4. Discussion
virologic failure, VF
Our study identified major DR in most CHIV with VF. The last published comprehensive DR surveillance for children in Kenya was in 2013 before the changes to the recommend PI-containing ART for children less than three years of age came into effect [Developing strategies to optimize cost-effective use for targeted DRT among CHIV with VF is key to achieving higher rates of viral suppression in CHIV. A prior history of VF was a strong predictor of major DR. This finding is important, as the guidelines in many countries do not take this into account in their algorithms to guide the management of children with VF. Studies in both adults and children have demonstrated the accumulation of new drug resistance with continued virologic failure [Our findings support the broader use of DRT in CHIV, which is lacking in many settings [The rapid transition to DTG-containing regimens in children provides hope for improved VS in all CHIV, including for those with VF. Our findings showed high viral resuppression in a small number of children with VF who were switched to a DTG-containing regimen. How DRT should be used in the setting of wide-spread DTG use in children remains uncertain. NRTI mutations were highly prevalent in the CHIV with VF in this cohort, which is similar to other reports in children [The limitations of this study include the inability to determine pre-treatment DR due to the fact that there were few children who were initiating ART in this cohort and the lack of data on maternal ART and DR history, which is likely to correlate with DR identified in participants. Additionally, our study utilized DRT laboratories in Kenya to optimize the generalizability of DRT use in CHIV, but INSTI DR testing was limited during the study period. While we observed a rapid transition to DTG-containing regimens, we were not able to perform INSTI DR on CHIV with VF on DTG. We plan to use stored samples to further explore these issues.