HIV-1 Drug Resistance in Children and Implications for Pediatric Treatment Strategies: A Systematic Review and Meta-Analysis

Failure in the prevention of mother-to-child HIV transmission (PMTCT) and pediatric treatment challenges led to pretreatment drug resistance (PDR) and acquired drug resistance (ADR) in children with HIV (CWHIV). Interventional and observational data published between 2010 and 2024 on PDR and ADR in CWHIV were included and analyzed by random effects models. Overall, 72 studies encompassing 9973 children were included. The prevalence (95% CI) of PDR was 32.48% (26.08– 39.21), and high among those who failed PMTCT prophylaxis (43.23% [32.94–53.82]) versus those without PMTCT-intervention (P < .01) and driven by nonnucleoside reverse transcriptase inhibitors (NNRTI) mutations (28.38% [18.74–39.08]; P = .013). The prevalence of ADR was 61.43% (49.82–72.45), driven by NNRTI-mutations (65.17% [53.95–75.63]; P < .001). INSTI-ADR was low (5.53% [2.49–9.53]) but emerging. There are high burdens of PDR and ADR among CWHIV, suggesting the need to phase out pediatric NNRTIs used for either PMTCT or treatment. Emerging INSTI resistance among CWHIV highlights the relevance of drug-resistance surveillance strategies.