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Over the last few years, HIV treatment regimens have continued to improve and the number of options and the level of overall antiviral activity of these options is higher than ever. The likelihood of patients achieving undetectable levels of HIV and preventing the emergence of drug-resistant virus is also at an all-time high. Based on clinical trial data and clinical experience, the current expectation is that approximately 80% of patients starting therapy for the first time will achieve undetectable levels of HIV within a few months of initiating treatment and will likely sustain viral suppression over many years.

Unprecedented advances in HIV have occurred over the past year, including the development of new drugs and the emergence of new data for managing treatment-experienced patients. Several new medications that were developed for treatment-experienced patients with multidrug resistant virus have become available; they’re providing new treatment options for patients with highly drug resistant virus and/or intolerance to previously available agents.

Tolerability & Virologic Failure

Although the tolerability of antiretroviral drugs varies from person to person, currently available HIV treatment regimens are generally easy to take and well tolerated. Clinicians have historically made efforts to address tolerability, but were left with the decision to either have their patients deal with these drug side effects or not be treated. Fortunately, newer treatment options have minimized the effect of tolerability concerns.

Although no single regimen will be tolerable by every patient, clinicians who work closely with their patients are more likely than ever to find an effective regimen with minimal side effects. When one regimen is intolerable, clinicians can now offer several different options without the potential for the development of multidrug-resistant virus. It should be noted that when tolerability issues become severe, virologic failure may result. Clinicians need to assess the reason behind the virologic failure so that appropriate treatment adjustments can be made.

Patients with tolerability issues often won’t take their HIV medications as directed because the side effects are too great a burden. In addition, they may miss doses for a variety of other reasons, such as having an important meeting at work or attending a social function. In other scenarios, underlying psychiatric social problems or drug abuse can reduce adherence to medications. Regardless of the circumstances, the key for clinicians is to talk openly with patients before and during treatment. It’s critical to find out about the patient’s personal situation and circumstances before therapy is initiated. Patients also need to understand that available treatment options may help them overcome some of their life obstacles.

Individualize Approaches

Clinicians should strive to identify patients at risk for tolerability issues or poor adherence before initiating therapy in order to reduce the risk of patients developing multidrug resistant virus while on therapy. This requires having a regular dialogue with patients; they should be informed about the efficacy of therapy and cautioned that no one regimen is perfect for everyone. It’s critical to get “buy in” from patients; they need to believe that their provider will listen to them, work with them, and make changes to treatment regimens if necessary. A greater emphasis should also be made to have patients understand the goals of therapy. We’re aiming to provide them with therapies that they’ll completely tolerate on a regular basis to achieve undetectable levels of virus. To achieve long-term success, establishing individualized approaches and carefully balancing tolerability with efficacy and the potential for drug resistance are paramount.

Eric S. Daar, MD has indicated to Physician’s Weekly that he has received grants and/or research support from Abbott, Boehringer Ingelheim, Gilead, GlaxoSmithKline, and Merck. He has also disclosed that he has served on the speaker’s bureau for and/or served as a consultant to Abbott, Boehringer Ingelheim, Gilead, GlaxoSmithKline, Merck, Bristol-Myers Squibb, Pfizer, Tibotec,Pathway Diagnostics, Oncolysis and Monogram.