N Prevalence % (95% CI) n/N Prevalence % (95% CI) n/N Prevalence % (95% CI) HIVDR among individuals on ART Any 30/368 9.5 (3.0–26.2) 89/349 29.2 (23.3–36.0) 87/350 22.4 (18.5–26.8) NNRTI 29/368 9.2 (2.9–25.6) 86/349 27.3 (21.7–33.7) 82/350 21.0 (17.3–25.1) NRTI 25/368 7.8 (2.5–22.2) 79/349 26.7 (20.9–33.5) 68/350 17.6 (14.4–21.4) PI 1/368 0.3 (0.0–4.1) 3/349 2.3 (0.6–7.9) 6/350 1.4 (0.8–2.3) NNRTI+NRTI 24/368 7.5 (2.4–21.4) 76/349 24.8 (19.3–31.2) 63/350 16.2 (13.2–19.7) HIVDR among individuals on ART with viral load ≥1000 copies/mL Any 30/40 76.5 (55.6–89.4) 89/103 92.0 (86.8–95.3) 87/110 75.5 (63.5–84.5) NNRTI 29/40 74.2 (51.8–88.5) 86/103 86.0 (73.7–93.0) 82/110 70.7 (58.7–80.3) NRTI 25/40 63.0 (43.7–78.9) 79/103 84.1 (76.7–89.5) 68/110 59.4 (48.1–69.8) PI 1/40 2.6 (0.3–21.6) 3/103 7.3 (1.8–25.1) 6/110 4.6 (2.2–9.5) NNRTI+NRTI 24/40 60.7 (42.6–76.2) 76/103 78.1 (66.6–86.5) 63/110 54.6 (43.3–65.4) HIVDR among individuals on first-line ART with viral load ≥1000 copies/mL Any 29/35 83.8 (57.8–95.1) 75/80 96.6 (91.9–98.6) 75/93 77.3 (63.3–87.0) NNRTI 28/35 81.1 (59.3–92.6) 73/80 94.8 (89.1–97.6) 70/93 71.6 (57.7–82.3) NRTI 25/35 71.6 (42.4–89.6) 67/80 88.0 (79.7–93.2) 58/93 59.7 (46.8–71.4) PI 1/35 2.9 (0.3–23.4) 1/80 0.6 (0.1–3.8) 2/93 1.8 (0.5–6.0) NNRTI+NRTI 24/35 68.9 (44.3–86.1) 65/80 86.2 (77.6–91.9) 53/93 54.0 (41.3–66.2) HIVDR among individuals on first-line NNRTI ART with viral load ≥1000 copies/mL Any 27/31 87.3 (67.8–95.7) 74/79 96.6 (91.9–98.6) 69/80 82.4 (66.4–91.8) NNRTI 26/31 84.3 (69.4–92.7) 72/79 94.8 (89.0–97.6) 66/80 78.1 (62.3–88.4) NRTI 24/31 76.9 (47.1–92.5) 67/79 87.9 (79.4–93.1) 53/80 63.8 (49.5–76.0) PI 1/31 3.3 (0.3–26.5) 1/79 0.6 (0.1–3.9) 2/80 1.8 (0.4–7.3) NNRTI+NRTI 23/31 73.9 (49.6–89.0) 65/79 86.1 (77.3–91.8) 50/80 59.4 (45.3–72.2) HIVDR among individuals on first-line NNRTI and TDF-based ART with viral load ≥1000 copies/mL TDF resistance 11/21 48.2 (30.4–66.5) 10/20 53.6 (27.7–77.7) 11/35 33.9 (19.0–52.9) FTC or 3TC resistance 18/21 85.2 (63.2–95.1) 15/20 79.1 (53.8–92.5) 20/35 59.5 (39.6–76.7) TDF + XTC resistance 11/21 48.2 (30.4–66.5) 10/20 53.6 (27.7–77.7) 11/35 33.9 (19.0–52.9) TDF + XTC + AZT resistance 3/21 13.1 (5.0–30.4) 4/20 28.7 (8.4–63.7) 1/35 2.3 (0.4–13.8) HIVDR among individuals on first-line NNRTI and AZT-based ART with viral load ≥1000 copies/mL AZT resistance 4/9 46.0 (24.1–69.6) 30/56 66.2 (49.8–79.4) 8/42 15.9 (6.9–32.5) FTC or 3TC resistance 5/9 57.6 (35.4–77.1) 48/56 89.2 (78.1–95.0) 28/42 57.0 (35.4–76.3) AZT + XTC resistance 3/9 35.5 (16.4–60.7) 30/56 66.2 (49.8–79.4) 7/42 14.3 (5.8–31.2) AZT + XTC + TDF resistance 3/9 35.5 (16.4–60.7) 22/56 55.8 (37.9–72.2) 4/42 8.2 (2.7–22.3) NNRTI resistance is defined as resistance to nevirapine (NVP) or efavirenz (EFV). NRTI resistance is defined as resistance to any NRTI, and any PI resistance is defined as resistance to atazanavir/ritonavir (ATV/r), lopinavir/ritonavir (LPV/r), or darunavir/ritonavir (DRV/r). Any HIVDR is defined as resistance to NVP/EFV, any NRTI, ATV/r, LPV/r or DRV/r. HIVDR is determined using the Stanford HIVdb algorithm: sequences classified as having low-, intermediate- or high-level resistance are considered resistant. 55HIV DRUG RESISTANCE REPORT 2019 Table 3.3h. Prevalence of ADR among individuals on ART, late time point (≥48 months), national ADR surveys – Western Pacific Viet Nam (≥48 months) n/N Prevalence % (95% CI) HIVDR among individuals on ART Any 24/718 3.4 (1.9–6.1) NNRTI 23/718 3.3 (1.8–5.9) NRTI 23/718 3.3 (1.8–5.9) PI 1/716 0.1 (0.0–0.7) NNRTI+NRTI 22/718 3.1 (1.7–5.7) HIVDR among individuals on ART with viral load ≥1000 copies/mL Any 24/27 88.5 (70.7–96.1) NNRTI 23/27 84.3 (66.0–93.7) NRTI 23/27 84.4 (58.6–95.4) PI 1/25 2.5 (0.3–21.1) NNRTI+NRTI 22/27 80.2 (56.0–92.8) HIVDR among individuals on first-line ART with viral load ≥1000 copies/mL Any 22/25 87.6 (67.6–96.0) NNRTI 21/25 83.1 (63.1–93.4) NRTI 21/25 83.2 (55.6–95.2) PI 1/24 2.6 (0.3–21.6) NNRTI+NRTI 20/25 78.7 (53.2–92.3) HIVDR among individuals on first-line NNRTI ART with viral load ≥1000 copies/mL Any 20/22 90.9 (71.2–97.6) NNRTI 19/22 85.9 (66.1–95.0) NRTI 19/22 86.1 (55.0–96.9) PI 0/21 0 NNRTI+NRTI 18/22 81.1 (53.6–94.1) HIVDR among individuals on first-line NNRTI and TDF-based ART with viral load ≥1000 copies/mL TDF resistance 5/9 53.8 (20.4–84.1) FTC or 3TC resistance 7/9 76.1 (28.1–96.3) TDF + XTC resistance 5/9 53.8 (20.4–84.1) TDF + XTC + AZT resistance 0/9 0 HIVDR among individuals on first-line NNRTI and AZT-based ART with viral load ≥1000 copies/mL AZT resistance 7/13 55.8 (24.6–83.1) FTC or 3TC resistance 12/13 92.8 (61.5–99.1) AZT + XTC resistance 7/13 55.8 (24.6–83.1) AZT + XTC + TDF resistance 4/13 23.8 (5.7–61.6) NNRTI resistance is defined as resistance to nevirapine (NVP) or efavirenz (EFV). NRTI resistance is defined as resistance to any NRTI, and any PI resistance is defined as resistance to atazanavir/ritonavir (ATV/r), lopinavir/ritonavir (LPV/r), or darunavir/ritonavir (DRV/r). Any HIVDR is defined as resistance to NVP/EFV, any NRTI, ATV/r, LPV/r or DRV/r. HIVDR is determined using the Stanford HIVdb algorithm: sequences classified as having low-, intermediate- or high-level resistance are considered resistant. 56 HIV DRUG RESISTANCE REPORT 2019 Table. HIV subtype distribution for all sequences from HIVDR surveys conducted between 2014 and 2018 Subtype (%) Country n A B C D F F2 G C RF 01 _A E C RF 02 _A G C RF 06 _c px C RF 11 _c px C RF 12 _B F C RF 18 _c px C RF 20 _B G U RF , o th er Argentina 294 – 49.0 3.7 – 1.7 – – – – – – 22.8 – – 22.8 Brazil 1566 0.1 70.3 13.9 0.2 11.1 – – – 0.3 – – 0.6 – – 3.5 Cameroon 960 9.1 0.4 0.2 1.7 0.1 3.0 5.5 1.0 68.9 0.5 2.4 – 1.1 – 6.0 Colombia 196 – 98.5 – – 0.5 – – – 0.5 – – – – – 0.5 Cuba 141 0.7 35.5 2.1 19.1 – – 1.4 – – – – – 14.9 7.1 19.1 Eswatini 312 0.6 – 99.0 – – – – – – – – – – – 0.3 Ethiopia 240 – – 99.2 0.4 – – – – 0.4 – – – – – – Guatemala 310 – 99.0 – 0.3 – – – – – – – 0.3 0.3 – – Honduras 325 – 98.8 0.9 – – – – – 0.3 – – – – – – Malawi 288 0.3 – 99.7 – – – – – – – – – – – – Mexico 2270 – 99.0 – – – – – 0.2 0.1 – 0.1 0.0 0.1 0.1 0.2 Myanmar 352 3.7 15.1 29.0 – – – – 45.5 – – – – – – 6.8 Namibia 388 2.3 – 92.5 – – – 0.3 0.3 3.9 0.3 – – 0.3 – 0.3 Nepal 215 0.9 0.5 94.4 – – – – 1.9 1.9 – – – – – 0.5 Nicaragua 317 – 99.1 0.3 – – – – – 0.3 – – 0.3 – – – Nigeria 430 5.8 0.5 0.5 0.5 – 0.2 40.7 – 46.5 4.4 – – – – 0.9 Papua New Guinea 317 0.3 0.3 99.4 – – – – – – – – – – – – Senegal 63 14.3 3.2 6.3 – – – 1.6 – 68.3 1.6 – – – – 4.8 South Africa 402 – – 99.8 0.2 – – – – – – – – – – – Togo 201 6.0 – – – – – 11.9 – 60.7 18.4 – – – – 3.0 Uganda 506 62.1 3.4 2.8 29.1 – – 2.0 – 0.2 – – – 0.2 – 0.4 Viet Nam 403 0.2 0.2 0.7 – – – – 96.5 – – – – – – 2.2 Zambia 27 – – 100.0 – – – – – – – – – – – – Zimbabwe 361 – – 100.0 – – – – – – – – – – – – CRF: circulating recombinant forms; URF: unique recombinant forms; URF and other includes B+F (Cuba, Brazil), B+C (Brazil, Myanmar), B+G (Cuba).

For more information, contact: World Health Organization Department of HIV/AIDS 20, avenue Appia 1211 Geneva 27 Switzerland E-mail: hiv-aids@who.int www.who.int/hiv