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SA Health News Desk
An adapted ITREMA-2 reflex strategy is moving into South African public HIV care, using dolutegravir exposure testing to target resistance testing more selectively.
South Africa has begun incorporating a more targeted way of deciding who needs HIV drug-resistance testing when dolutegravir-based treatment stops fully suppressing the virus.
The approach comes from the ITREMA-2 implementation study conducted at Hillbrow Community Health Centre and Helen Joseph Hospital in Johannesburg. Researchers from Wits University, the National Health Laboratory Service and University Medical Center Utrecht studied 288 adults on dolutegravir-based antiretroviral therapy whose viral load had rebounded to at least 400 copies per millilitre.
Instead of sending every patient with confirmed viraemia for costly resistance testing, the strategy first measures whether dolutegravir is detectable in the same blood sample used for viral-load monitoring. If the drug is present despite ongoing viral replication, resistance testing is then targeted to patients at higher risk of carrying resistant virus.
The study was published in The Lancet HIV on 2 September 2026. Wits announced on 25 September that an adapted version of the reflex-testing strategy has now been incorporated into South African public HIV care.
Researchers analysed 400 samples from 288 people between May 2023 and January 2025. The median participant age was 44, 56% were women and 83% had previously used antiretroviral treatment that did not contain dolutegravir.
Dolutegravir was detectable in 108 participants, or 38%.
Among participants whose samples could be successfully sequenced, dolutegravir resistance was found in 13 of 102 people with detectable drug levels, compared with three of 138 people whose dolutegravir level was undetectable.
Across the successfully evaluated group, the prevalence of dolutegravir resistance was 6.7%.
The absence of detectable dolutegravir was particularly useful for ruling out resistance: the strategy had a negative predictive value of 97.8% for the absence of dolutegravir resistance.
When viral load rises during treatment, clinicians need to work out why. One possibility is resistance; another is interrupted or missed doses. Those situations require different responses.
The ITREMA-2 approach is designed to narrow that uncertainty earlier by using drug-exposure information already present in a blood sample.
Researchers modelled that monitoring costs per patient would be 23% lower than under the previous national approach because full resistance testing could be concentrated on patients most likely to benefit from it. That figure is a modelled laboratory-cost estimate, not evidence that the entire HIV programme will become 23% cheaper.
According to Wits, the National Department of Health has now implemented an adapted version of the reflex-testing strategy in public HIV care.
The practical change is not a new HIV medicine. It is a change in how laboratories and clinicians investigate treatment that appears not to be working.
The study does not support changing or stopping antiretroviral treatment without clinical assessment.
SA Health News is journalism, not medical advice. People receiving HIV treatment should discuss viral-load results or treatment changes with their healthcare provider.
Source: SA Health News Desk
