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Managing HIV/AIDS Therapy in Treatment-Experienced Patients
What is your final advice on treatment failure and switching?
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Dr. Bellos (OC): I think the main point is to determine why they are failing therapy. Is it an issue of adherence? And if it is an issue of adherence, is that issue related to toxicity? Is that issue related to pill burden? What's the reason? If it is not necessarily related to adherence, and the patient has been adherent and is failing for virologic reasons, then, I think one needs to take one step further and look at their immunologic response. If they are maintaining their immunologic foundation in terms of maintaining their CD4 count, then I think that would be somebody I would probably watch, and not necessarily alter their regimen.
However, if they are failing immunologically, then I think we need to move forward, and look at altering their regimen, and look at novel sorts of attempts at salvage in those patients, depending where they are in their treatment history. If they have failed three or four regimens, then maybe a dual boosted PI with entry inhibitor would be an option for that patient, or maybe just a dual boosted PI.
Dr. Kwakwa (OC): I think it's important to remind the patient, as they are initiating therapy, or as they are coming in at each line of therapy, that really, this is as simple as it gets right now. It's as simple as it's going to get, that if this regimen is lost because of resistance, the next regimen will likely be a little more complicated or a lot more complicated, and the next even more complicated, and so on, and I think that gives the patient a little bit of an added incentive to try to preserve that regimen to the extent that it is in their power to do so, and at that point, every little added incentive certainly helps. I think that once a patient has lost one regimen, or two regimens, and is in salvage, or going towards salvage, it becomes even more important to plan for several lines of therapy going down, because once resistance starts to occur, it becomes a little bit easier to continue to accumulate resistance mutations, whereas with a naïve patient, there is a reasonable expectation to really try and maintain that regimen for years to come. In the treatment-experienced patient who has already begun to accumulate resistance mutations, it's a little more difficult.
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