Introduction Endémique dans certaines parties de l’Afrique de l’Ouest, la fièvre Lassa est une zoonose associée à une maladie hémorragique aiguë et causée par le virus Lassa avec plusieurs décès annuellement dans cette partie de l’Afrique. Contrairement aux épidémies des années antérieures qui apparaissent en saison sèche, le Bénin a connu en pleine saison pluvieuse (Août – septembre) de l’année 2023 plusieurs cas de fièvres hémorragiques à virus Lassa en milieu hospitalier dans les villes de Parakou et de Boko au Nord-Est du pays. Face une telle résurgence en pleinement saison pluvieuse, la présence étude s’est intéressée à la caractérisation génomique des isolats des cas positifs pour une meilleure compréhension épidémiologique de cette fièvre. Methods Les échantillons diagnostiqués positifs à partir du kit Altona 2. 0 au Laboratoire de Référence des Fièvres hémorragiques Virales du Bénin (LFHV) ont été conservés à -20 degrés pour le séquençage à l’Institut de Recherche Clinique du Bénin (IRCB). Les librairies étaient préparées sur la plate-forme Illumina (ISEQ100) et l’enrichissement viral s’est fait par sondes (comprehensive viral panel, Twist Bioscience) à l’IRCB et au LFHV. Un pipeline bioinformatique, GeVarLi, a été utilisé pour le contrôle de qualité, le filtre, l’alignement et l’assignation des virales. Les nouvelles séquences sont alignées avec les séquences de références humaines disponible dans la genbank pour les analyses phylogénétique (PhyML). Results Sur un total de 30 cas suspects en provenance du Nord Bénin pendant la saison pluvieuse, 7 cas ont été diagnostiqués positifs et tous étaient de long (L) fragment du virus Lassa. Les résultats de séquençage révèlent des génomes complets pour le virus Lassa, et les analyses phylogénétiques montrent que ces génomes sont étroitement en lien avec les précédentes souches de lignée VII de Lassa isolées au Bénin Conclusion Les résultats de ce travail de séquençage montrent que le Bénin à son propre réservoir du virus Lassa. Il urge à cet effet que les autorités sanitaires mettent l’accent sur la surveillance sanitaire de cette fièvre afin d’anticiper les épidémies.

BACKGROUND:Several variants of SARS-CoV-2 have a demonstrated impact on public health, including high and increased transmissibility, severity of infection, and immune escape. Therefore, this study aimed to determine the SARS-CoV-2 lineages and better characterize the dynamics of the pandemic during the different waves in Guinea. METHODS:Whole genome sequencing of 363 samples with PCR cycle threshold (Ct) values under thirty was undertaken between May 2020 and May 2023. The Illumina iSeq 100 technology was used. The sequences were then analyzed using the GeVarli pipeline to generate consensus sequences and variant calling. All sequences isolated in Guinea and available on GISAID were included in the analysis for phylogenetic tree and phylodynamic determination. Nextstain tools were used for these analyses. Statistical analysis was done using GraphPad Prism version 10. RESULTS:The circulation of SARS-CoV-2 in Guinea can be distributed in three different periods. The first, lasting from May to June 2020, was characterized by lineages B1 and B.1.1. The second period, from January 2021 to July 2021, was characterized by the lineages B.1.1.7 (Alpha), AY.122, B.1.1.318, R1, B.1.525 and B.1.629. The third period, between December 2021 and May 2023, was characterized by the Omicron variant, with nine subvariant majorities found. In addition, detecting variants in the period out of their circulation was documented. The importation and exportation investigation showed the strong movement viral association between Guinea and Senegal on the one hand and Guinea and Nigeria on the other. CONCLUSION:In summary, this study contributes to understanding the epidemic dynamics of the disease by describing the significant variants that circulated in Guinee and the distribution of this variant in the population. It also shows the importation and exportation of the virus during the pandemic. Sub-sampling and degradation of samples for sequences were observed. Organization and collaboration between laboratories are needed for a good sample-collecting and storage system for future direction.

Monitoring pre-treatment drug resistance is a priority to assess the emergence of HIV resistance to antiretrovirals, especially in countries where the transition from dolutegravir-based regimens is already effective on a large scale. The aim of this study was to estimate the prevalence of resistance mutations to different classes of antiretrovirals (ARVs) in HIV-1-naïve persons in Togo in 2023. A cross-sectional study was conducted in 30 HIV care centers for people living with HIV in Togo between March and August 2023. Persons newly diagnosed with HIV-1, aged 18 and over and naïve to any ART with a viral load ≥ 6500.00 copies/ml were included for genotypic resistance testing for protease (PR), reverse transcriptase (RT) and integrase (IN) genes using Next-generation sequencing. Mutations were interpreted using the updated Stanford HIVDB and ANRS algorithms after genotypic testing for protease, reverse transcriptase and integrase resistance. Among 376 enrolled people living with HIV (PLHIV), resistance analyses were carried out on 321 samples. The median age was 39 years, Interquartile range (IQR) [30-47] and 64.9% were women. No resistance mutations to dolutegravir (DTG) were detected. However, accessory mutations (genetic changes that do not confer significant resistance by themselves) as E157Q/E157EQ (43/57) and T97A/T97TA (14/57) associated with resistance against first-generation integrase inhibitors (INIs) as raltegravir, elvitegravir were found in 17.2% of samples. No major mutations (genetic changes that, on their own, confer high-level resistance of the virus to one or more antiretroviral drugs) were observed in the protease gene. The mutations as T215TS and K70KE (detected as a mixture) associated with possible resistance were detected in 0.6% (2/316) for NRTIs and 6.3% (20/316) for NNRTIs. The most frequent NNRTI mutations were K103N (4.4%) and G190A (1.3%). The dominant subtypes were CRF02_AG (64.8%) and CRF06_cpx (12.8%). These results support the continued use of dolutegravir-based regimens in Togo and call for continued monitoring of primary resistance to maintain the effectiveness of therapeutic strategies in Togo.

Background and Aims:The only previous sequence report of measles virus from the Republic of the Congo (RoC) dates back to samples collected in 2000. To update the molecular epidemiology of measles virus in the RoC, our study genotyped measles virus strains circulating in the country from January 2023 to May 2024. Methods:A total of 584 serum or plasma samples were collected by the National Laboratory of Public Health through its nationwide measles surveillance activities. Among these 584 suspected cases, 231 were IgM seropositive, and 170 of them were selected for molecular detection based on their collection date. Results:Of these, 20 cases were RT-qPCR positive, and six sequences were suitable for sequence analysis. Phylogenetic analysis confirmed that the detected measles virus belongs to genotype B3, which is one of the two genotypes currently circulating globally, alongside genotype D8. Genetic comparison revealed three closely related variants, suggesting either ongoing endemic transmission or potential importation. Notably, 45% of PCR-positive samples had received two vaccine doses, highlighting the need for robust vaccine efficacy evaluation. Conclusion:This study emphasizes the critical role of measles virus surveillance, genotyping capacities, and genetic characterization to strengthen regional disease monitoring and containment strategies.

BACKGROUND AND OBJECTIVES:Data on HIV drug resistance in Madagascar are rare and outdated. In this study, we assessed the prevalence of HIV drug resistance mutations to antiretrovirals (ARVs) and genetic diversity of circulating strains in treatment-naive people living with HIV (PLHIV) in Madagascar. MATERIALS AND METHODS:We amplified the protease (PR), fragments of the Reverse Transcriptase (RT) and Integrase (IN) genes according to the French ANRS protocol. The amplicons were sequenced using next-generation sequencing technology on an Illumina platform (MiSeq). We determined HIV-1 subtypes through phylogenetic analysis using maximum likelihood in PhyML. Resistance interpretation was performed using the Stanford algorithm (version 9.5.1). RESULTS:We included 239 HIV-infected adults and children, sampled between January 2019 and November 2023, with a median age of 30 years and a mean plasma HIV viral load of 6.3 Log copies/mL. We sequenced at least one genomic fragment (PR or RT or IN) of the 239 samples, but 9 were excluded from analysis (mean depth < 10,000×). Phylogenetic analysis of 230 sequences revealed the presence of subtype C (33.91 %), A1 (11.30 %), B (11.30 %), CRF02_AG (9.56 %), subtype G (3.04 %), subtype D (0.43 %), CRF01_AE (0.43 %), and a significant proportion of unique recombinant forms (URFs) (30.30 %). The prevalence of transmitted drug resistance (TDR) was 4.95 % (10/202) among patients aged 15 years and older. When stratified by ARV class, this prevalence was 4.79 % for non-nucleoside reverse transcriptase inhibitors (NNRTIs), 0.59 % for Nucleoside Reverse Transcriptase inhibitors (NRTIs), and 0.50 % for integrase strand transfer inhibitors (INSTIs). Among children under 15 years old (n = 28), the prevalence of TDR was 14.28 % (4/28), with all mutations conferring resistance to NNRTIs. No mutation conferring resistance to protease inhibitors was found, neither in children nor in adults. CONCLUSION:Our results show a low prevalence of ARV resistance mutations among adult treatment-naive PLHIV in Madagascar. In children under 15 years old, 92 % were infants under two years old, the high resistance rate is likely related to mother-to-child transmission. No resistance mutation to dolutegravir was detected. We also observed high frequencies of subtypes C, B, A1 and a high proportion of URFs, highlighting an ongoing dynamic epidemic.

OBJECTIVE:Dengue is a widespread viral infection transmitted from mosquitoes to humans, mainly in tropical and subtropical climates. In Benin, only dengue virus (DENV) serotype 2 infection has been previously described in humans. This study aimed to investigate DENV infection and serotypes in suspected patients. METHODS:Plasma samples from 464 patients attending health centers in February 2023 with clinical symptoms and suspected for dengue infection were included, and analyzed for DENV by real time quantitative Polymerase Chain Reaction (Dengue Altona 3.0 kit). PCR positives samples were further characterized by whole genome sequencing and phylogenetic analysis to identify the circulating DENV serotype. RESULTS:The RT-qPCR results showed that four patients (D6, D23, D28, D44) were positive with the cycle threshold values less than 40 (31.3, 34.7, 14.7 and 14.3) respectively. Full-length DENV sequences were obtained for D6, D28 and D44. One patient (D6) was infected with DENV-1 serotype, and the two others (D28 and D44) were positive for DENV-3. Phylogenetic analysis shows that the new DENV-1 sequence is close to those obtained in Burkina Faso in 2022 and Nigeria in 2023, and the two DENV-3 sequences form a separate cluster with sequences obtained in Burkina Faso in 2022. CONCLUSION:We showed for the first time, the presence of dengue serotype 1 and serotype 3 infection in Benin. These results send a strong signal to health authorities and show that arbovirus surveillance efforts must be integrated into pathogen monitoring programs.

Type-1 HIV (HIV-1) group M (HIV-1M) genetic diversity is highest in the Congo Basin where the epidemic ignited a century ago. HIV-1M has diversified into multiple subtypes, sub-subtypes, and circulating and unique recombinant forms (CRFs/URFs). An unanswered question is why some rare subtypes never reached epidemic levels despite their age. Several studies identified the role of HIV-1M accessory genes nef and vpu in virus adaptation to human hosts and subsequent spread. Other reports also pointed out the pivotal role of gag in transmissibility, virulence, and replication capacity. In this study we characterized the HIV-1 gag gene of 148 samples collected in different localities of the Democratic Republic of the Congo (DRC) between 1997 and 2013. We used nested polymerase chain reaction (PCR) to amplify the whole gag gene. PCR products were sequenced either by Sanger method or by next generation sequencing on Illumina MiSeq or iSeq100 platforms. Generated sequences were used for subsequent analyses using different bioinformatic tools. Phylogenetic analysis of the generated sequences revealed a high genetic diversity with up to 22 different subtypes, sub-subtypes, CRFs. Up to 15% (22/148) URFs were identified, in addition to rare subtypes such as H, J, and K. At least two amino acid motifs present in the gag gene have been shown to modulate HIV-1 replication, budding, and fitness: the P(T/S)AP and the LYPXnL motifs. Structural analysis revealed the presence of P(T/S)AP in all the 148 sequences with the majority (136/148) bearing the PTAP. Three samples presented a duplication of this motif. The LYPXnL motif was identified in 38 of 148 sequences. There was no clear link between the frequency of these motifs and HIV-1M subtypes. In summary, we confirmed a high genetic diversity of HIV-1M in the DRC. We observed the presence of amino acid motifs important for viral replication and budding even in some rare HIV-1 subtypes. Their impact on viral fitness needs be further evaluated by in vitro studies.

Background Data on human immunodeficiency virus (HIV) seroconversion among men who have sex with men (MSM) using pre-exposure prophylaxis (PrEP) in West Africa are needed. This study aimed to document HIV seroconversion and associated determinants, PrEP adherence, plasma drug concentrations, and HIV drug resistance in MSM using event-driven or daily PrEP in Burkina Faso, Cote d'Ivoire, Mali, and Togo. Methods A prospective cohort study was conducted in 2017-2021 among HIV-seronegative MSM aged 18 or over who were at high risk of HIV infection. Participants could choose between event-driven and daily PrEP, switch regimens, and discontinue or restart PrEP. The determinants of HIV incidence were investigated using a multivariate mixed-effects Poisson regression analysis. Results A total of 647 participants were followed for a total time of 1229.3 person-years. Of 5371 visits, event-driven PrEP was chosen in 3873 (72.1%), and daily PrEP in 1400 (26.1%). HIV incidence was 2.4 per 100 person-years (95% confidence interval [CI] 1.5-3.6) for event-driven PrEP, and 0.6 per 100 person-years (95% CI .1-2.3) for daily PrEP (adjusted incidence rate ratio 4.40, 95% CI 1.00-19.36, P = .050). Adequate adherence was lower with event-driven than daily PrEP (44.3% vs 74.9%, P < .001). Plasma drug concentrations were undetectable in 92 (97.9%) of the 94 measures taken for 23 participants who seroconverted. Only 1 participant had resistance to PrEP drugs. Conclusions HIV seroconversions mainly occurred in participants who chose event-driven PrEP. The study's data highlighted major difficulties with adherence to this regimen. Improving adherence to event-driven PrEP constitutes a major research and public health priority in this context. Human immunodeficiency virus seroconversions mainly occurred in West African men who have sex with men who chose event-driven pre-exposure prophylaxis. The study's pharmacological data, self-reported quantitative data and interview discourses highlighted major difficulties with adherence.

With 12 of the 31 outbreaks, the Democratic Republic of Congo (DRC) is highly affected by Ebolavirus disease (EVD). To better understand the role of bats in the ecology of Ebola viruses, we conducted surveys in bats during two recent EVD outbreaks and in two areas with previous outbreaks. Dried blood spots were tested for antibodies to ebolaviruses and oral and rectal swabs were screened for the presence of filovirus using a broadly reactive semi-nested RT-PCR. Between 2018 and 2020, 892 (88.6%) frugivorous and 115 (11.4%) insectivorous bats were collected. Overall, 11/925 (1.2%) to 100/925 (10.8%) bats showed antibodies to at least one Ebolavirus antigen depending on the positivity criteria. Antibodies were detected in fruit bats from the four sites and from species previously documented to harbor Ebola antibodies or RNA. We tested for the first time a large number of bats during ongoing EVD outbreaks in DRC, but no viral RNA was detected in the 676 sampled bats. Our study illustrates the difficulty to document the role of bats as a source of Ebolaviruses as they might clear quickly the virus. Given the increasing frequency of EVD outbreaks, more studies on the animal reservoir are urgently needed.

Research on male clients of male sex workers (MCMSW) has been neglected for a long time globally. We aimed to characterize MCMSW and to identify factors associated with their sexual practices using data from the prospective cohort study CohMSM conducted in Burkina Faso, Côte d’Ivoire, Mali and Togo. Our study focused on HIV-negative men who have sex with other men (MSM) recruited between 06/2015 and 01/2018 by a team of trained peer educators. Scheduled study visits at 6, 12 and 18 months included medical examinations, HIV screening, risk-reduction counselling and face-to-face interviews to collect information on their sociodemographic characteristics, sexual behaviours, and HIV risk-reduction strategies (HIV-RRS). Three stigmatization sub-scores were constructed (experienced, perceived and internalized). Mixed-effects logistic regression was used for data analysis. Of the 280 participants recruited at baseline, 238, 211 and 118, respectively, had a follow-up visit at 6, 12 and 18 months. Over a total of 847 visits, 47 transactional sex (TS) encounters were reported by 38 MCMSW (13.6%). Of the latter, only one participant reported systematic TS (2.6%), 18 (47.4 %) stopped reporting TS after baseline, and 6 (15.8%) reported TS after baseline. Thirteen participants (34.2 %) reported occasional TS. After adjusting for country of study and age, the following self-reported factors were associated with a greater likelihood of being MCMSW: protected anal sex, exclusively insertive anal sex with male sexual partners, avoidance of sex after consuming psychoactive products and experiencing stigmatization (all during the previous 6 months). The majority of MCMSW in this study employed HIV-RRS with male sexual partners, including engaging in protected anal sex, avoidance of sex when consuming psychoactive products, and practising exclusively insertive anal sex.

Empowerment is an ongoing process through which individuals and communities appropriate power and acquire the capability to function autonomously. Research on empowerment in men who have sex with men (MSM) is lacking in community-based contexts. We investigated the relationship between willingness to be empowered and HIV care needs in West African MSM accessing community-based organisations' (CBO) services. Fifty-three interviews were administered to HIV-negative MSM participating in the CohMSM study (Mali, Burkina Faso, Côte d'Ivoire, Togo). Five indicators of empowerment were identified from a discourse analysis: (i) motivation to access HIV services, (ii) willingness to improve HIV services, (iii) desire to be involved in new activities, (iv) desire to participate in such services, (v) willingness to collaborate in decision making. Based on these indicators, participants were classified into two profiles: high (19/53, 36%) and low (34/53, 64%) level of willingness to be empowered (HWE, LWE). Using a thematic analysis, HWE participants were focused on collective benefit (preventive follow-up, questions about MSM identity), while LWE participants were centred on individual benefit (medical care). CBOs should consider empowerment as a tool to advance collective health benefits for MSM. To improve empowerment in MSM, specific training on issues regarding sexual identity and stigma is needed for CBO providers.

Abstract Background Although men who have sex with men (MSM) are at high risk of hepatitis B virus (HBV) infection, they do not have access to vaccination in West Africa, which is a highly endemic region. We investigated HBV prevalence and associated factors, as well as acceptability and difficulties of vaccination in MSM enrolled in an operational research program in Burkina Faso, Côte d’Ivoire, Mali, and Togo. Methods We followed up 779 MSM in 2015–2018. Participants who were negative for both hepatitis B surface antigen (HBsAg) and antibodies (anti-HBs) at enrollment were offered HBV vaccination. Factors associated with HBV infection were identified using logistic regression models. Results Overall, HBV prevalence was 11.2% (95% confidence interval [CI], 9.0%–13.6%). It was lower in Togo than in Côte d’Ivoire (2.7% vs 17.3%; adjusted odds ratio [aOR], 0.12; 95% CI, 0.02–0.28) and higher in participants with 6+ recent male sexual partners (21.0% vs 9.3%; aOR, 1.48; 95% CI, 1.12–1.97). Of 528 participants eligible for vaccination, 484 (91.7%) were willing to be vaccinated and received at least 1 dose (ranging from 68.2% in Abidjan to 96.4% in Bamako; P < .001). Of the latter, 390 (80.6%) received 3 or 4 doses. The proportion of participants for whom the minimum required time between each dose was respected ranged from 10.9% in Bamako to 88.6% in Lomé (P < .001). Conclusions MSM in West Africa should be targeted more for HBV screening and vaccination. Although vaccination is well accepted by MSM, greater training of health care workers and education of MSM are required.

Background: Population-based studies to estimate viral load (VL) suppression and rate of acquired HIV drug resistance (ADR) are essential in sub-Saharan Africa. We conducted the first nationally representative study estimating VL suppression and ADR in Cameroon. Methods: Eligible participants were patients on antiretroviral therapy (ART) for 12 to 24 months (ART 12-24) or 48 to 60 months (ART 48-60). ART 12-24 participants were recruited from 24 randomly selected clinics in both urban and rural regions. ART 48-60 participants were recruited from 7 urban clinics. Recruitment occurred from February to August 2015. Dried blood spots (DBSs) and plasma specimens were collected and tested for HIV-1 RNA level and presence of drug resistance mutations (DRM) when VL >= 1000 copies/ml. Results: Overall, 1064 ART 12-24 and 388 ART 48-60 participants were recruited. Viral suppression in the ART 12-24 group was 72.1% (95% CI: 66.3-77.2) overall, 75.0% (65.2-82.7) in urban sites, and 67.7% (58.3-75.8) in rural sites. In the ART 48-60 group, viral suppression was 67.7% (55.8-77.7). Overall, HIV drug resistance (HIVDR) was 17.7% (15.1-20.6) and 28.3% (17.4-42.5) in the ART 12-24 and ART 48-60 groups, respectively. However, among patients with VL >= 1000 copies/ml, HIVDR was identified in 63.3% (52.0-73.3) of ART 12-24 patients, and in 87.7% (67.4-96.1) of ART 48-60 patients. Conclusions: Results of this first nationwide study indicate alarming levels of virological failure and ADR in Cameroon. Better ART management is urgently needed and should focus on improving ART adherence, availability of VL monitoring, and more timely switches to second-line ART. (C) 2018 The Author(s). Published by Elsevier Ltd.

Background:Pretreatment HIV drug resistance (PDR) has the potential to affect treatment outcome and mortality. We present here the first nationally representative PDR study conducted in Cameroon. Methods:From February to July 2015, HIV-infected ART initiators were recruited from 24 randomly selected clinics situated in both urban and rural regions. Dried blood spot specimens were collected from study participants at these clinics and centralized in a reference laboratory in Yaoundé, Cameroon, for drug resistance testing. HIV drug resistance mutations were identified using the Stanford algorithm. Results:Overall, from the 379 participants recruited, 321 pol sequences were successfully interpreted. Two hundred and five sequences were from patients attending urban ART clinics and 116 from patients seen at rural facilities. Nine percent of sequences (29/321) were from participants reporting previous exposure to antiretrovirals. PDR prevalence among all initiators was 10.4% (95% CI 5.4%-19.1%), with 14.2% (95% CI 6.6%-27.9%) reported in urban areas and 4.3% (95% CI 1.2%-14.3%) in rural areas. Among participants with no prior exposure to antiretrovirals, PDR prevalence was 10.4% (95% CI 4.7%-21.5%) overall, with 13.5% (95% CI 5.1%-31.5%) and 5.3% (95% CI 1.4%-17.5%) reported in urban and rural areas, respectively. Conclusions:Our findings indicate that at least 10% of patients initiating ART in Cameroon carry viruses with PDR and may be at risk of premature ART failure. The high level of NNRTI-associated resistance is of particular concern and supports introduction of drugs with a higher genetic barrier to resistance.

In resource-limited countries (RLCs), WHO recommends HIV viral load (VL) on dried blood spots (DBS) for antiretroviral therapy (ART) monitoring of patients living in non-urban settings where plasma VL is not available. In order to reduce the impact of proviral DNA interference, leading to false positive results in samples with low plasma VL, we compared three different nucleic acid preparation methods with the NucliSens (Biomérieux) extraction, known for its high recovery of nucleic acids on DBS. Paired plasma-DBS samples (n=151) with predominantly low plasma VL (≤10,000 copies/ml; 74%) were used. At the threshold of 1,000 copies/ml on DBS, 51% and 10% were misclassified as false positives or false negatives, respectively with NucliSens, versus 41% and 20% with m2000sp (Abbott), described as more specific for RNA recovery. DNase treatments of nucleic acid extracts and free virus elution (FVE) protocol before nucleic acid extraction, reduced the proportion of false positives to 0% and 19%, but increased the proportion of false negatives to 40% and 73%. More efforts are thus still needed to improve performance of VL assays on DBS to monitor patients on ART in RLCs and allow timely switch to more costly second or third line ART regimes.

INTRODUCTION:Antiretroviral treatment (ART) has been scaled up over the last decade but compared to adults, children living with HIV are less likely to receive ART. Moreover, children and adolescents are more vulnerable than adults to virological failure (VF) and emergence of drug resistance. In this study we determined virological outcome in perinatally HIV-1-infected children and adolescents receiving ART in Togo. METHODS:HIV viral load (VL) testing was consecutively proposed to all children and adolescents who were on ART for at least 12 months when attending HIV healthcare services for their routine follow-up visit (June to September 2014). Plasma HIV-1 VL was measured using the m2000 RealTime HIV-1 assay (Abbott Molecular, Des Plaines, IL, USA). Genotypic drug resistance was done for all samples with VL>1000 copies/ml. RESULTS AND DISCUSSION:Among 283 perinatally HIV-1-infected children and adolescents included, 167 (59%) were adolescents and 116 (41%) were children. The median duration on ART was 48 months (interquartile range: 28 to 68 months). For 228 (80.6%), the current ART combination consisted of two nucleoside reverse transcriptase inhibitors (NRTIs) (zidovudine and lamivudine) and one non-nucleoside reverse transcriptase inhibitor (NNRTI) (nevirapine or efavirenz). Only 28 (9.9%) were on a protease inhibitor (PI)-based regimen. VL was below the detection limit (i.e. 40 copies/ml) for 102 (36%), between 40 and 1000 copies/ml for 35 (12.4%) and above 1000 copies/ml for 146 (51.6%). Genotypic drug-resistance testing was successful for 125/146 (85.6%); 110/125 (88.0%) were resistant to both NRTIs and NNRTIs, 1/125 (0.8%) to NRTIs only, 4/125 (3.2%) to NNRTIs only and three harboured viruses resistant to reverse transcriptase and PIs. Overall, 86% (108/125) of children and adolescents experiencing VF and successfully genotyped, corresponding thus to at least 38% of the study population, had either no effective ART or had only a single effective drug in their current ART regimen. CONCLUSIONS:Our study provided important information on virological outcome on lifelong ART in perinatally HIV-1-infected children and adolescents who were still on ART and continued to attend antiretroviral (ARV) clinics for follow-up visits. Actual conditions for scaling up and monitoring lifelong ART in children in resource-limited countries can have dramatic long-term outcomes and illustrate that paediatric ART receives inadequate attention.

In the context of lifelong antiretroviral treatment (ART) as early as possible and to end the HIV/AIDS epidemic as a public health treat by 2030, it is important to evaluate the potential risk of transmission of HIV-1 drug resistance (HIVDR) in resource-limited countries (RLCs). Since HIV transmission is driven by HIV-1 RNA viral load (VL), we studied the association between plasma VL and HIVDR profiles in 451 adults failing first-line ART from the 2LADY-ANRS12169/EDCTP trial in Burkina Faso, Cameroon, and Senegal. Median duration on first-line ART was 49 months (IQR: 33-69) and 91% patients were asymptomatic. Genotypic drug resistance testing was successful for 446 patients and 98.7% of them were resistant to at least one of the first-line drugs; 40.6% and 55.8% were resistant to two or three drugs of their ongoing first-line ART, respectively. The median VL was higher in patients with HIVDR to all ongoing first-line drugs than in those still susceptible to at least one drug; 4.7 log10 copies/ml (IQR: 4.3-5.2) versus 4.2 log10 copies/ml (IQR: 3.7-4.7), respectively (p < .001). The proportion of patients with HIVDR to all ongoing first-line drugs was highest (77.9% [95/122]) in patients with VL >5.0 log10 copies/ml. High rates of cross-resistance to other nucleoside reverse-transcriptase inhibitors were observed and were also highest in patients with high VL. Without improvement of patient monitoring to avoid late switch to second-line regimens, a potential new epidemic caused by HIVDR strains could emerge in sub-Saharan Africa and compromise all efforts to reach 90-90-90 UNAIDS objective by 2020.

Objective:In resource-limited countries, antiretroviral therapy (ART) has been scaled up, but individual monitoring is still suboptimal. Here, we studied whether or not ART had an impact on the frequency and selection of drug resistance mutations (DRMs) under these settings. We also examined whether differences exist between HIV-1 genetic variants. Design:A total of 3736 sequences from individuals failing standard first-line ART (n = 1599, zidovudine/stavudine + lamivudine + neviparine/efavirenz) were analyzed and compared with sequences from reverse transcriptase inhibitor (RTI)-naive individuals (n = 2137) from 10 West and Central African countries. Methods:Fisher exact tests and corrections for multiple comparisons were used to assess the significance of associations. Results:All RTI-DRM from the 2015 International Antiviral Society list, except F227C, and nine mutations from other expert lists were observed to confer extensive resistance and cross-resistance. Five additional independently selected mutations (I94L, L109I, V111L, T139R and T165L) were statistically associated with treatment. The proportion of sequences with multiple mutations and the frequency of all thymidine analog mutations, M184V, certain NNRTIS, I94L and L109I showed substantial increase with time on ART. Only one nucleoside and two nonnucleoside RTI-DRMs differed by subtype/circulating recombinant form. Conclusion:This study validates the global robustness of the actual DRM repertoire, in particular for circulating recombinant form 02 predominating in West and Central Africa, despite our finding of five additional selected mutations. However, long-term ART without virological monitoring clearly leads to the accumulation of mutations and the emergence of additional variations, which limit drug options for treatment and can be transmitted. Improved monitoring and optimization of ART are necessary for the long-term effectiveness of ART.

BACKGROUND:As part of its policy to shift monitoring of antiretroviral therapy (ART) to primary health care (PHC) workers, the Ministry of Health of the Democratic Republic of Congo (DRC) tested the feasibility of using dried blood spots (DBS) for viral load (VL) quantification and genotypic drug resistance testing in off-site high-throughput laboratories.METHODS:DBS samples from adults on ART were collected in 13 decentralized PHC facilities in the Nord-Kivu province and shipped during program quarterly supervision to a reference laboratory 2000 km away, where VL was quantified with a commercial assay (m2000rt, Abbott). A second DBS was sent to a World Health Organization (WHO)-accredited laboratory for repeat VL quantification on a subset of samples with a generic assay (Biocentric) and genotypic drug resistance testing when VL >1000 copies per milliliter.FINDINGS:Constraints arose because of an interruption in national laboratory funding rather than to technical or logistic problems. All samples were assessed by both VL assays to allow ART adjustment. Median DBS turnaround time was 37 days (interquartile range: 9-59). Assays performed unequally with DBS, impacting clinical decisions, quality assurance, and overall cost-effectiveness. Based on m2000rt or generic assay, 31.3% of patients were on virological failure (VF) and 14.8% presented resistance mutations versus 50.3% and 15.4%, respectively.CONCLUSION:This study confirms that current technologies involving DBS make virological monitoring of ART possible at PHC level, including in challenging environments, provided organizational issues are addressed. Adequate core funding of HIV laboratories and adapted choice of VL assays require urgent attention to control resistance to ART as coverage expands.