Assessing HIV resistance in developing countries: Brazil as a case study

Increased transmission of resistant HIV has been raised as a potential consequence of expanded access to antiretroviral therapy. We review how limitations in resources and health care infrastructure may impact the transmission of resistant HIV, and we examine data from Brazil as a case study. We introduce a biological and clinical framework to identify the major determinants of transmitted resistance and to discuss how these determinants may be affected by a lack of infrastructure. We then use our framework to examine HIV resistance data from Brazil. This country was chosen as a case study due to its extensive experience delivering antiretroviral drugs and because of the availability of data on the prevalence of resistant HIV there. The data from Brazil show that antiretroviral therapy can be delivered in a resource-limited setting without resulting in widespread transmission of resistant virus. Mile the Brazilian experience does not necessarily generalize to countries with less health care infrastructure, neither theory nor data support a foregone conclusion that resistance will necessarily dominate HIV epidemics in the developing world to a greater extent than it does in the developed world.