Managing HIV/AIDS Therapy in Treatment-Experienced Patients What are the key factors in making the decision to change therapy?
	Enlarged Version of Graphics Below	Dr. Kwakwa (OC): I change therapy more with virologic failures than with the other two kinds of failures, with immunological or clinical failures, just because of the potential consequence of resistance with virologic failure that is not addressed in a timely fashion. And at what virologic load I switch really depends. It depends on the adherence of the patient. If the patient has been adherent, and then for a defined period is not adherent, and that is associated with an increase in viral load, my threshold to change would be higher in that circumstance than in someone who may be experiencing an increase in viral load for reasons other than temporary nonadherence. The regimen a patient is on also plays a role. If a patient is on a regimen that has very high barriers for resistance, my threshold to change may be higher than in a patient who may be on a regimen with very low barriers to resistance, for example, and so, that differs, but viral load that is consistently rising, with a rising pattern more than an absolute cutoff point; I am much more likely to change the therapy. Dr. Wohlfeiler (OC): ...when you've got your nucleoside backbone, which in most cases is going to include either 3TC or FTC, when you have a failure in a regimen containing either FTC or 3TC the likelihood is that that first resistant mutation that's going to emerge is going to be an M184V mutation associated with either 3TC or FTC resistance. You know also that that is a very salvageable mutation if you act on it quickly enough. Dr. Kwakwa (OC): There are certain instances where there are inconsistencies in the CD4 counts, or CD4 counts that have been declining have been reported, and of course, I would evaluate the patient to see whether one of those instances would apply to them. For example, the use of Viread and Videx together, particularly the higher dose, the 400 mg of Videx when used in combination with Viread, has now been reported to be associated, sometimes, with a declining CD4 count, so that would be something to look for. Dr. Bellos (OC): ...I think when you change the regimen, you have to change the entire regimen. The analogy, again, in the infectious disease world is similar to what we do with tuberculosis. When someone is failing a tuberculosis regimen, we don't just change one drug, or add one drug. We have to change the entire regimen, and it's same thing with respect to HIV, in that if a patient is beginning to fail the regimen, we need to look at the entire regimen, and we probably need to replace the majority of it.
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