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4 Treatment-Experienced Patients

Overview

  • The goal of ARV therapy regardless of previous ARV treatment experience is sustained suppression of pVL <40 copies/mL

  • Due to variability of the current pVL assay near the lower limit of detection, pVL between 40 and 250 copies/mL does not necessarily indicate virologic failure.

  • Virologic failure is defined as pVL >250 copies/mL × 2 consecutively, especially if accompanied by genotypic resistance. Determinants of treatment failure (especially suboptimal adherence) should be addressed.

  • A new regimen should be constructed including two and ideally three fully active drugs, taking into consideration treatment history, past and present resistance test results, and previous tolerability and toxicity issues.
  • Virologic failure with multidrug resistance should be managed by an expert.

  • In patients with immunologic failure (suboptimal CD4 count responses despite pVL consistently <40 copies/mL), neither ARV strategies (e.g. changing or intensification) nor immune-based therapies have shown consistent success; these are not currently recommended.

  • Treatment interruptions should be avoided.

How do I manage my treatment-experienced patient?

  • What is the patient's pVL(copies/mL)?
    • < 40
    • 40 – 250
    • > 250
    • > 250 ×2 consecutively
  • Is toxicity or tolerability an issue?
    • Yes
    • No
  • Does the genotype show any resistance?
    • Yes
    • No
  • Assess and manage:

    Repeat pVL in approx. 4 weeks.

  • Assess and manage:

    Repeat pVL in approx. 4 weeks and order genotype test on both samples.

    • Consider replacing 1 or more drugs with other active agents

    • Check prior demonstrated genotypic resistance

    • Check for overlapping toxicity/tolerability profiles

  • Continue regimen
  • Consider consulting an expert for guidance regarding a prompt regimen change.
    Available for contact: BC-CfE REACH Line
  • Assess and manage:

    Consider consulting an expert for guidance regarding a prompt regimen change. Available for contact: BC-CfE REACH Line

Treatment simplification

  • Once daily dosing may be associated with better adherence

  • Fixed dose combinations reduce pill burden and may improve adherence

  • In virologically suppressed patients, switching regimens to improve tolerability and/or convenience is generally safe and effective, but maintenance of virologic suppression is paramount.
  • See also: 6 Appendix: ARV Drug Information

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