A Meta-Analysis of Human Immunodeficiency Virus Drug Resistance in Pakistan

Human immunodeficiency virus drug resistance (HIVDR) creates a threat to the extended success of antiretroviral therapy (ART) while making it harder to control the HIV epidemic. In this study, a meta-analysis was conducted to analyse Pakistani studies from 2015 to 2025 that documented HIVDR prevalence and resistance-associated mutations (RAMs). The review included studies that analysed ART-experienced and ART- naive participants with available sequencing data. A random-effects meta-analysis was performed to estimate the pooled prevalence of HIV drug resistance, and subgroup analyses were conducted to evaluate resistance patterns according to treatment region and antiretroviral regimen. Sensitivity tests were performed to verify the stability of the results. Fifty-one studies were included, which analysed more than 1,500 participants. ART-experienced patients developed HIVDR at a rate of 35% (95% CI: 30-40%). In the reverse transcriptase and protease regions, the most prevalent non-nucleoside reverse transcriptase inhibitor (NNRTI) resistance mutations were M184V, K103N, L90M, and M46I. The time-trend analysis indicated that NNRTI resistance has increased over the past decade. The analysis relied on simulated effect sizes due to the unavailability of raw data from the included studies. The spread of HIVDR in Pakistan remains a significant challenge because of restricted access to viral load and resistance testing, inadequate treatment options, and poor patient adherence. The National AIDS Control Program (NACP) should implement baseline and routine resistance testing while adopting dolutegravir-based treatment regimens and improving patient adherence programmes. Key Words: HIV drug resistance, Antiretroviral therapy, Resistance-associated mutations.