Management of the highly experienced patient

The availability of new agents active against drug-resistant viruses provides new opportunities for HIV-infected patients with multidrug treatment experience. Understanding the emerging principles that guide this treatment is essential to maximize the impact of these new drugs.

Infection with multidrug-resistant virus is associated with increased risk of mortality. The use of more than one active agent is critical to treatment success in patients with triple class treatment experience. New protease inhibitors such as tipranavir and darunavir offer the opportunity to achieve virologic suppression when teamed with a second active agent (such as enfuvirtide). Higher CD4 lymphocyte counts, lower viral loads, and greater numbers of active agents in the treatment regimen are all associated with a more favorable prognosis. When virologic suppression is no longer a viable option, it may be possible to achieve durable immunologic stability despite an inability to suppress viral replication.

New drugs and new approaches to the management of HIV-infected patients with multidrug-resistant infections have emerged recently and offer new hope to this difficult-to-treat population. Clinical research continues to define the best approach to treating these patients and is likely to lead to additional new agents and new strategies in the future.