Targeted HIV drug resistance testing moves into routine care in South Africa
· Medical Xpressedited by Swati Mestri, reviewed by Andrew Zinin
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Researchers at Wits University, South Africa's National Health Laboratory Service (NHLS) and University Medical Center Utrecht have developed a new way to help people whose HIV viral load increased while they were taking the highly effective standard antiretroviral treatment dolutegravir (DTG).
The Intensified Treatment Evaluation and Monitoring Approach (ITREMA-2) implementation study aims to prevent the accumulation and spread of HIV-1 drug resistance in resource-limited settings.
The study was published in The Lancet HIV on Sept. 2.
About the ITREMA-2 study
A total of 288 people with HIV participated in the study at Hillbrow Community Health Centre and Helen Joseph Hospital, two large public HIV clinics in Johannesburg.
Instead of guessing why dolutegravir wasn't working, researchers used a blood exposure test to check whether the medicine was in a person's blood:
- If the medicine is not in the person's blood, it suggests they have not been able to take their pills recently (adherence issues), so the chance of a resistant virus is low.
- If the medicine is in their blood but the virus is still growing, the virus may have become resistant to dolutegravir, making a resistance test important.
"An increased viral load does not automatically mean that treatment is failing because of drug resistance," says lead researcher Professor Annemarie Wensing of Wits Ezintsha and University Medical Center Utrecht. "Measuring dolutegravir in the same sample helps identify who needs resistance testing and provides clinicians and nurses with objective information to better support medication intake."
Why this strategy matters
When a patient's viral load spikes, doctors face a difficult dilemma. They must decide whether to provide counseling to help the patient take their current pills or switch them to a completely new, more expensive regimen.
Previously, doctors had to wait months, provide repeated counseling and run expensive resistance tests on everyone to find out what was wrong.
With the ITREMA-2 strategy, the blood exposure test helps doctors identify who needs more support taking their pills and who needs resistance testing to determine whether a medication switch is necessary.
Practical application in South African public health
The multidisciplinary research team also studied how this treatment and evaluation strategy could be integrated into routine care.
When incorporated into the care pathway after virologic failure was confirmed, estimated laboratory monitoring costs were 23% lower than with the previous standard approach because unnecessary resistance tests could be avoided.
The South African Department of Health recently implemented an adapted version of the reflex testing strategy in public HIV care.
Dr. Kim Steegen, co-principal investigator of the ITREMA-2 study at the NHLS and Wits University, played a key role in helping the department translate ITREMA from laboratory research into routine practice in South African public hospitals.
Steegen says, "We have worked with the National Department of Health since the onset of the project and kept them informed on the study results as the project progressed. By doing this, we have been able to include an adapted version of ITREMA-2 into the national guidelines, which means the people who need resistance testing the most can be easily identified."
Benefits for patients
For individuals living with HIV, the ITREMA-2 study introduces three major benefits:
- Faster, appropriate care: If the virus has become resistant, people won't waste months taking a pill that doesn't work. Doctors can spot the problem sooner and switch to a working medicine faster.
- Better support, less blame: If people are struggling to take their pills daily because of stress, side effects or life challenges, the test can help identify missed doses. This allows clinic staff to offer tailored counseling and support for treatment nonadherence.
- Protected public health care: Because this strategy saves money on unnecessary, expensive resistance tests, public clinics can stretch their budgets further. This helps ensure a steady, uninterrupted supply of high-quality HIV medications for everyone in the community.
Publication details
Kim Steegen et al, Plasma dolutegravir exposure testing to identify people with HIV at highest risk for dolutegravir resistance (ITREMA-2): a two-centre, prospective implementation study in South Africa, The Lancet HIV (2026). DOI: 10.1016/s2352-3018(26)00144-x
Journal information: The Lancet HIV
Key medical concepts
DolutegravirHIV Viral Load Measurement
Clinical categories
Infectious diseasesHIV & AIDSLaboratory medicineClinical pharmacology Provided by Wits University Who's behind this story?
Swati Mestri
Swati Mestri holds a bachelor's degree in Electronics Engineering and has worked as a content editor since 2019. She has experience editing research documents across technology, health care, and materials science, and has a particular interest in technology and space. Full profile →
Andrew Zinin
Master's in physics with research experience. Long-time science news enthusiast. Plays key role in Science X's editorial success. Full profile →
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