Characteristics and risk factors of acquired drug resistance among people living with HIV: A retrospective study in Guangzhou, China (2018–2023)

Abstract Background: Acquired drug resistance (ADR) in people living with HIV (PLWH) reduces treatment efficacy, restricts drug options, and increases the risk of human immunodeficiency virus (HIV) transmission. The resistance characteristics and associated risk factors of PLWH suffering from virological failure (VF) in Guangdong remain unclear, thus highlighting the need for further research in this area. This retrospective study examines the prevalence, resistance characteristics, and contributing factors of ADR among PLWH who experienced VF in Guangzhou, China, between 2018 and 2023. Methods: Blood samples, epidemiological and demographic data were collected from PLWH with VF at Guangzhou Eight People’s Hospital in Guangzhou, China, between January 1, 2018 and December 1, 2023. ADR was analyzed through HIV pol sequences, with drug resistance mutations (DRMs) identified using the Stanford University HIV Drug Resistance Database. A 1:1 matched group of virologically suppressed (VS) patients was randomly selected using the “sample” function in R from those who maintained VS during the same study period to facilitate the study’s analysis of ADR-associated factors, which were chosen based on clinical relevance, previous studies, and data availability, and identified through logistic regression models. Results: A total of 1592 patients experienced VF during the study period, with 959 having protease/reverse transcriptase sequences and 479 having integrase sequences. DRMs were identified in 60.2% (577/959) of the patients, with an overall ADR prevalence of 46.1% (442/959). The resistance rates for specific drug classes were as follows: nucleotide reverse transcriptase inhibitors (NRTIs) at 33.3% (319/959), non-nucleoside reverse transcriptase inhibitors (NNRTIs) at 36.8% (353/959), protease inhibitors at 3.3% (32/959), and integrase strand transfer inhibitors (INSTIs) at 1.5% (7/479). The multivariable logistic regression analysis revealed several factors linked to a higher risk of ADR, including World Health Organization clinical stages III and IV, baseline CD4 + T cell counts <200 cells/mm 3 , and relatively more antiretroviral therapy regimen changes. Conversely, patients who were on 2NRTI+INSTI regimens and experienced heterosexual transmission were at relatively lower risk of ADR. Conclusion: The prevalence of ADR in Guangzhou was primarily driven by NNRTI resistance. The choice and use of treatment regimens are closely linked to ADR occurrence, and minimizing unnecessary regimen changes may help significantly lower ADR risk.