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Optimizing antiretroviral therapy (ART) in heavily treatment–experience patients is an increasingly important topic, both because of evolving data and the fact that we are seeing treatment failure less often and, therefore, many healthcare professionals have had fewer opportunities to manage these complicated cases.
We generally define virologic failure as 2 consecutive HIV-1 RNA measurements >200 copies/mL.1 One of the first things to consider when your patient experiences virologic failure is some of the reasons for failure, both to best understand how to improve the likelihood of success in the future and to try to address any concerns that the patient may have moving forward.
There are patient-related issues, including psychosocial factors, unstable housing, access to medications, and pill burden and/or dosing issues, all of which may affect adherence.
There are HIV-related factors, such as transmitted or acquired resistance.
Finally, there are antiretroviral regimen–related factors, such as suboptimal pharmacokinetics or virologic potency. There are drugs with lower or higher barriers to resistance that may affect outcomes. Of importance, there are drug–drug and drug–food interactions that should be considered. Prescribing errors may be avoided by giving appropriate instructions so patients take their medications correctly.