Prevalence, predictors and geospatial patterns of HIV drug resistance in South Africa: Insights from the 2017 national HIV household survey

Abstract

Background South Africa bears the highest HIV burden globally, marked by a substantial expansion of antiretroviral therapy (ART) that curbs HIV and AIDS cases, morbidity, and mortality. As a result, it faces potential challenges from HIV drug resistance (HIVDR), which could undermine these advancements and prevent the attainment of UNAIDS 95-95-95 targets. This study investigated the national prevalence, geospatial trends, and predictors of HIVDR in people 15 years and older in South Africa in 2017 before the introduction of dolutegravir containing ART regimens. Methods This study used the 2017 secondary data of 1,974 virally unsuppressed adults aged ≥ 15 years old and were tested for HIVDR from a nationally representative cross-sectional multi-stage stratified cluster random sample survey, the South African National HIV Prevalence, Incidence, Behaviour and Communication Survey (SABSSM V). Univariate and multivariable logistic regression models were used to determine predictors for HIVDR. Geospatial analyses were applied to estimate HIVDR prevalence in all nine provinces and three locality types. Survey weights were used across all analyses to adjust for unequal sampling probabilities and non-responses. Results Of 1,253 participants of PLHIV aged ≥ 15 years, a large portion constituted the 25–34 years age group (33.6%) and females (55.7%). The virally unsuppressed rate was estimated at 37.8% (95%CI: 35.2 to 40.2) for viral non-suppression (≥ 1,000 copies/mL) and 26.3% (95%CI: 22.5 to 30.5) for national HIVDR prevalence (n = 369). Eastern Cape province had the highest HIVDR prevalence at 36.6%, while North-West had the lowest at 21.6%. Multivariable logistic regression model established that exposure to ART (adjusted odds ratio [aOR] 4.44, 95%CI: 2.78 to 7.10, p < 0.001), HIV stigmatisation (aOR 1.66, 95%CI: 1.06 to 2.59, p = 0.025), and secondary schooling as highest education level (aOR 1.71, 95%CI: 1.05 to 2.81, p = 0.032) were risk factors for HIVDR. However, being aged 25–34 years (aOR 0.50, 95%CI: 0.25 to 0.99, p = 0.047) and ≥ 45 years old (aOR 0.45, 95%CI: 0.21 to 0.94, p = 0.033) were identified as protective factors against HIVDR compared to the younger age group of 15–24 years. Conclusion High HIVDR prevalence estimates among the virally unsuppressed PLHIV on ART emphasize the importance of increasing viral load testing, enhancing adherence counselling, and prompt switching to the appropriate ART regimens. The analysis revealed that exposure to ART, HIV stigmatisation, and secondary education level were identified as risk factors associated with HIVDR, while older age groups, specifically 25–34 and ≥ 45 years old, exhibited a protective effect against HIVDR.