Geospatial analysis reveals similar HIV-1 drug resistance patterns among antiretroviral therapy-experienced children and adolescents (0-17 years) of South Africa.

BACKGROUND: HIV-1 drug resistance (HIVDR) complicates antiretroviral therapy (ART) in children and adolescents living with HIV (CALWH), particularly in high-prevalence areas such as KwaZulu-Natal, South Africa. This study describes trends in HIVDR and patterns by drug class and geographic location among ART-experienced CALWH in KwaZulu-Natal. METHODS: We analysed 914 routine HIV-1 genotypic resistance tests (GRTs) obtained between January 2018 and June 2022 from 0-17-year-old CALWH, integrating facility-linked Geographic Information Systems (GIS) coordinates for geospatial, descriptive and logistic regression analyses. RESULTS: Here we show that 80.96% (740/914) of GRTs from CALWH (median age 13, interquartile range 7-15 years) across 114 facilities demonstrate HIVDR. Of the 740 individuals with HIVDR, 609 (82.30%) had non-nucleoside reverse transcriptase inhibitor (NNRTI) mutations, and among them, 32 (5.25%) were on NNRTI treatment. Additionally, 525 (70.95%) had nucleoside reverse transcriptase inhibitor (NRTI) mutations, and 181 (24.46%) had major protease inhibitor (PI) mutations. One in every 6 GRTs with HIVDR (129/740; 17.43%) have triple-class NRTI, NNRTI and PI mutations. When analysed by age, ~9 in every 10 GRTs from CALWH aged 0-9 years (237/257, 92.22%) have HIVDR, compared to 76.56% (503/657) aged 10-17 years (OR = 3.63, 95% CI: 2.22-5.93, p < 0.001). GIS-interpolation maps show potential-low-level resistance to tenofovir, low-to-intermediate-level resistance to abacavir (high-level in northern localities) and intermediate-to-high-level resistance to lamivudine, nevirapine and efavirenz. CONCLUSIONS: Routine GRTs demonstrate high HIVDR prevalence among younger children, while ART susceptibility maps show overall uniformity with variations in certain regions, such as northern KwaZulu-Natal localities. GIS-linked real-time monitoring of HIVDR is crucial to assess the impact of the revised HIV-1 treatment guidelines for CALWH in South Africa.