Accelerated emergence of dolutegravir resistance among children in Malawi: implications for antimicrobial resistance control in HIV programmes
1
Global Health, Stellenbosch University, Cape Town, South Africa
2
HIV, STIs & Viral Hepatitis, Ministry of Health, Lilongwe, Malawi
Popul. Med. 2026;8(Supplement Supplement 1):A187
ABSTRACT
BACKGROUND:
Dolutegravir (DTG) based regimens form the backbone of contemporary HIV treatment due to their high potency and high genetic barrier to resistance. However, the emergence of DTG resistance poses a growing antimicrobial resistance (AMR) threat to sustained HIV epidemic control. Evidence on age-related differences in the timing of DTG resistance remains limited, yet is critical for informing paediatric HIV treatment strategies and resistance surveillance.
OBJECTIVES:
To compare the duration of DTG exposure at the time of resistance detection between children (≤14 years) and adults (≥15 years) in Malawi.
METHODS:
We conducted a retrospective analysis of ART-experienced individuals receiving DTG-based regimens who underwent HIV drug resistance testing within the Malawi national HIV programme from January 2019 to October 2025. DTG resistance was defined as a resistance score ≥30. The primary outcome was duration of DTG exposure (months) at resistance detection. As DTG exposure time was not normally distributed, results were summarised using medians and interquartile ranges. Differences between children and adults were assessed using the Wilcoxon rank-sum (Mann–Whitney U) test, with statistical significance set at p<0.05.
RESULTS:
Among 200 individuals with confirmed DTG resistance, 68 (34%) were children and 132 (66%) were adults. Children developed DTG resistance after substantially shorter exposure than adults. Median DTG duration at resistance detection was 28 months (IQR: 21–37) among children compared with 48.5 months (IQR: 33–58) among adults. Mean DTG exposure was 29.5 months in children and 47.4 months in adults.
CONCLUSIONS:
The earlier emergence of DTG resistance among children represents a critical AMR concern for HIV programmes. These findings underscore the need for intensified paediatric viral load monitoring, age-appropriate adherence support, and timely regimen optimisation. Prioritising children within national AMR surveillance frameworks is essential to preserve DTG effectiveness and sustain long-term HIV epidemic control in Malawi and similar high-burden settings.
Dolutegravir (DTG) based regimens form the backbone of contemporary HIV treatment due to their high potency and high genetic barrier to resistance. However, the emergence of DTG resistance poses a growing antimicrobial resistance (AMR) threat to sustained HIV epidemic control. Evidence on age-related differences in the timing of DTG resistance remains limited, yet is critical for informing paediatric HIV treatment strategies and resistance surveillance.
OBJECTIVES:
To compare the duration of DTG exposure at the time of resistance detection between children (≤14 years) and adults (≥15 years) in Malawi.
METHODS:
We conducted a retrospective analysis of ART-experienced individuals receiving DTG-based regimens who underwent HIV drug resistance testing within the Malawi national HIV programme from January 2019 to October 2025. DTG resistance was defined as a resistance score ≥30. The primary outcome was duration of DTG exposure (months) at resistance detection. As DTG exposure time was not normally distributed, results were summarised using medians and interquartile ranges. Differences between children and adults were assessed using the Wilcoxon rank-sum (Mann–Whitney U) test, with statistical significance set at p<0.05.
RESULTS:
Among 200 individuals with confirmed DTG resistance, 68 (34%) were children and 132 (66%) were adults. Children developed DTG resistance after substantially shorter exposure than adults. Median DTG duration at resistance detection was 28 months (IQR: 21–37) among children compared with 48.5 months (IQR: 33–58) among adults. Mean DTG exposure was 29.5 months in children and 47.4 months in adults.
CONCLUSIONS:
The earlier emergence of DTG resistance among children represents a critical AMR concern for HIV programmes. These findings underscore the need for intensified paediatric viral load monitoring, age-appropriate adherence support, and timely regimen optimisation. Prioritising children within national AMR surveillance frameworks is essential to preserve DTG effectiveness and sustain long-term HIV epidemic control in Malawi and similar high-burden settings.
| eISSN: | 2654-1459 |
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