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Reversion can occur because the M184V mutation results in a virus that replicates less efficiently than a drug-susceptible wild-type virus [126]. Thus, the drug-resistant virus could be outgrown by faster-replicating revertant viruses. Another explanation for the low levels of transmission of the M184V is that this mutation strongly reduces the viral load [25, 127]. As viral load is key to the transmission of the virus [5], M184V-containing viruses are less likely to be transmitted. Transmission of the K65R mutation was rare and only reported in two studies [108, 110]. It is not surprising that transmission of K65R was not found in most studies as this mutation was also uncommon http://www.selleckchem.com/products/ly2157299.html in studies on acquired resistance (see Table?3). Moreover, K65R-containing HIV strains are, similar to viruses including M184V, associated with a lower viral load [128], which makes transmission of this mutation less likely. Resistance to protease inhibitors was reported in a few studies, albeit at a limited level of up to 3.8%. Protease inhibitors are not widely used in Africa as they are expensive [83] and are reserved for second-line treatment [82, 90]. Some protease inhibitor resistance-associated mutations occur naturally at a low level in HIV subtypes A, C, D and G [129], which are common in Africa [23, 130]. These polymorphic mutations may explain the low level of transmitted protease inhibitor resistance found in some studies. It should be noted that virtually all epidemiological studies in resource-poor and in resource-rich settings used population sequencing to identify drug-resistance-associated mutations. Population sequencing does not allow quantification http://www.selleckchem.com/products/z-vad-fmk.html of minority species that are present in http://www.selleck.cn/products/BIBW2992.html reduce the benefits of a T&T programme. However, in a successful T&T programme increased numbers of patients will start treatment, which may lead to larger number of patients in whom drug-resistant viruses emerge. These viruses can be transmitted to others. Treatment options are limited in Africa and it is therefore likely that if transmission of resistance occurs, future antiretroviral therapy in a newly infected individual may be affected. Treatment of a transmitted drug-resistant variant is associated with an increased risk of virological failure [24]. Patients infected with a drug-resistant variant may therefore continue to spread their virus to others, leading to forward transmission. Studies in resource-rich countries have identified transmission networks of drug-resistant HIV [136, 137].