Selecting an antiretroviral regimen for treatment-experienced HIV-infected patients who are failing therapy
- Eric S Daar, MD
Eric S Daar, MD
- Professor of Medicine
- David Geffen School of Medicine at UCLA
- Section Editors
- John G Bartlett, MD
John G Bartlett, MD
- Editor-in-Chief — Infectious Diseases
- Section Editor — HIV; Pulmonary Infections
- Professor Emeritus
- Johns Hopkins University School of Medicine
- Paul E Sax, MD
Paul E Sax, MD
- Section Editor — HIV
- Clinical Director, Division of Infectious Diseases
- Brigham and Women's Hospital
- Professor of Medicine
- Harvard Medical School
The standard of care in HIV management is to maximally suppress plasma HIV RNA to prevent HIV disease progression and the emergence of drug-resistant virus. Achieving virologic suppression can be difficult for HIV-infected patients with drug-resistant virus; however, advances in drug development have enabled great progress in the treatment of this patient population, even among those who have resistance to one or two classes of antiretroviral agents.
This topic will discuss how to select a combination antiretroviral therapy regimen for treatment-experienced patients who are failing therapy. Topic reviews that provide an overview of drug resistance testing and discuss how to evaluate treatment-experienced patients failing therapy are presented elsewhere. (See "Overview of HIV drug resistance testing assays" and "Interpretation of HIV drug resistance testing" and "Evaluation of the treatment-experienced patient failing HIV therapy".)
GOALS OF THERAPY
The goal of antiretroviral therapy (ART) is to suppress the viral load to below the level of detection using most commercial assays. Maintaining an undetectable viral load helps prevent disease progression, improve survival, prevent the emergence of drug-resistant virus, and reduce the risk of transmitting HIV to others.
Minimizing the viral load is best achieved with the use of an ART regimen that consists of two to three fully active agents from at least two different classes of drugs . Among patients with virologic failure and drug-resistant virus, this goal can still be achieved even if fewer than two to three active agents are used; however, the likelihood of virologic suppression depends upon the drugs used and number and types of drug-resistant mutations that are present.
Patients with drug-resistant virus who are failing an initial regimen that includes a first-line nucleoside/nucleotide reverse transcriptase inhibitor (NRTI) backbone plus a non-nucleoside reverse transcriptase inhibitor (NNRTI), an integrase strand transfer inhibitor (INSTI), or a pharmacologically boosted protease inhibitor (PI) are likely to achieve viral suppression with their subsequent regimen. These first-line regimens are less likely to result in highly resistant virus compared with older regimens that were less potent. For patients with drug-resistant virus who have failed multiple regimens, the treatment goal is still to decrease the viral load to below the level of detection, and if this is not attainable, to the lowest level possible.To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
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- GOALS OF THERAPY
- DRUGS BY CLASS AND ABBREVIATIONS USED
- INITIAL EVALUATION
- PATIENTS WITHOUT DRUG-RESISTANT VIRUS
- PATIENTS WITH DRUG-RESISTANT VIRUS
- General principles
- Patients failing their initial regimen
- - NNRTI-containing regimens
- - INSTI-containing regimen
- - A pharmacologically boosted PI
- Patients who have failed multiple regimens
- - If a fully active PI is available
- - If a fully active INSTI is available
- - If a fully active PI is NOT available
- VIRAL LOAD MONITORING
- MANAGEMENT OF PATIENTS WITH INCOMPLETE VIRAL SUPPRESSION
- OVERVIEW OF SPECIFIC ANTIRETROVIRAL AGENTS
- Nucleoside/nucleotide reverse transcriptase inhibitors
- Protease inhibitors
- Integrase strand transfer inhibitors
- Non-nucleoside reverse transcriptase inhibitors
- CCR5 antagonists
- Fusion inhibitors
- SOCIETY GUIDELINE LINKS
- SUMMARY AND RECOMMENDATIONS