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Review
. 2025 Sep;12(9):e664-e668.
doi: 10.1016/S2352-3018(25)00108-0. Epub 2025 Jun 18.

Do we need routine integrase resistance testing before starting antiretroviral therapy?

Rami Kantor  1 , Alice K Pau  2 , Michael J Kozal  3 , Emily P Hyle  4
Affiliations
Review

Do we need routine integrase resistance testing before starting antiretroviral therapy?

Rami Kantor et al. Lancet HIV. 2025 Sep.

Abstract

Oral second-generation integrase strand transfer inhibitors are now anchor drugs of antiretroviral therapy (ART) globally due to their high resistance barriers. In high-income settings, guidelines recommend routine protease and reverse transcriptase resistance testing before ART initiation but suggest routine integrase resistance testing only for individuals at elevated risk of integrase resistance. Improved characterisation of transmitted integrase resistance, its detection, and its clinical impact will guide future recommendations for clinical decision making. Balancing the need to protect this important drug class against concerns about resource allocation and care complexity presents a substantial challenge. Shifting the responsibility to providers to decide whether and when to test for integrase resistance before ART initiation can be problematic, particularly given the uncertainty around the need to reassess related available recommendations. As our understanding of integrase resistance evolves, prioritising this discussion is essential, and providers, researchers, and policy makers should engage in addressing this important issue.

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Conflict of interest statement

Declaration of interests RK reports receiving support from the US National Institutes of Health (NIH) paid to his institution, support from Gilead Sciences for a research grant on COVID-19 paid to his institution, honoraria from Thermofisher for a lecture at a conference workshop on drug resistance in integrase strand transfer inhibitors, and support for attending meetings and travel from WHO for an HIV drug resistance meeting. AKP reports being the executive secretary of the Department of Health and Human Services Panel on Antiretroviral Treatment Guidelines for Adults and Adolescents, the executive secretary of the NIH COVID-19 Treatment Guidelines (ended Aug 16, 2024), and the co-chair of the Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV. EPH reports receiving support from the NIH and Massachusetts General Hospital paid to her institution, support from UpToDate paid to herself, and support for attending meetings and travel from WHO for an HIV drug resistance meeting. MJK declares no competing interests.

References

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