ArticleBMC public health2026
Prevalence, associated factors and geospatial patterns of HIV drug resistance in South Africa among the virally unsuppressed adults: updated results from the 2017 national HIV household survey.
Article in BMC public health, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
backgroundSouth Africa bears the highest HIV burden globally, with substantial antiretroviral therapy (ART) scale-up. HIV drug resistance (HIVDR) threatens progress toward UNAIDS 95–95-95 targets. We assessed national HIVDR prevalence and associated factors among virally unsuppressed adults in 2017, before dolutegravir (DTG)-rollout.
methodsSecondary analysis of the 2017 national HIV household survey, included 1 253 virally unsuppressed (defined as ≥ 1 000 copies/mL) adults (≥ 15 years) with HIVDR results. Survey-weighted analysis generated nationally representative estimates. Weighted multivariable logistic regression identified factors associated with HIVDR by treatment status. Province-stratified analyses examined sub-national disparities.
resultsNationally, the study found high viral non-suppression estimated at 37.8% (95%CI: 35.2 to 40.2), and overall HIVDR prevalence of 26.3% (95%CI: 22.5 to 30.5; n = 369), driven predominantly by efavirenz-associated NNRTI resistance (14.0%). Prevalence was highest in Eastern Cape (36.6%) and rural farms (35.0%); provincial variation was not statistically significant. Stratified analysis revealed HIVDR concentration among divorced individuals (75.0%, 95% CI: 41.7–92.6) and those with high stigma (19.9%, 95% CI: 13.3–28.7) in Eastern Cape, whereas North West showed consistently low prevalence. HIVDR was higher among ARV-positive (43.3%) vs. ARV-negative individuals (21.1%, adjusted odds ratio [aOR] 4.44, 95% CI: 2.78–7.10, p < 0.001). In EFV-negative subgroup, the strongest risk factor was TB history (aOR = 4.94, 95% CI:1.46–16.67, p = 0.010), followed by secondary education (aOR = 2.24, 95% CI:1.15–4.35, p = 0.017) and stigma (aOR = 1.86, 95% CI:1.09–3.19, p = 0.023). Older age was associated with reduced odds of HIVDR (25–34 years: aOR = 0.46, 95% CI:0.23–0.93); ≥ 45 years: aOR = 0.44, 95% CI:0.19–0.99). For EFV-positive individuals, being never married increased HIVDR odds (aOR = 3.23, 95% CI:1.05–9.95, p = 0.042), while employment substantially reduced odds (aOR = 0.32, 95% CI:0.10–0.97, p = 0.044). Elevated HIVDR among youth (15–24 years) likely reflects perinatal infection, prolonged paediatric ART, and treatment interruptions during transition to adult care.
conclusionThe 2017 pre-DTG baseline reveals high HIVDR (26.3%) shaped by clinical (ART, TB) and socio-structural (unemployment, stigma, marital status) factors. Distinct provincial and age-specific risk profiles, including youth with paediatric treatment histories, underscore the need for geographically tailored interventions, expanded resistance testing and youth-focused adherence and transition programmes.
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