Here: a step-by-step guide to the ART management of HIV-infected individuals who are “heavily treatment experienced.”
Without question, the management of previously antiretroviral (ART)-naÃ¯ve persons has become substantially easier in the last 3 years. Newly-approved, fixed-dose combination therapies associated with once-daily dosing and fewer side effects than older drugs are readily available. In addition, guidelines, such as the US Department of Health and Human Services Guidelines,1 list options for therapy for the ART-naÃ¯ve--with advantages and disadvantages of various regimens well-described. Furthermore, HIV incidence in the US is increasing, and is likely to do so for at least another 5 years. Consequently, and justifiably, the major emphasis on treating HIV-infected persons in the last several years has been on the diagnosis, linkage to care, initiation of treatment, and retention in care of the previously undiagnosed or newly-diagnosed, ART-naÃ¯ve, person.
Nevertheless, there exists a small, but important, group of HIV-infected individuals who are “heavily treatment experienced.” Many are “failing” their current ART. Whether due to previous non-adherence to therapy, or having started treatment in the “sequential monotherapy” era, these individuals have few options left as a result of resistance to multiple classes of antiretrovirals. How should you manage their therapy?
What follows is a step-by-step guide to the ART management in this population, which probably consists of only 5% of all HIV-infected persons. First, some background:
Now, the management steps, with caveats and commentary:
Truly, it is experience and the approach that matters: thoughtful analysis of the entire ART history, awareness of available antiretrovirals, access to trials of new classes of therapy, following the DHHS guidelines recommendation of adding (or changing to) at least 2 “fully active” drugs to a failing ART regimen, and scrupulous attention to adherence.