7
Management of the Treatment-Experienced Patient
Î Assess adherence in patients with suppressed viremia.
Î Change drugs to manage toxicity.
Î Assess:
• The severity of HIV disease.
• The ARV treatment history – duration, drugs used, ARV potency and response;
adherence history; drug intolerance/toxicity; concomitant medication
interactions; HIV RNA and CD4 T-cell count trends; and the results of prior
drug resistance testing.
Î Optimal virologic response to treatment is maximal virologic
suppression (eg, HIV RNA level <48 copies/mL).
Î Virologic failure is defined as a confirmed viral load >200 copies/mL.
Î Obtain drug resistance testing while the patient is taking the failing
ARV regimen (or within 4 weeks of treatment discontinuation) (AI).
Î The goal of treatment for ARV-experienced patients with drug
resistance who are experiencing virologic failure is to re-establish
virologic suppression (eg, HIV RNA <48 copies/mL) (AI).
Î To design a new regimen, consider the patient's treatment history
and the past and current resistance test results (AII). Expert advice is
critical.
Î Adding at least two (preferably three) fully active agents to an
optimized background antiretroviral regimen can provide significant
antiretroviral activity (AII).
Î Immunologic failure:
Definition: Failure to achieve and maintain an adequate CD4 response despite
virologic suppression.
• Assess current medications, untreated coinfection, and serious medical conditions.
• There is no consensus for when and how to treat immunologic failure.
• The immunomodulator interleukin-2 has not demonstrated clinical benefits in
randomized trials and is NOT recommended (AI).
Î For some highly treatment-experienced patients, maximal virologic
suppression is not possible. In this case, continue ARV with regimens
designed to minimize toxicity, preserve CD4 cell counts, and avoid
clinical progression. Expert advice is essential.
