HIV Treatment Monitoring in Resource-Limited Settings: Current Paradigms and Future Strategies

The human immunodeficiency virus (HIV) has a profound impact on global health and severely affects many low- and middle-income countries in sub-Saharan Africa. Antiretroviral therapy (ART) has transformed HIV infection from a deadly disease into a treatable chronic condition. However, ART is not always successful.
This thesis aims to contribute to the durable effectiveness of ART through the development of novel strategies for laboratory monitoring during treatment for sub-Saharan African countries. Most of this research was performed in South Africa, where approximately 12.8% of inhabitants are currently living with HIV.
This thesis shows that while ART is usually effective, success is not attained in all cases for a variety of reasons. It confirms that the risk of therapy failure is not solely determined by patient-related factors such as gender and income, but equally by characteristics of the virus, in particular viral resistance to ART. It also shows that there is a considerable delay between the detection of therapy failure and clinical action to address this problem in routine clinical care in South Africa.
The thesis subsequently explores novel strategies for HIV treatment monitoring in sub-Saharan Africa. A more stringent definition of treatment success, that is currently already in use in high-income countries, should also be used in low- and middle-income countries, as this definition allows for earlier identification of therapy failure. Furthermore, innovative tools for drug exposure testing may be used to detect suboptimal adherence to treatment and to identify persons who are at risk of harbouring drug resistant HIV.