HIV-1 Treatment-Experienced Patients: Treatment Options and Management

Human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS) are a global health crisis of unprecedented dimensions, causing over 25 million deaths worldwide since it was first recognized as a disease entity in the early 1980s.(Joint United Nations Program on HIV/AIDS 2008) In 2008 alone, there were approximately 2.7 million newly infected and over 33 million persons living with HIV globally, of whom between 1.8 and 2.3 million died.(Joint United Nations Program on HIV/AIDS 2011) In the 24 years since zidovudine was approved for the treatment of HIV infection, remarkable advances have been made in the understanding of disease pathogenesis and translating that knowledge into practical therapeutics. Most notably, the advent of highly active antiretroviral therapy (HAART) has transformed HIV from an inevitably fatal disease to one that, if managed appropriately, can be considered a chronic condition. As a result, the overall number of people living with HIV is increasing as these regimens extend life and as new infections outnumber AIDS deaths. (www.unaids.org; Joint United Nations Program on HIV/AIDS 2011) The number of HIV treatment regimens has grown exponentially, particularly in the past decade. This, coupled with advances in the understanding of disease pathogenesis and progression, has made HIV disease management among the most dynamic fields in modern medicine. A number of guidelines have been developed to assist practitioners with often complex treatment decisions. These include the 2010 International AIDS Society (IAS/IASUSA) guidelines and the 2011 US Department of Health and Human Services (DHHS) HIV treatment guidelines.(Thompson, et al., 2010; http//:www.aidsinfo.nih.gov; Thompson, et al., 2010; United States Department of Health and Human Services (US DHHS) Panel on Antiretroviral Guidelines for Adults and Adolescents 2011) Close to 30 individual drugs and fixed-dose combinations are available to treat HIV. Despite the availability of a broad range of individual antiretroviral treatments and combinations, drug resistance remains a common phenomenon, and treatment failure is still frequently observed. Moreover, treatment advances—together with recent demographic shifts—have resulted in a dramatic expansion in the population of treatment-experienced patients. This group comprises an ever-increasing proportion of the patients whom HIV clinicians are called upon to treat. This review attempts to integrate guideline recommendations and evidence from recent clinical trials to identify best practices in the management of these patients.