Background The prevalence of pretreatment HIV drug resistance (PDR) to efavirenz-based ART is increasing in East Africa, which may decrease the effectiveness of antiretroviral therapy (ART) programs. The recent implementation of dolutegravir-based ART is an important strategy to address PDR. However, concerns about a potential increased risk of neural tube defects associated with use of dolutegravir by women at the time of conception will likely prevent a large proportion of women from using this drug.

Methods We developed an HIV simulation model to project the prevalence of PDR among Kenyan women prior to initiating ART, as well as to evaluate multiple health outcomes among men and women, including rate of virologic failure, over a 15-year time horizon, starting in 2019. The model simulated the emergence and transmission of resistance mutations to efavirenz-based ART, calibrated to the Kenyan epidemic. Our base-case scenario assumed dolutegravir coverage gradually increased such that, by 2022, 100% of men initiating ART receive dolutegravir and only 40% of women initiating ART receive dolutegravir.

Results In 2019, the baseline PDR prevalence among women was 11.5%. In the base-case scenario, PDR prevalence peaked in 2021 to 12.3% and by the end of 2034 was 8.6%. On average over 15 years, among patients with PDR to efavirenz, 61.7% of men and 59.2% of women achieved viral suppression. When we assumed 100% dolutegravir coverage for women by 2022, PDR prevalence among women was 7.8% by the end of 2034.

Conclusion Although efavirenz-associated PDR prevalence is projected to decrease over time as dolutegravir coverage expands, the prevalence of PDR will remain high among women, even several years from now. It remains important to identify cost-effective strategies to address PDR in populations for whom dolutegravir is not an option, particularly women.

Disclosure No significant relationships.