{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,1]],"date-time":"2026-10-01T00:16:02Z","timestamp":1790813762161,"version":"4.1.0"},"reference-count":56,"publisher":"MDPI AG","issue":"6","license":[{"start":{"date-parts":[[2020,6,5]],"date-time":"2020-06-05T00:00:00Z","timestamp":1591315200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"Mexican Government","award":["Comisi\u00f3n de Equidad y G\u00e9nero de las Legislaturas LX-LXI y Comisi\u00f3n de Igualdad de G\u00e9nero de la Legislatura LXII de la H. C\u00e1mara de Diputados de la Rep\u00fablica Mexicana"],"award-info":[{"award-number":["Comisi\u00f3n de Equidad y G\u00e9nero de las Legislaturas LX-LXI y Comisi\u00f3n de Igualdad de G\u00e9nero de la Legislatura LXII de la H. C\u00e1mara de Diputados de la Rep\u00fablica Mexicana"]}]},{"DOI":"10.13039\/501100003141","name":"Consejo Nacional de Ciencia y Tecnolog\u00eda","doi-asserted-by":"publisher","award":["CONACyT SALUD-2017-01-289725"],"award-info":[{"award-number":["CONACyT SALUD-2017-01-289725"]}],"id":[{"id":"10.13039\/501100003141","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Viruses"],"abstract":"<jats:p>Higher accessibility and decreasing costs of next generation sequencing (NGS), availability of commercial kits, and development of dedicated analysis pipelines, have allowed an increasing number of laboratories to adopt this technology for HIV drug resistance (HIVDR) genotyping. Conventional HIVDR genotyping is traditionally carried out using population-based Sanger sequencing, which has a limited capacity for reliable detection of variants present at intra-host frequencies below a threshold of approximately 20%. NGS has the potential to improve sensitivity and quantitatively identify low-abundance variants, improving efficiency and lowering costs. However, some challenges exist for the standardization and quality assurance of NGS-based HIVDR genotyping. In this paper, we highlight considerations of these challenges as related to laboratory, clinical, and implementation of NGS for HIV drug resistance testing. Several sources of variation and bias occur in each step of the general NGS workflow, i.e., starting material, sample type, PCR amplification, library preparation method, instrument and sequencing chemistry-inherent errors, and data analysis options and limitations. Additionally, adoption of NGS-based HIVDR genotyping, especially for clinical care, poses pressing challenges, especially for resource-poor settings, including infrastructure and equipment requirements and cost, logistic and supply chains, instrument service availability, personnel training, validated laboratory protocols, and standardized analysis outputs. The establishment of external quality assessment programs may help to address some of these challenges and is needed to proceed with NGS-based HIVDR genotyping adoption.<\/jats:p>","DOI":"10.3390\/v12060617","type":"journal-article","created":{"date-parts":[[2020,6,9]],"date-time":"2020-06-09T05:16:14Z","timestamp":1591679774000},"page":"617","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":88,"title":["Next-Generation Sequencing for HIV Drug Resistance Testing: Laboratory, Clinical, and Implementation Considerations"],"prefix":"10.3390","volume":"12","author":[{"given":"Santiago","family":"\u00c1vila-R\u00edos","sequence":"first","affiliation":[{"name":"Centre for Research in Infectious Diseases, National Institute of Respiratory Diseases, Calzada de Tlalpan 4502, Col. Secci\u00f3n XVI, Mexico City 14080, Mexico"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5824-3388","authenticated-orcid":false,"given":"Neil","family":"Parkin","sequence":"additional","affiliation":[{"name":"Data First Consulting, Inc., Sebastopol, CA 95472, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ronald","family":"Swanstrom","sequence":"additional","affiliation":[{"name":"Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Roger","family":"Paredes","sequence":"additional","affiliation":[{"name":"IrsiCaixa AIDS Research Institute, Badalona, 08916 Catalonia, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2513-2643","authenticated-orcid":false,"given":"Robert","family":"Shafer","sequence":"additional","affiliation":[{"name":"Division of Infectious Diseases, Stanford University School of Medicine, Stanford, CA 94305, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5451-6294","authenticated-orcid":false,"given":"Hezhao","family":"Ji","sequence":"additional","affiliation":[{"name":"National HIV and Retrovirology Laboratories at JC Wilt Infectious Diseases Research Centre, Public Health Agency of Canada, Winnipeg, MB R3E 3R2, Canada"},{"name":"Department of Medical Microbiology and Infectious Diseases, University of Manitoba, Winnipeg, MB R3E 0J9, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3659-1108","authenticated-orcid":false,"given":"Rami","family":"Kantor","sequence":"additional","affiliation":[{"name":"Division of Infectious Diseases, Brown University Alpert Medical School, Providence, RI 02906, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2020,6,5]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"97","DOI":"10.1016\/j.virusres.2016.12.008","article-title":"Promises and pitfalls of Illumina sequencing for HIV resistance genotyping","volume":"239","author":"Brumme","year":"2017","journal-title":"Virus Res."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"3559","DOI":"10.1128\/JCM.41.8.3559-3565.2003","article-title":"Quality control trial for human immunodeficiency virus type 1 drug resistance testing using clinical samples reveals problems with detecting minority species and interpretation of test results","volume":"41","author":"Korn","year":"2003","journal-title":"J. Clin. Microbiol."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"243","DOI":"10.1089\/088922202753472801","article-title":"Underestimation of HIV type 1 drug resistance mutations: Results from the ENVA-2 genotyping proficiency program","volume":"18","author":"Schuurman","year":"2002","journal-title":"AIDS Res. Hum. Retrovir."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"1634","DOI":"10.1038\/s41598-020-58544-z","article-title":"Performance comparison of next generation sequencing analysis pipelines for HIV-1 drug resistance testing","volume":"10","author":"Lee","year":"2020","journal-title":"Sci. Rep."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"e579","DOI":"10.1016\/S2352-3018(16)30119-9","article-title":"Pretreatment HIV-drug resistance in Mexico and its impact on the effectiveness of first-line antiretroviral therapy: A nationally representative 2015 WHO survey","volume":"3","author":"Ji","year":"2016","journal-title":"Lancet HIV"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"207","DOI":"10.1093\/cid\/ciy881","article-title":"Impact of next-generation sequencing defined human immunodeficiency virus pretreatment drug resistance on virological outcomes in the ANRS 12249 treatment-as-prevention trial","volume":"69","author":"Derache","year":"2019","journal-title":"Clin. Infect. Dis. Off. Pub. Infect. Dis. Soc. Am."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"e638","DOI":"10.1016\/S2352-3018(18)30177-2","article-title":"Clinically relevant thresholds for ultrasensitive HIV drug resistance testing: A multi-country nested case-control study","volume":"5","author":"Inzaule","year":"2018","journal-title":"Lancet HIV"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"1327","DOI":"10.1001\/jama.2011.375","article-title":"Low-frequency HIV-1 drug resistance mutations and risk of NNRTI-based antiretroviral treatment failure: A systematic review and pooled analysis","volume":"305","author":"Li","year":"2011","journal-title":"JAMA"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"941","DOI":"10.1097\/QAD.0000000000002134","article-title":"Minority and majority pretreatment HIV-1 drug resistance associated with failure of first-line nonnucleoside reverse-transcriptase inhibitor antiretroviral therapy in Kenyan women","volume":"33","author":"Milne","year":"2019","journal-title":"Aids"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"e25193","DOI":"10.1002\/jia2.25193","article-title":"Bioinformatic data processing pipelines in support of next-generation sequencing-based HIV drug resistance testing: The Winnipeg Consensus","volume":"21","author":"Ji","year":"2018","journal-title":"J. Int. AIDS Soc."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"69","DOI":"10.1016\/j.virusres.2016.10.019","article-title":"Deep sequencing for HIV-1 clinical management","volume":"239","author":"Casadella","year":"2017","journal-title":"Virus Res."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1016\/j.ygeno.2015.11.003","article-title":"The sequence of sequencers: The history of sequencing DNA","volume":"107","author":"Heather","year":"2016","journal-title":"Genom."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"2167","DOI":"10.1128\/AAC.02710-13","article-title":"Sensitive deep-sequencing-based HIV-1 genotyping assay to simultaneously determine susceptibility to protease, reverse transcriptase, integrase, and maturation inhibitors, as well as HIV-1 coreceptor tropism","volume":"58","author":"Gibson","year":"2014","journal-title":"Antimicrob. Agents Chemother."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"18","DOI":"10.1186\/s12981-018-0206-y","article-title":"Characterization of minority HIV-1 drug resistant variants in the United Kingdom following the verification of a deep sequencing-based HIV-1 genotyping and tropism assay","volume":"15","author":"Silver","year":"2018","journal-title":"AIDS Res. Ther."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"e00105","DOI":"10.1128\/JCM.00105-18","article-title":"Comparison of an In Vitro Diagnostic Next-Generation Sequencing Assay with Sanger Sequencing for HIV-1 Genotypic Resistance Testing","volume":"56","author":"Tzou","year":"2018","journal-title":"J. Clin. Microbiol."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"2823","DOI":"10.1093\/jac\/dkx232","article-title":"RNA and DNA Sanger sequencing versus next-generation sequencing for HIV-1 drug resistance testing in treatment-naive patients","volume":"72","author":"Alidjinou","year":"2017","journal-title":"J. Antimicrob. Chemother."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"104207","DOI":"10.1016\/j.jcv.2019.104207","article-title":"Routine drug resistance testing in HIV-1 proviral DNA, using an automated next- generation sequencing assay","volume":"121","author":"Alidjinou","year":"2019","journal-title":"J. Clin. Virol. Off. Pub. Pan Am. Soc. Clin. Virol."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"1684","DOI":"10.1002\/jmv.25474","article-title":"Routine drug resistance testing in proviral HIV-1 DNA: Prevalence of stop codons and hypermutation, and associated factors","volume":"91","author":"Alidjinou","year":"2019","journal-title":"J. Med. Virol."},{"key":"ref_19","doi-asserted-by":"crossref","unstructured":"Aitken, S.C., Wallis, C.L., Stevens, W., de Wit, T.R., and Schuurman, R. (2015). Stability of HIV-1 Nucleic Acids in Dried Blood Spot Samples for HIV-1 Drug Resistance Genotyping. PLoS ONE, 10.","DOI":"10.1371\/journal.pone.0131541"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"2868","DOI":"10.1128\/JCM.00544-14","article-title":"Field study of dried blood spot specimens for HIV-1 drug resistance genotyping","volume":"52","author":"Parry","year":"2014","journal-title":"J. Clin. Microbiol."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"107","DOI":"10.1177\/135965350701200114","article-title":"HIV-1 drug resistance surveillance using dried whole blood spots","volume":"12","author":"Bertagnolio","year":"2007","journal-title":"Antivir. Ther."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"206","DOI":"10.1016\/j.jcv.2004.11.006","article-title":"Assessment of drug resistance mutations in plasma and peripheral blood mononuclear cells at different plasma viral loads in patients receiving HAART","volume":"33","author":"Chew","year":"2005","journal-title":"J. Clin. Virol. Off. Pub. Pan Am. Soc. Clin. Virol."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"283","DOI":"10.1016\/j.jcv.2007.12.011","article-title":"Evaluation of dried blood spot specimens for HIV-1 drug-resistance testing using the Trugene HIV-1 genotyping assay","volume":"41","author":"Hallack","year":"2008","journal-title":"J. Clin. Virol. Off. Pub. Pan Am. Soc. Clin. Virol."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"134","DOI":"10.2174\/157016210790442740","article-title":"Stability of dried blood spots for HIV-1 drug resistance analysis","volume":"8","author":"Hearps","year":"2010","journal-title":"Curr. HIV Res."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"1191","DOI":"10.1093\/jac\/dkn412","article-title":"Development and optimization of an internally controlled dried blood spot assay for surveillance of human immunodeficiency virus type-1 drug resistance","volume":"62","author":"Buckton","year":"2008","journal-title":"J. Antimicrob. Chemother."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"2503","DOI":"10.1097\/QAD.0b013e3281c618db","article-title":"High concordance between HIV-1 drug resistance genotypes generated from plasma and dried blood spots in antiretroviral-experienced patients","volume":"21","author":"Masciotra","year":"2007","journal-title":"Aids"},{"key":"ref_27","doi-asserted-by":"crossref","unstructured":"Ji, H., Li, Y., Liang, B., Pilon, R., MacPherson, P., Bergeron, M., Kim, J., Graham, M., Van Domselaar, G., and Sandstrom, P. (2013). Pyrosequencing dried blood spots reveals differences in HIV drug resistance between treatment naive and experienced patients. PLoS ONE, 8.","DOI":"10.1371\/journal.pone.0056170"},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"8540","DOI":"10.1128\/JVI.00522-15","article-title":"Primer ID validates template sampling depth and greatly reduces the error rate of next-generation sequencing of HIV-1 genomic RNA populations","volume":"89","author":"Zhou","year":"2015","journal-title":"J. Virol."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"1917","DOI":"10.1093\/jac\/dky103","article-title":"Low prevalence of transmitted HIV-1 drug resistance detected by a dried blood spot (DBS)-based next-generation sequencing (NGS) method in newly diagnosed individuals in Cameroon in the years 2015-16","volume":"73","author":"Mbunkah","year":"2018","journal-title":"J. Antimicrob. Chemother."},{"key":"ref_30","doi-asserted-by":"crossref","unstructured":"Varghese, V., Wang, E., Babrzadeh, F., Bachmann, M.H., Shahriar, R., Liu, T., Mappala, S.J., Gharizadeh, B., Fessel, W.J., and Katzenstein, D. (2010). Nucleic acid template and the risk of a PCR-Induced HIV-1 drug resistance mutation. PLoS ONE, 5.","DOI":"10.1371\/journal.pone.0010992"},{"key":"ref_31","doi-asserted-by":"crossref","unstructured":"Macalalad, A.R., Zody, M.C., Charlebois, P., Lennon, N.J., Newman, R.M., Malboeuf, C.M., Ryan, E.M., Boutwell, C.L., Power, K.A., and Brackney, D.E. (2012). Highly sensitive and specific detection of rare variants in mixed viral populations from massively parallel sequence data. PLoS Comput. Biol., 8.","DOI":"10.1371\/journal.pcbi.1002417"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"657","DOI":"10.1086\/655397","article-title":"Minority variants of drug-resistant HIV","volume":"202","author":"Gianella","year":"2010","journal-title":"J. Infect. Dis."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"1584","DOI":"10.1093\/infdis\/jiz650","article-title":"Low-abundance drug-resistant HIV-1 variants in antiretroviral drug-naive individuals: A systematic review of detection methods, prevalence, and clinical impact","volume":"221","author":"Mbunkah","year":"2020","journal-title":"J. Infect. Dis."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"2033","DOI":"10.1101\/gr.177881.114","article-title":"Tn5 transposase and tagmentation procedures for massively scaled sequencing projects","volume":"24","author":"Picelli","year":"2014","journal-title":"Genome Res."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"752","DOI":"10.1126\/science.aai8690","article-title":"DNA damage is a pervasive cause of sequencing errors, directly confounding variant identification","volume":"355","author":"Chen","year":"2017","journal-title":"Science"},{"key":"ref_36","doi-asserted-by":"crossref","unstructured":"Quail, M.A., Smith, M., Coupland, P., Otto, T.D., Harris, S.R., Connor, T.R., Bertoni, A., Swerdlow, H.P., and Gu, Y. (2012). A tale of three next generation sequencing platforms: Comparison of ion torrent, pacific biosciences and illumina MiSeq sequencers. BMC Genom., 13.","DOI":"10.1186\/1471-2164-13-341"},{"key":"ref_37","doi-asserted-by":"crossref","unstructured":"Tzou, P.L., Kosakovsky Pond, S.L., Avila-Rios, S., Holmes, S.P., Kantor, R., and Shafer, R.W. (2020). Analysis of unusual and signature APOBEC-mutations in HIV-1 pol next-generation sequences. PLoS ONE, 15.","DOI":"10.1371\/journal.pone.0225352"},{"key":"ref_38","unstructured":"WHO (2020, May 28). The Use of Next-Generation Sequencing Technologies for the Detection of Mutations Associated with Drug Resistance in Mycobacterium Tuberculosis Complex: Technical Guide. Available online: https:\/\/apps.who.int\/iris\/handle\/10665\/274443."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"869","DOI":"10.1089\/aid.1998.14.869","article-title":"Comparative performance of high-density oligonucleotide sequencing and dideoxynucleotide sequencing of HIV type 1 pol from clinical samples","volume":"14","author":"Gunthard","year":"1998","journal-title":"AIDS Res. Hum. Retrovir."},{"key":"ref_40","doi-asserted-by":"crossref","unstructured":"Lee, E.R., Enns, E., Parkin, N., Brumme, C.J., Howison, M., Avila-Rios, S., Jennings, C., Van Domselaar, G., Noguera-Julian, M., and Harrigan, P.R. (2019, January 4\u20137). Comparison of next-generation sequencing analysis pipelines for HIV-1 drug resistance. Proceedings of the Conference on Retroviruses and Opportunistic Infections, Seattle, WA, USA. Abstract 542.","DOI":"10.1038\/s41598-020-58544-z"},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"182","DOI":"10.1016\/j.ijid.2020.02.004","article-title":"Shall I trust the report? Variable performance of Sanger sequencing revealed by deep sequencing on HIV drug resistance mutation detection","volume":"93","author":"Chen","year":"2020","journal-title":"Int. J. Infect. Dis. IJID: Off. Pub. Int. Soc. Infect. Dis."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"1486","DOI":"10.1002\/jmv.25224","article-title":"Performance comparison of deep sequencing platforms for detecting HIV-1 variants in the pol gene","volume":"90","author":"Nicot","year":"2018","journal-title":"J. Med. Virol."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"12","DOI":"10.1016\/j.jviromet.2014.11.003","article-title":"Evaluation of GS Junior and MiSeq next-generation sequencing technologies as an alternative to Trugene population sequencing in the clinical HIV laboratory","volume":"212","author":"Ram","year":"2015","journal-title":"J. Virol. Methods"},{"key":"ref_44","doi-asserted-by":"crossref","unstructured":"Ji, H., Parkin, N., Gao, F., Denny, T., Jennings, C., Sandstrom, P., and Kantor, R. (2020). External quality assessment program for next generation sequencing-based HIV drug resistance testing: Logistical considerations. Viruses, 12.","DOI":"10.3390\/v12050556"},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"7","DOI":"10.1016\/j.jviromet.2016.11.008","article-title":"MinVar: A rapid and versatile tool for HIV-1 drug resistance genotyping by deep sequencing","volume":"240","author":"Huber","year":"2017","journal-title":"J. Virol. Methods"},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"1588","DOI":"10.1093\/cid\/cix1070","article-title":"Impact of Human Immunodeficiency Virus Type 1 Minority Variants on the Virus Response to a Rilpivirine-Based First-line Regimen","volume":"66","author":"Raymond","year":"2018","journal-title":"Clin. Infect. Dis. Off. Pub. Infect. Dis. Soc. Am."},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"1631","DOI":"10.1093\/cid\/ciz219","article-title":"Building the framework for standardized clinical laboratory reporting of next-generation sequencing data for resistance-associated mutations in mycobacterium tuberculosis complex","volume":"69","author":"Tornheim","year":"2019","journal-title":"Clin. Infect. Dis. Off. Pub. Infect. Dis. Soc. Am."},{"key":"ref_48","doi-asserted-by":"crossref","unstructured":"Lee, E.R., Gao, F., Sandstrom, P., and Ji, H. (2020). External quality assessment for next-generation sequencing-based HIV drug resistance testing: Unique requirements and challenges. Viruses, 12.","DOI":"10.3390\/v12050550"},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"550","DOI":"10.3390\/v12050550","article-title":"Dry panels supporting external quality assessment programs for next generation sequencing-based HIV drug resistance testing","volume":"12","author":"Lee","year":"2020","journal-title":"Viruses"},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"346","DOI":"10.1016\/S1473-3099(17)30702-8","article-title":"HIV-1 drug resistance before initiation or re-initiation of first-line antiretroviral therapy in low-income and middle-income countries: A systematic review and meta-regression analysis","volume":"18","author":"Gupta","year":"2018","journal-title":"Lancet Infect. Dis."},{"key":"ref_51","unstructured":"WHO (2019). HIV Drug Resistance Report 2019, WHO. Available online: https:\/\/www.who.int\/hiv\/pub\/drugresistance\/hivdr-report-2019\/en\/."},{"key":"ref_52","unstructured":"UNAIDS (2020, May 28). 90-90-90: An Ambitious Treatment Target to Help End the AIDS Epidemic. Available online: http:\/\/www.unaids.org\/sites\/default\/files\/media_asset\/90-90-90_en_0.pdf."},{"key":"ref_53","unstructured":"(2020, May 28). WHO Global Action Plan on HIV Drug Resistance 2017\u20132021. Available online: http:\/\/www.who.int\/hiv\/pub\/drugresistance\/hivdr-action-plan-2017-2021\/en\/."},{"key":"ref_54","unstructured":"(2020, May 28). WHO Surveillance of HIV Drug Resistance in Adults Receiving ART (Acquired HIV Drug Resistance), Concept Note. Available online: http:\/\/www.who.int\/hiv\/pub\/drugresistance\/acquired_drugresistance\/en\/."},{"key":"ref_55","unstructured":"(2020, May 28). WHO Surveillance of HIV Drug Resistance in Adults Initiating Antiretroviral Therapy (Pre-Treatment HIV Drug Resistance). Concept Note. Available online: http:\/\/www.who.int\/hiv\/pub\/drugresistance\/pretreatment_drugresistance\/en\/."},{"key":"ref_56","unstructured":"WHO (2020, May 28). WHO\/HIV ResNet HIV Drug Resistance Laboratory Operational Framework. Available online: http:\/\/www.who.int\/hiv\/pub\/drugresistance\/hivdr-laboratory-framework-2017\/en\/."}],"container-title":["Viruses"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1999-4915\/12\/6\/617\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,11]],"date-time":"2025-10-11T09:35:54Z","timestamp":1760175354000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1999-4915\/12\/6\/617"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2020,6,5]]},"references-count":56,"journal-issue":{"issue":"6","published-online":{"date-parts":[[2020,6]]}},"alternative-id":["v12060617"],"URL":"https:\/\/doi.org\/10.3390\/v12060617","relation":{},"ISSN":["1999-4915"],"issn-type":[{"value":"1999-4915","type":"electronic"}],"subject":[],"published":{"date-parts":[[2020,6,5]]}}}