Tristan Barber

This symposium focussed on global use of integrase inhibitors, integrase resistance, and sequencing antiretroviral therapy after first line. Jürgen Rockstroh (Bonn) and Meg Doherty (WHO) co-chaired. Current guidance, evidence on resistance and clinical, and how to manage therapy in environments where monitoring is limited were discussed by the presenters.

Pavel Khaykin presented the rationale for WHO’s approach to DTG, with a fantastic review of the wealth of supportive evidence, including early trials versus efavirenz favouring DTG. Data in the context of TB, pregnant women, and children and adolescents, were also presented. Nick Paton asked if resistance testing is futile in the INSTI era? Setting up for requirements to be met if resistance testing was to be considered useful in the public health approach to ART, he then took these apart, showing integrase resistance testing to be of limited utility overall in the context of current WHO recommended ART regimens. We were reminded of data from the EARNEST and NADIA trials. In summary, the suggestion was that targeted resistance testing may be considered, if we wish to avoid the pills, cost, and toxicities of a boosted PI, especially for those for whom an NNRTI had failed, received an AZT backbone, or for those (if/when available) considering injectable ART. Finally, we heard from Francois Venter on how to sequence from TLD on the ground with limited monitoring in support of Nick Paton’s conclusions, also considering the rational use of resistance testing only in certain specific, similar cases.

During the discussion, a pertinent question was asked by Anton Pozniak about whether drugs (especially low barrier) for prevention should be from the same classes as those for treatment. Monica Gandhi also raised that access to generic single-tablet PI therapy would be extremely useful. The panel was asked for better access to adherence counselling and viral load monitoring to be in the next WHO guideline. For now DTG is working, but with increasing INSTI resistance in countries of high HIV prevalence, we must remain vigilant, and will continue to need new drugs for ongoing success of the public health response.