Beating HIV from day 1: strengthening same-day antiretroviral therapy in South Africa: challenges, realities, and the path forward

The growing use of antiretroviral therapy (ART) has transformed HIV infection into a chronic, manageable disease, yet the emergence of drug resistance continues to threaten global progress. Morocco, located at the crossroads of Sub-Saharan Africa and Europe, offers a unique context for understanding the molecular evolution of HIV in the Middle East and North Africa. This systematic review synthesizes all available data on HIV-1 genotyping and resistance mutations in Morocco from 2009 to 2024, providing the first national overview of molecular resistance patterns. Six studies comprising 673 individuals met the inclusion criteria, spanning 2004-2015. Subtype B predominated (73.8%), followed by CRF02_AG (17.6%), reflecting increasing viral diversification linked to cross-regional transmission. Among ART-experienced patients, acquired drug resistance reached 19.5% at the population level and 53.3% among successfully sequenced samples, with NRTI (48.9%) and PI (22.2%) mutations predominating. The most frequent mutations were M184V (44%), K103N (8.9%), and V82A/L (13.3%). In ART-naïve individuals, transmitted resistance remained limited (1.55%), with no major integrase strand-transfer inhibitor mutations detected, though accessory polymorphisms such as L74M/I and E157Q were present in 3-5% of cases. CD4 counts and viral load suppression improved in later cohorts. These findings underline the critical need to re-establish molecular surveillance in Morocco to capture post-2019 resistance dynamics under dolutegravir-based therapy. Strengthening genotypic monitoring and integrating resistance testing into clinical care will be pivotal to preserving long-term ART efficacy and achieving the UNAIDS 95-95-95 and HIV elimination targets by 2030.