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The goals of therapy differ for antiretroviral-experienced patients that have limited drug exposure (i.e., developing resistance to their first antiretroviral regimen) versus those with extensive exposure (i.e., developing resistance to their third or fourth antiretroviral regimen). It is reasonable to expect maximal viral suppression in those with limited drug exposure. However, this may not be feasible for patients with prior exposure to multiple medications. In antiretroviral-experienced patients, a reasonable goal is to simply preserveimmune function and prevent clinical progression.

Several issues need to be considered in choosing a salvage regimen for HIV infection. Knowing prior medication exposure can assist in identifying which drugs to avoid. However, direct HIV resistance testing can better identify the resistance and susceptibility patterns of the major viral strains. Because HIV may be susceptible to certain components of the failing antiretroviral regimen, these drugs can be recycled into future regimens. Resistance testing should be used when all patients enter into care, in patients with virologic failure on a current ARV regimen, or with suboptimal suppression after initiation of ARV therapy. Testing is generally preferred for antiretroviral naive patients. For resistance testing to be useful, the patient should have a plasma HIV RNA of at least 1,000 copies/mL, and should be currently taking their antiretroviral medications (or be within 4 weeks of discontinuing antiretroviral therapy). This viral concentration is necessary to yield reliable amplification of the virus, and the antiretroviral medications are needed because the dominant viral species reverts to wild-type within 4 to 6 weeks after medications are stopped.

Two types of HIV resistance testing are available, genotyping and phenotyping. Genotyping involves detecting mutations by genetically sequencing the virus, while phenotyping determines the ability of the virus to replicate in the presence of varying ARV concentrations. Genotyping is more rapid and less costly than phenotyping, but results in a list of mutations that may be more difficult to interpret than phenotyping. A virtual phenotype report may also be obtained when genotypes are ordered.8- 5 This compares the patient's viral sequence to a database of matched genotypes and drug susceptibilities. Because the predictability of virtual phenotypes are dependent on the robustness of the database from which they are derived, some clinicians believe their utility is limited. Web-based tools are available to assist with interpretation of resistance mutations (e.g., Stanford University's HIV Drug Resistance Database; http://hivdb.stanford.edu/index.htmT). However, expert interpretation of genotype and phenotype reports is recommended.

Certain guiding principles should be considered when treating ARV-experienced patients, and expert opinion is advised before selecting therapy. As with ARVnaive patients, three or more active drugs should be prescribed.11,16-18 Because considerable cross-resistance can occur between medications within an antiretroviral class, simply using drugs to which the patient has not been exposed may be insufficient. Complete cross-resistance occurs within the NNRTI class, whereas the NRTIs and PIs have variable overlapping resistance patterns. For this reason, HIV resistance assays are important tools for choosing subsequent effective therapies. The following factors are associated with superior virologic response: lower viral load at the time therapy is changed, using a new class of antiretroviral agent, and using ritonavir enhanced PIs in patients previously exposed to PIs.19,20

Table 87-4 provides general treatment options based on previous drug use. If patients fail therapy with resistance to only one drug, one or two active agents may be substituted for this drug while retaining the remaining drugs in the regimen. If pa tients fail therapy with resistance to more than one drug, changing classes of antiret-rovirals and/or adding new active drugs is warranted. New NRTIs should be selected from resistance testing. If this is not available, the assumption should be made that resistance has developed to all NRTIs used in the failing regimen. In general, HIV that is resistant solely to lamivudine and/or emtricitabine will be susceptible to other NRTIs. If HIV develops resistance solely to tenofovir, then it may have reduced susceptibility to didanosine, but should remain susceptible to zidovudine, stavudine, lamivudine, emtricitabine, and abacavir. Cross-resistance occurs between zidovudine and stavudine.

Three new antiretrovirals have been FDA-approved for use in antiretroviral experienced patients. Two of these agents, Isentress (raltegravir) and Selzentry (maraviroc) have unique mechanisms of action compared to previous agents lending to their advantage in treating antiretroviral experienced patients with limited treatment options and resistance. The final agent, Intelence (etravirine), a member of the NNRTI class, is known as a second-generation NNRTI which is effective at reducing viral load in patients with first generation NNRTI resistance virus. These agents add to the antiret-roviral armamentarium in HIV infected treatment experienced patients.

If a patient appears to fail an antiretroviral regimen without detectable HIV resistance, adherence should be investigated, and the adequacy of the plasma HIV RNA concentration in the resistance sample confirmed. Options include continuing the current regimen or starting a new regimen and repeating the resistance test 2 to 4 weeks after adherence is verified. An increasing number of patients have extensive HIV resistance, such that antiretroviral regimens cannot be designed to which the virus is fully susceptible. For these patients, continuing the current regimen may be beneficial because drug-resistant virus may have a compromised replication capacity. Other strategies may be considered for this type of patient, including pharmacokinetic enhancement with ritonavir, retreatment with prior antiretroviral agents, treatment with multidrug regimens (four or more antiretroviral drugs), and the use of new agents through expanded access programs or clinical trials.

Treatment Considerations in Special Populations

Acute HIV Infection

Diagnosis of acute HIV infection is difficult, since many patients are asymptomatic, or have nonspecific clinical symptoms similar to other common respiratory infections. If acute HIV infection is suspected, HIV antibody tests and a plasma HIV RNA con centration should be obtained. A clear diagnosis is made when an HIV antibody test is negative and the plasma HIV RNA concentration is high. There are limited outcomes data for treating acutely infected patients. Treatment of acute infection can decrease the severity of acute disease and decrease the viral set point; this may decrease pro-

gression rates and reduce the rate of viral transmission. Limitations include an increased risk of chronic drug-induced toxicities and the development of viral resistance. Resistance testing should be performed prior to initiation of therapy due to an increase in resistance of antiretroviral naive patients.5

Adolescent Patients

As a result of similar modes of HIV transmission, adolescents infected after puberty are treated with similar considerations as adults. In this population, dosing of antiret-roviral drugs should not be based on age, but on the Tanner stage (which considers external primary and secondary sexual characteristics). Adolescents in early puberty should be dosed according to pediatric guidelines, while those in late puberty should be dosed as adults. During growth spurts, adolescents should be monitored closely for drug efficacy and toxicity, since rapid changes in weight can lead to altered drug concentrations. Adherence is of concern in this population due to denial of the disease, misinformation, distrust of health care professionals, low self-esteem, and lack of family and/or social support. Additionally, asymptomatic patients this age find it more difficult to adhere to therapy while feeling well.

Pediatric Patients

There are unique considerations in the treatment of HIV-infected children. Specific treatment guidelines exist,26 but a thorough review is outside the scope of this chapter. Most children acquire HIV infection through perinatal transmission either in utero, intrapartum, or postpartum through breast-feeding, although antiretroviral interventions have dramatically reduced transmission rates.5 Antiretroviral therapy is limited in pediatric patients, as some drugs have no dosing recommendations for this population, or are not available in a formulation that can be easily administered to children. Additionally, drug exposures can change dramatically during ontogeny due to altered drug-metabolizing enzyme and drug transporter activities.

Drugs of Abuse

Treatment challenges in illicit drug users include comorbidi-ties (such as hepatitis infection), limited access to care, inadequate adherence to therapy, side effects and tox-icities, and the need for treatment of substance abuse which can lead to drug interac tions. Many drugs of abuse have the potential to interact with antiretroviral medications, and a number of case reports have documented drug overdose when combined

with PI therapy. In these populations, without addiction control, adherence is suboptimal and treatment failure is common.2 Most PIs and NNRTIs decrease methadone concentrations up to 50%. As this can result in the development of withdrawal symptoms, patients should be closely monitored for 4 to 8 weeks after initiation of antiretroviral therapy. Withdrawal symptoms can be alleviated with a methadone dose increase of 5 to 10 mg. Although there are fewer data, buprenorphine concentrations may be similarly affected, and therefore this drug requires close monitoring.

Pregnancy and Women ofReproductive Potential

The goals of antiretroviral therapy for women of reproductive age and pregnant women are the same as for other adult patients. Specific guidelines for HIV-infected preg-

nant women are available. Recommended therapies in pregnancy include zidovud-

ine, lamivudine, lopinavir/ritonavir, and if the CD4+ count is less than 250 cells/mm , nevirapine. Drugs to be avoided include efavirenz (due to potential teratogenicity), the combination of didanosine and stavudine (due to a high incidence of lactic acidos-

is), nevirapine in patients with a CD4 count greater than 250 cells/mm (due to an increased risk of hepatotoxicity), and the liquid formulation of amprenavir (due to high concentrations of propylene glycol). The goal of therapy is to reduce plasma HIV

RNA below 1,000 copies/mL and prevent MTCT of HIV. Limited data are available on antiretroviral pharmacokinetics in pregnancy, and standard doses of antiretroviral drugs are currently recommended with close HIV RNA and CD4 monitoring in the third trimester of pregnancy. Some experts will consider increasing lopinavir/ritonavir dosing in the third trimester from 2 to 3 tablets twice daily; however, studies are un-

derway to better assess this approach.

Women of reproductive potential prescribed efavirenz should be counseled on its potentially teratogenic effects and the importance of birth control. Additionally, nevirapine, nelfinavir, ritonavir, lopinavir/ritonavir, and tipranavir/ritonavir decrease the concentrations ofestrogens and/or progestins in oral contraceptives, which could lead to failure.5 For patients prescribed these drugs, barrier forms of contraception are preferred to prevent pregnancy. Atazanavir may be taken with oral contraceptives with caution, as it can increase or decrease the exposure to estrogen and progesterone, depending on whether it is used in combination with ritonavir. DepoProvera may be a safe alternative, as it does not affect nelfinavir, efavirenz, or nevirapine concentrations; although the effect of antiretrovirals on medroxyprogesterone concentrations has not been examined, no evidence of ovulation has been seen in women on these combinations.29

Hepatitis B Coinfection

HIV-infected patients coinfected with hepatitis B virus (HBV) have higher concentrations of DNA and hepatitis B early antigen (HBeAg), and higher rates of HBV-asso-ciated liver disease. Therapy for HBV should be offered to patients who are HBeAg-positive, or have HBV DNA greater than 105 copies/mL and have either liver serologies (alanine aminotransferase) greater than two times the upper limit of normal or histologic evidence of moderate disease or fibrosis. Options include interferon alfa 2a or 2b and nucleoside/tide analogs. Nucleoside/tide analogs that treat HBV but not HIV are adefovir and entecavir. Nucleoside/tide analogs that treat HBV and HIV are lam-ivudine, emtricitabine, and tenofovir. These latter agents should be considered when treating HIV infection in HBV coinfected patients.

Hepatitis C Coinfection

Patients coinfected with hepatitis C virus (HCV) and HIV have a threefold increase in rate of progression to cirrhosis compared to those with HCV alone. Therapy for HCV is considered in patients with detectable plasma HCV RNA and a liver biopsy showing bridging or portal fibrosis. Patients with HCV genotype 2 and 3 (and a CD4 count greater than 200 cells/mm ) treated with pegylated interferon plus ribavirin have a better sustained viral response at 48 weeks (60%-70%) compared to those with HCV genotype 1 (15%-28%). Comprehensive treatment guidelines for HIV/HCV coinfec-

30_32

ted patients are available. Important considerations addressed in these guidelines include avoiding the combination of ribavirin with didanosine, and stavudine (due to increased risk of pancreatitis and/or lactic acidosis) and ribavirin with zidovudine (due to increased risk of anemia). Growth factors and erythropoietin may be needed to treat neutropenia from interferon and anemia from ribavirin. Antiretrovirals such as nevirapine, efavirenz, and tipranavir are hepatotoxic and in most cases should be avoided in HCV/HIV-infected patients.

Patient Encounter, Part 2: Medical History, Physical Exam, and Diagnostic Tests

PMH: Hypertension for 5 years; it is often not well controlled because of poor patient adherence; GERD, currently controlled on histamine antagonists; history of hepatitis B

FH: Father died of myocardial infarction at the age of 68 years; mother is still alive with history of diabetes

SH: Works as a truck driver; reports distant history of IV drug use in his 20s; drinks alcohol occasionally

Meds: Hydrochlorothiazide 25 mg by mouth once daily; famotidine 20 mg by mouth twice daily

ROS: (+) weight loss, decreased appetite, shortness of breath, and cough; (-) chest pain, nausea, vomiting, diarrhea

HEENT: Mild thrush on tongue

CV: RRR, normal Si, S2; no murmurs, rubs, gallops

Abd: Soft, nontender, nondistended; (+) bowel sounds, no hepatosplenomegaly Rectal: Deferred

Labs: Sodium 135 mEq/L (135 mmol/L), potassium 3.6 mEq/L (3.6 mmol/L), chloride 100 mEq/L (100 mmol/L), bicarbonate 24 mEq/L (24 mmol/L), blood urea nitrogen 14 mg/dL (5 mmol/L), creatinine 1.0 mg/dL (88 ^mol/L), WBC 5.2 x 103/mm3 (5.2 x 109/L), hemoglobin 11.5 g/dL (115 g/L or 7.1 mmol/L), hematocrit 34.1%, platelets 151 x 103/mm3 (151 x 109/L), neutrophils 58%, bands 9%, lymphocytes 32%, monocytes 1%, eosinophils 0%, basophils 0%, CD4 150 cells/mm3

HIV ELISA: Pending

CXR: Diffuse interstitial infiltrates bilaterally

Given this additional information, what is your assessment of the patient's condition? What other laboratory tests would you recommend? Identify your treatment goals for the patient.

What nonpharmacologic and pharmacologic alternatives are available for the patient?

outcome evaluation

O The success of antiretroviral therapy is measured by the degree to which the therapy: (a) restores and preserves immunologic function, (b) maximally and durably suppresses HIV RNA, (c) improves quality of life, (d) reduces HIV-related morbidity and mortality, and (e) prevents opportunistic infections. The major outcome parameters are CD4+ lymphocyte absolute count and percentage, and plasma HIV RNA. Adequate immunologic response in antiretroviral-nai've patients consists of an increase in CD4+ cell count that averages 50 to 150 cells/mm (with a faster response in the first 3 months), and a 1 log decrease in HIV RNA by 2 to 8 weeks after starting medications, followed by concentrations less than 50 copies/mL by 12 to 16 weeks (if HIV RNA less than 100,000/mL or by 16-24 weeks if HIV RNA greater than 100,000/mL). Upon initiating or changing antiretroviral therapy, HIV RNA should be measured after 2 to 8 weeks and every 4 to 8 weeks until undetectable. Once stable, HIV RNA and CD4 count are monitored generally every 3 to 6 months. In highly treatment-experienced patients, adequate immunologic response may be only a stable, or slightly increased, CD4 T-cell count, and a stable HIV RNA. This may be enough to prevent clinical progression. However, with the recent new agents and new therapeutic classes of antiretrovirals available for treatment-experienced patients, the goal of treatment should be to reestablish maximal viral suppression to less than50 HIV RNA copies/ mL.

Each patient should have a plan to assess the effectiveness of antiretroviral therapy after initiation. At each clinic visit, patients should be evaluated for the presence of adverse drug reactions, drug allergies, medication adherence, and potential drug interactions. Antiretrovirals have both class-associated and drug-specific adverse effects (see Table 87-5). If the patient experiences any of the serious, life-threatening effects (Table 87-6), the offending agent should be discontinued promptly, and in most cases the patient cannot be rechallenged. Potential long-term complications that may reduce the quality of life are listed in Table 87-7. For drugs with a high likelihood of intolerability (such as nelfinavir-associated diarrhea), patients should be counseled to anticipate these effects and have concomitant prescriptions available for preemptive management (such as an antidiarrheal agent). Patients should have follow-up within the 1st week after initiating a new drug regimen. If the patient does not tolerate a medication despite all efforts to the contrary, consider changing the drug.

Currently, treatment of HIV infection is lifelong. Unplanned short-term treatment interruptions may be necessary due to drug toxicity or illness that precludes administration of oral therapy. If a patient must interrupt therapy due to toxicity, all drugs of the regimen should be stopped at the same time, regardless of half-life. The strategy of scheduling elective treatment interruptions (where patients stop and start antiretroviral therapy based on CD4 T-cell count criteria) has been evaluated in several clinical trials. Viral rebound occurs quickly after stopping therapy, and worsens immune function, clinical progression, and may even result in death. If either short-term (less than 7 days) or long-term treatment interruption is needed, drug half-life must be taken into consideration. For regimens where all components have similar half-lives, all drugs can be stopped simultaneously. If the regimen contains components with significantly different half-lives (e.g., Atripla), stopping all drugs at the same time could result in the drug with the longest half-life (usually NNRTIs) lingering in the body and functioning as monotherapy. The ideal time to stop the NNRTIs (efavirenz, etravirine, or nevirapine) is unknown as these drugs can continue to be detectable 1 to 3+ weeks in patients. Options include either: (a) stopping the NNRTI first and continuing the other drugs in the regimen for up to 4 weeks or (b) substituting the NNRTI with a PI and continuing the PI with dual NRTIs for up to 4 weeks. In this situation, therapeutic drug monitoring of the long half-life drug can be useful in determining when to stop the NRTI ± PI coverage.

Patient Encounter, Part 3

Based on the information presented, create a care plan for this patient's HIV/AIDS. Your plan should include:

(a) A statement of the best drug combinations and reasons supporting each drug recommended, as well as any adverse effects or potential drug-related problems.

(b) Goals of therapy.

(c) A patient-specific, detailed therapeutic plan.

(d) A plan for follow-up to determine whether the goals have been achieved and adverse effects avoided.

Patient Encounter, Part 4

Your patient begins treatment with atazanavir 300 mg by mouth once daily, ritonavir 100 mg by mouth once daily, tenofovir 300 mg by mouth once daily, and lamivudine

300 mg by mouth once daily. He initially does well on this regimen, but after about 3 months, he has difficulty taking his medications at the same time every day due to his busy schedule. Because of his job, he relocated to Alabama, and has not been seen in your clinic for 2 years. He returns today to see you in clinic and complains of feeling tired, but otherwise no specific complaints.

What laboratory tests do you recommend?

What additional information do you need to know before creatinga treatment plan for this patient?

Table 87-6 Serious Adverse Effects and Management

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Table S7-7 Other Adverse Effects and Management

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Patient Care and Monitoring Patient Assessment

1. Medication history

• Get a thorough history of prescription, nonprescription, and natural drug product use. Determine what prior antiretroviral regimens, if any, were used in the past.

• Is the patient taking the appropriate dose of each medication? Are the doses adjusted for renal or hepatic failure? Are the doses adjusted for drug interactions with concomitant medications?

• Evaluate the patient for the presence of adverse drug reactions, drug allergies, and drug interactions.

• Assess improvement in quality-of-life measures such as physical, psychological, and social functioning and well-being. Is the patient experiencing any drug-induced adverse effects? What can you do to help manage these adverse effects?

2. Review any available diagnostic data to determine status of his HIV/AIDS.

3. Determine if initiation of antiretroviral therapy is indicated. Evaluate the patient's ability to adhere to medications, daily routine, social support, and financial stability. Is the patient taking any medications that may interfere with the individual components of potential regimens? Does the patient have medical insurance and prescription coverage?

4. Develop a plan to assess the effectiveness and tolerability of antiretroviral therapy. Patient Education

1. Educate the patient on HIV/AIDS disease and the importance of strict adherence to medication (the patient must ideally take his or her medications at the same time every day). Recommend a therapeutic regimen that is as easy as possible for the patient to take. Talk to the patient specifically about when and how the patient will be taking the medications. What time do they eat meals? When do they wake up? What other medications are they taking at the same time? Educate patients whether to take their medications with or without food.

2. Educate the patient on common adverse drug effects and a few of the key signs and symptoms of severe toxicity (i.e., jaundice and abacavir hypersensitivity reaction). Tell them to call their provider immediately if any of those symptoms occur. Make sure they have the correct telephone number for the clinic.

Abbreviations Introduced in This Chapter

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