Содержание
- 2. July 2016 www.aidsetc.org About This Presentation These slides were developed using the April 2015 guidelines and
- 3. The Treatment-Experienced Patient: Contents Considerations Evaluation and Management of Virologic Failure Poor CD4 Recovery and Persistent
- 4. Treatment-Experienced Patients The recommended initial ARV regimens should suppress HIV to below the lower level of
- 5. Treatment-Experienced Patients Assessment and management of ART failure is complex: consult with experts July 2016 www.aidsetc.org
- 6. Definitions of Virologic Response Virologic suppression: Confirmed HIV RNA below LLOD (eg, Virologic failure: Inability to
- 7. Virologic Failure Failure of current first-line regimens usually caused by suboptimal adherence or transmitted drug resistance
- 8. Virologic Failure (2) Causes of treatment failure include: Patient factors Higher pretreatment HIV RNA (depending on
- 9. Virologic Failure (3) Causes of treatment failure include (cont.): ARV regimen factors Toxicity and adverse effects
- 10. Virologic Failure: Assessment Approach to subsequent ART depends on the cause of regimen failure and remaining
- 11. Virologic Failure: Assessment (2) Explore in depth issues of: Suboptimal adherence Carefully assess adherence, identify and
- 12. Virologic Failure: Assessment (3) Pharmacokinetic issues Review food requirements for each ARV, history of vomiting or
- 13. Virologic Failure: Management If virologic failure persists, resistance testing should be done and ART should be
- 14. Virologic Failure: Management (2) Goal of ART change: to establish virologic suppression (HIV RNA General principles
- 15. Virologic Failure: Addressing Viremia Low-level viremia (LLOD to 1,000 copies/mL): LLOD- Transient “blips”: no change in
- 16. Virologic Failure: Addressing Viremia (2) HIV RNA >1,000 copies/mL and no resistance identified: Usually caused by
- 17. Virologic Failure: Addressing Viremia (3) HIV RNA >1,000 copies/mL and drug resistance: Goal: suppress HIV RNA
- 18. Management of Virologic Failure: First ART Failure Failure of NNRTI + NRTIs Often resistance to NNRTI
- 19. Management of Virologic Failure: First ART Failure (2) Failure of INSTI + NRTIs May have resistance
- 20. Management of Virologic Failure: Second-Line Failure and Beyond Drug resistance with treatment options that allow full
- 21. Management of Virologic Failure: Second-Line Failure and Beyond (2) Multidrug resistance without treatment options that allow
- 22. Management of Virologic Failure: Second-Line Failure and Beyond (3) Previous treatment and suspected drug resistance, in
- 23. Isolated CNS Virologic Failure and New Onset Neurologic Symptoms Rarely, patients may present with new (usually
- 24. Isolated CNS Virologic Failure and New Onset Neurologic Symptoms (2) Management: Consider drug resistance testing of
- 25. Poor CD4 Recovery and Persistent Inflammation Despite Viral Suppression Morbidity and mortality are higher in HIV-infected
- 26. Poor CD4 Recovery and Persistent Inflammation Despite Viral Suppression (2) Poor CD4 recovery Persistently low CD4
- 27. Poor CD4 Recovery and Persistent Inflammation Despite Viral Suppression (3) Management: Evaluate for underlying causes (eg,
- 28. Poor CD4 Recovery and Persistent Inflammation Despite Viral Suppression (4) Persistent immune activation and inflammation Systemic
- 29. Poor CD4 Recovery and Persistent Inflammation Despite Viral Suppression (5) Causes of persistent immune activation not
- 30. Regimen Switching in Setting of Virologic Suppression Changing a suppressive ARV regimen to: Reduce pill burden
- 31. Regimen Switching in Setting of Virologic Suppression (2) Goals: improve patient’s quality of life, maintain ART
- 32. Regimen Switching in Setting of Virologic Suppression (3) Principles Maintain viral suppression and avoid jeopardizing future
- 33. Regimen Switching in Setting of Virologic Suppression (4) Within-class switches: Usually maintain viral suppression if no
- 34. Regimen Switching in Setting of Virologic Suppression (5) Switch strategies not recommended: RTV-boosted PI monotherapy Less
- 35. Interruption of ART May cause viral rebound, immune decompensation, and clinical progression Not recommended as a
- 36. Interruption of ART: Short-Term Considerations for stopping ART In case of severe or life-threatening toxicity: Stop
- 37. Interruption of ART: Long-Term Potential risks, including: Viral rebound CD4 decline Acute retroviral syndrome Disease progression,
- 38. Interruption of ART: ARV-Specific Issues Discontinuation of EFV, ETR, or NVP: These ARVs have long half-lives;
- 39. Interruption of ART: ARV-Specific Issues (2) Discontinuation and reintroduction of NVP: If NVP has been interrupted
- 40. Interruption of ART: ARV-Specific Issues (3) Discontinuation of FTC, 3TC, TAF, or TDF in patients with
- 41. Interruption of ART: Patient Counseling If therapy must be discontinued, counsel patients on: Need for close
- 42. Testing for Drug Resistance Recommended in case of virologic failure, to determine role of resistance and
- 43. Testing for Drug Resistance (2) HIV RNA generally must be >1,000 copies/mL (may be successful if
- 44. Genotyping Detects drug resistance mutations in specific genes (eg, reverse transcriptase, protease, integrase) Order specific genotype
- 45. Phenotyping Measures the ability of viruses to grow in various concentrations of ARV drugs Results within
- 46. Drug Resistance Testing: Limitations Lack of uniform quality assurance Relatively high cost Insensitivity for minor viral
- 47. Coreceptor Tropism Assay Test for tropism before using CCR5 antagonist MVC should be given only to
- 48. Websites to Access the Guidelines July 2016 www.aidsetc.org http://www.aidsetc.org http://aidsinfo.nih.gov
- 50. Скачать презентацию