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Clinical Management of Treatment-Experienced, HIV/AIDS Patients in the Combination Antiretroviral Therapy Era

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  • Mark A. Boyd

    (National Centre in HIV Epidemiology and Clinical Research, University of New South Wales, Sydney, New South Wales 2010, Australia)

  • Andrew M. Hill

    (Department of Pharmacology, University of Liverpool, UK and Tibotec BVBA, Mechelen, Belgium)

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    Abstract

    Despite the success of combination antiretroviral therapy (ART) in improving clinical outcomes, treatment failure remains a significant challenge, particularly for highly treatment-experienced patients. This review evaluates current issues in the management of HIV-infected, treatment-experienced patients. It may provide guidance in selecting active, tolerable drug combinations that promote a reasonable quality of life, full adherence and a durable treatment response. Current treatment guidelines and clinical trial data were reviewed to identify reasons for treatment failure and to summarize therapy options for treatment-experienced and highly treatment-experienced patients. Current treatment options include nucleoside reverse transcriptase inhibitors (NRTIs) and non-nucleoside reverse transcriptase inhibitors (NNRTIs), protease inhibitors (PIs), and inhibitors of viral fusion, entry and integration. The use of NRTIs may be limited by resistance and short- and long-term toxicities. Resistance has restricted the NNRTI class with cross-resistance preventing their sequential use. Etravirine, a next-generation NNRTI, however, demonstrates effective virological suppression in patients with baseline NNRTI resistance. Boosted PIs are key components of ART for treatment-experienced patients. The newer boosted PIs tipranavir and darunavir have demonstrated impressive activity in patients with resistance to NRTIs, NNRTIs and PIs, as well as in less treatment-experienced patients for darunavir. The fusion inhibitor enfuvirtide has demonstrated efficacy in heavily treatment-experienced patients, although injection-site reactions can be problematical. The recently approved integrase inhibitor raltegravir has also shown impressive potency and tolerability in highly treatment-experienced patients. Finally, the entry inhibitor maraviroc has also been approved recently, although its use is somewhat limited by the need for HIV tropism testing. The availability of potent next-generation PIs, NNRTIs, integrase and entry-inhibitors may offer improved therapy for treatment-experienced patients, including those with multiresistant virus. These new drugs may reduce HIV immunological and clinical progression and in doing so may also reduce treatment costs.

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    Bibliographic Info

    Article provided by Springer Healthcare | Adis in its journal PharmacoEconomics.

    Volume (Year): 28 (2010)
    Issue (Month): S1 ()
    Pages: 17-34

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    Handle: RePEc:wkh:phecon:v:28:y:2010:i:s1:p:17-34

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    Web page: http://pharmacoeconomics.adisonline.com/

    Related research

    Keywords: Antiretrovirals; therapeutic use; HIV-infections; treatment; Non-nucleoside-reverse-transcriptase-inhibitors; therapeutic use; Nucleoside-reverse-transcriptase-inhibitors; therapeutic use; Peptide-hydrolase-inhibitors; therapeutic use;

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