High level of pretreatment and acquired HIV drug resistance in El Salvador: A nationally representative survey, 2018–2019

Background HIV drug resistance (HIVDR) can negatively impact the effectiveness of ART, increasing the number of AIDS-associated deaths, new HIV infections, and ART programme costs. Objective Estimate the prevalence of pretreatment HIVDR (PDR) among ART initiators and the prevalence of viral load (VL) suppression and acquired HIVDR among individuals receiving ART for 12 ± 3 months (ADR12) and ≥48 months (ADR48) in El Salvador. Patients and methods Nationally-representative cross-sectional PDR, ADR12, and ADR48 surveys were conducted among adults living with HIV from October 2018 to August 2019, following WHO-recommended methods. Demographic and clinic data and blood specimens were collected. Results 260 participants were enrolled in the PDR survey, 230 in the ADR12 survey and 425 in the ADR48 survey. 27.0% (95% CI: 17.1–39.9%) ART initiators had PDR to efavirenz or nevirapine. The prevalence of VL suppression was 88.8% (83.1–92.8) in ADR12 and 80.5% (76.6–84.0) in ADR48 surveys. Among PLHIV receiving a first-line non-nucleoside reverse transcriptase inhibitor (NNRTI)-based ART regimen and with unsuppressed VL, the prevalence of ADR to efavirenz or nevirapine was 72.0% (39.1–91.2) and 95.0% (72.0–99.3) in the ADR 12 and ADR48 surveys, respectively. ADR12 to boosted protease inhibitors (PI/r) or integrase strand transfer inhibitors (INSTI) was not observed. ADR48 to PI/r was 1.3% (0.4–4.9) and 2.1% (0.8–5.6) to INSTI. Conclusion Programmatic improvements in ART delivery are urgently needed in El Salvador to address the high levels of resistance to efavirenz or nevirapine among ART initiators and the low VL suppression prevalence among individuals on treatment.