Approach to the treatment-experienced patient

Failure of antiretroviral therapy can occur for a variety of reasons, but is often caused by or accompanied by drug resistance, which increases with continued time on nonsuppressive, failing regimens. Response to early virologic failure on an initial regimen may be associated with minimal or no resistance and can sometimes be managed simply by reinforcing adherence or by intensifying therapy. Resistance testing is an important tool for managing patients who are failing therapy; it should be used in most cases to guide selection of the next regimen. For patients with extensive treatment experience and drug resistance, there are a variety of approaches that have been suggested when fully suppressive options are not available. Clinicians caring for such patients must balance the benefit of slower progression associated with continued therapy against the risk of increasing drug resistance and loss of future treatment options.