Management of the Treatment-Experienced Patient ÎAssess adherence in patients with suppressed viremia.
ÎChange drugs to manage toxicity.
ÎAssess: • 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.
ÎOptimal virologic response to treatment is maximal virologic suppression (eg, HIV RNA level < 48 copies/mL).
ÎVirologic failure is defined as a confirmed viral load > 200 copies/mL.
ÎObtain drug resistance testing while the patient is taking the failing ARV regimen (or within 4 weeks of treatment discontinuation) (AI).
ÎThe 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).
ÎTo design a new regimen, consider the patient's treatment history and the past and current resistance test results (AII). Expert advice is critical.
ÎAdding at least two (preferably three) fully active agents to an optimized background antiretroviral regimen can provide significant antiretroviral activity (AII).
ÎImmunologic 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).
ÎFor 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.
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