The management of treatment-experienced HIV patients (including virologic failure and switches)

Abstract

Significant advances in the potency and tolerability of antiretroviral therapy (ART) have led to very high rates of virologic success for most who remain adherent to therapy. As a result, the life expectancy of people living with HIV (PLWH) has increased significantly. PLWH do, however, continue to experience a significantly higher risk of noninfectious comorbidities and chronic age-related complications, including cardiovascular disease and malignancies, which are now the biggest drivers of this excess morbidity and mortality. Therefore, in addition to virologic failure, the management of the treatment-experienced patient increasingly requires optimization of ART to enhance tolerability, avoid drug-drug interactions, and mitigate non-AIDS complications and comorbid conditions. This article will present principles of the management of virologic failure, poor immunologic recovery, and strategies for optimizing ART in the setting of virologic suppression.

Keywords: HIV; adherence; comorbidities; virologic failure.

Figure 1.

Analyzing the causes of virologic failure. ARV, antiretroviral; DDI, drug–drug interactions; PK/PD, pharmacokinetics/pharmacodynamics.

Figure 2.

Suggested management approach to selecting a new ART regimen. For more details, please refer to Department of Health and Human Services ART guidelines (https://aidsinfo.nih.gov/guidelines/) or European AIDS Clinical Society guidelines (http://www.eacsociety.org/guidelines/eacs-guidelines/eacs-guidelines.html). AIDS, acquired immunodeficiency syndrome; ART, antiretroviral therapy; CKD, chronic kidney disease; CVD, cardiovascular disease; DDI, drug–drug interactions; DTG, Dolutegravir; HBV, hepatitis B virus; HIV, human immunodeficiency virus; INSTI, integrase inhibitors; Mgmt, management; PK/PD, pharmacokinetics/pharmacodynamics; Pt, patient; Rx, prescribed regimen; VL, viral load.