Objectives: The objective of this study was to inform public health actions to limit first-line ART failure and HIV
drug resistance in Mozambique.
Methods: This was a cross-sectional study. HIV-1-infected adults on first-line ART for at least 1 year attending
routine visits in the Manhic¸a District Hospital, in a semi-rural ...»»»»
Objectives: The objective of this study was to inform public health actions to limit first-line ART failure and HIV
drug resistance in Mozambique.
Methods: This was a cross-sectional study. HIV-1-infected adults on first-line ART for at least 1 year attending
routine visits in the Manhic¸a District Hospital, in a semi-rural area in southern Mozambique with no HIV-1 RNA
monitoring available, were evaluated for clinical, socio-demographic, therapeutic, immunological and virological
characteristics. Factors associated with HIV-1 RNA ≥1000 copies/mL and HIV drug resistance were determined
using multivariate logistic regression.
Results: The study included 334 adults on first-line ART for a median of 3 years, of which 65% (214/332)
had suppressed viraemia, 11% (37/332) had low-level viraemia (HIV-1 RNA 150–999 copies/mL) and 24%
(81/332) had overt virological failure (HIV-1 RNA ≥1000 copies/mL). HIV drug resistance was detected in 89%
of subjects with virological failure, but in none with low-level viraemia. Younger age [OR¼0.97 per additional
year (95% CI¼0.94–1.00), P¼0.039], ART initiation at WHO stage III/IV [OR¼2.10 (95% CI¼1.23–3.57),
P¼0.003] and low ART adherence [OR¼2.69 (95% CI¼1.39–5.19), P¼0.003] were associated with virological
failure. Longer time on ART [OR¼1.55 per additional year (95% CI¼1.00–2.43), P¼0.052] and illiteracy
[OR¼0.24 (95% CI¼0.07–0.89), P¼0.033] were associated with HIV drug resistance. Compared with HIV-1
RNA, clinician’s judgement of ART failure, based on clinical and immunological outcomes, only achieved 29%
sensitivity and misdiagnosed 1 out of every 4.5 subjects.
Conclusions: Public health programmes in Mozambique should focus on early HIV diagnosis, early ART initiation
and adherence support. Virological monitoring drastically improves the diagnosis of ART failure, enabling a better
use of resources.^^^^