Researchers at Wits University, the National Health Laboratory Service (NHLS), and University Medical Center Utrecht have developed a faster way to identify HIV drug resistance in public clinics. The approach — called the Intensified Treatment Evaluation and Monitoring Approach (ITREMA-2) — has now been adopted by the South African National Department of Health for routine HIV care.
The study was published in The Lancet HIV on 2 September 2026.
The problem ITREMA-2 solves
When a patient on dolutegravir-based antiretroviral treatment has a rising viral load, doctors face a difficult choice. Either the patient is struggling to take their pills consistently — or the virus has mutated and become resistant to the drug. The two situations need completely different responses, but until now, telling them apart required months of counselling and expensive resistance testing.
That delay has a cost. Patients with undetected resistance keep taking a drug that is not working. Patients with adherence problems get switched to expensive second-line regimens they do not need. And the public health system pays for resistance tests that could have been avoided.
How the new test works
ITREMA-2 uses a quick blood exposure test that measures how much dolutegravir is present in the patient's blood at the time of the viral load test.
- If the drug is not in the blood — the patient has likely not been able to take their pills recently, so resistance is unlikely. The right response is support and counselling, not a regimen change.
- If the drug is in the blood but the virus is still growing — resistance is likely. That is the person who needs a resistance test and, if confirmed, a new treatment regimen.
"An increased viral load does not automatically mean that treatment is failing because of drug resistance. Measuring dolutegravir in the same sample helps identify who needs resistance testing." — Prof Annemarie Wensing, lead researcher
Why this matters for South Africa
South Africa has the largest HIV treatment programme in the world. Any change to how resistance is managed at scale has enormous implications for both patient outcomes and the public health budget.
According to the Wits release, incorporating the reflex testing strategy into routine care at confirmed virological failure reduced estimated laboratory monitoring costs by 23% compared to the previous standard approach. Those savings come from avoiding unnecessary resistance tests, which means public clinics can stretch their budgets further and maintain a steady supply of HIV medications.
Patient impact
The study highlights three benefits for people living with HIV:
- Faster, right-first-time care. If the virus has become resistant, patients do not waste months on a pill that is not working.
- Better support, less blame. If the test shows the drug is absent, it confirms that adherence is the issue — which allows clinic staff to offer tailored counselling rather than judgement.
- Protected public healthcare. The savings on unnecessary lab tests help ensure a stable supply of high-quality medications for everyone.
What comes next
The South African National Department of Health has already implemented an adapted version of the reflex testing strategy in public HIV care. Dr Kim Steegen of the NHLS and Wits, co-principal investigator of ITREMA-2, said the team has worked with the Department since the project began to keep them informed as results came in.
"By doing this, we have been able to include an adapted version of ITREMA-2 into the national guidelines, which means the people who need resistance testing the most can be easily identified." — Dr Kim Steegen, co-principal investigator
The ITREMA-2 study was funded by the Amsterdam Dinner Foundation through Aidsfonds and the Dutch Research Council (NWO).
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