Treatment failure can be assessed by an immunological, virological or clinical measure. The establishment of the measurement of RNA copies is a surrogate marker for HIV disease progression 11. The low-level RNA copies may not predict virologic failure, however, the high RNA copy number is a risk of treatment failure 12. The successful antiretroviral treatment is specifically defined as viral suppression in people living with HIV (PLHIV) 13. The viral load has become the cornerstone for evaluating the success of anti-retroviral therapy in clinical and research. Few North Indian patients in the present study had higher endpoint viral loads than baseline in presence of resistance to the first line ART drugs.
It has been suggested that, CD4 count of individual patients after therapy confirms, the risk of the progression of AIDS or death 14. But in present study, decline in CD4 count was observed irrespective of drug resistance status of North Indian patients. Few North Indian patients died during treatment although their CD4 count was increased.
The clinical goal for each patient requires an effective, active, tolerable and minimal side effects regimen to achieve maximal clinical benefits to avoid the definition of treatment failure. In this study, drug resistance was found to various first-line drugs such as zidovudine, lamivudine, tenofovir, stavudine, efavirenz and nevirapine. HIV drug resistance has been monitored by affordable HIV drug resistance testing in Sub-Saharan Africa 15. From the multi-centric study in India, it was concluded that Nevirapine therapy is reasonable alternative for efavirenz 16. In this North Indian population study, resistance to Nevirapine and Efavirenz was most commonly observed.
Tenofovir is an important regimen included in the first-line antiretroviral therapy. Tenofovir based virological monitoring predicted treatment failure for patients 17. In this study, 18 North Indian patients were found to be resistant to Tenofovir 18, addressed the monitoring of the degree of genotypic resistance to zidovudine. In this study, Lamivudine resistance was found in 35 North Indian patients. Zidovudine resistance was found in 23 North Indian patients. Similar finding was observed in a study where in zidovudine and lamivudine combinatorial therapy, both zidovudine and lamivudine therapy failure were marked in HIV-1 infected North Indian patients 19.
Stavudine exhibits antiretroviral activity as a monotherapy or combination therapy to manage the adults with HIV infection 20. The rate of treatment failure for stavudine/lamivudine /nevirapine was determined in Asian region 21. In this study, out of 11 North Indian patients on SLE/SLN combination therapy, 9 North Indian patients were developed resistance to stavudine.
Abacavir is a suitable antiretroviral drug with lamivudine for treatment of HIV patients 22 .One patient was treated with ALN regimen and Abacavir treatment failure was observed in that one patient.
The management of HIV resistance differs in lower middle-income countries compared to high income countries. It has been recommended that HIV drug resistance testing should like a point of care test 23. This study utilized WHO dried blood spot protocol 2010 polymerase chain reaction and sequencing primers. Thermal conditions are useful in genotyping test which can reduce the cost of the test.
In India, the antiretroviral therapy is still introduced at an advanced stage of disease without drug resistance testing. This might be the main cause of mortality of HIV patients. The studies assessing the relationship between DRMs and their effect on treatment outcome are limited. An insight into HIV drug resistance pattern and its effect on prognosis of AIDS in individual patients is important. It can also enable the health care providers to monitor HIV drug resistance over the period of treatment. However, utility of such test at the level of national health program needs to be studied in detail before formulation of policy.