Nicolette Naidoo

This session reviewed challenges and insight into new and current HIV testing algorithms in the context of new and emerging PrEP products. Clinical conundrums affecting patient management was also addressed with a balanced view of community centric approaches to improve messaging and advocacy for testing and PrEP introduction.

Bernard Branson highlighted the limitations of current modalities in detecting acute infection (AI) HIV emphasizing the need to improve testing pathways through point of care (POC) RNA & viral load tests for diagnosis, particularly in settings with early treatment and PrEP. Jean-Michel Molina noted that PrEP may select for drug-resistant HIV through Mk847 and K65R mutations (the latter conferring lower TDF/FTC efficacy). Emphasis placed on regular monitoring at 3-monthly intervals to re-enforce adherence and detect early HIV-infection, clinical guidance to manage false positive and ambiguous cases. Daniel Kuritzkes expounded on the PrEP paradox presenting data from a systematic review indicating drug resistance mutations in 23% with AI vs. 3% with incident HIV infections. However; concerning data showing that 70% of patients who failed TDF-containing first-line ART had K65R mutation. Lastly, Ntando Yola emphasized the need to translate this complex science into messaging for communities to avoid undermining of prevention programmes.

This session provided critical insight into the need to diversify the HIV testing and diagnosis pathways in the context of PrEP whilst also understanding the correlates for resistance to ensure better clinical management. Although a brief glimmer of the implications of these novel technologies in resource limited settings (RLS), it will be important to further explore the feasibility and cost of scaling these technologies where the burden of disease is high. More data is also needed to permit better modeling of the risk-benefit ratio of PrEP with respect to resistance.