Antiretroviral therapy (ART) sometimes needs to be changed if the treatment is not working. This usually happens when the HIV viral load (see Fact Sheet 125) rises instead of staying very low. A rise in viral load in someone taking ART almost always means that HIV has developed resistance (see fact sheet 126) to the antiretroviral drugs (ARVs). When the HIV viral load begins to increase even when someone is taking ART, it is called treatment failure. Resistance and treatment failure are often caused by missing doses of ARVs (poor adherence, see Fact Sheet 405).
When treatment failure is caused by drug resistance, it is important for your health care provider to change your ARVs to a new combination that can reduce the HIV viral load despite the resistance. Changing only one ARV may not be enough because HIV can quickly become resistant to a single new drug. It takes a combination of effective ARVs to stop HIV from growing, which means treatment is successful.
As a person’s virus becomes more and more resistant, it becomes harder to choose ARVs that can control it. When a person has very few treatment options available, they need “salvage therapy.”
The best way to avoid salvage therapy is to make your ART last as long as you can. Be sure to stick to taking doses on a regular schedule and avoid missing doses. Ask your health care provider how to avoid treatment failure and ensure treatment success (see Fact Sheet 405 on tips for adherence).
If possible, you should always have two or more active ARVs in your ART regimen. An active ARV is expected to work against your own virus based on its particular drug resistance. If your viral load is rising, find out if your HIV has resistance to any ARVs. Your health care provider will need to review the results of a resistance test (see Fact Sheet 126) to tell which ARVs are active against your HIV. There are two types of resistance tests: genotypic test or phenotypic test.
When treatment failure continues for too long, the chances of serious HIV disease are higher. This is especially true for patients with low CD4 counts (see Fact Sheet 124.) You may need to change your ART right away if:
When drug-resistant HIV cannot be controlled because there are not enough active ARVs available, you need salvage therapy.
However, if your health and CD4 count are stable, you can take a “holding regimen” while you wait for new ARVs to be developed. Do not stop taking medications to prevent opportunistic infections (OIs, see Fact Sheet 500). The drugs you need to take to prevent OIs are based on your CD4 count.
If there are not least two active ARVs that you can use, you need to preserve your CD4 count and keep your viral load as low as possible. You also want to preserve your treatment options. This normally means stopping any ARVs that are only partly effective so that your virus doesn’t develop more resistance to them. The greater resistance would make these ARVs totally ineffective. However, stopping all ARVs can be harmful.
Managing salvage therapy is not easy. Your health care provider must evaluate the most current treatment information to strike a balance between getting the most out of available ARVs and avoiding disease, while keeping options open for the future when new ARVs become available.
You may not have to wait until new ARVs are approved before you can use them. It may be possible to join a clinical trial (see Fact Sheet 105) of a new ARV in development. Some new ARVs become available through an expanded access program long before they are approved.
Remember that you want to be able to combine a new ARV with at least one other active ARV. You should review clinical trials carefully with your health care provider to be sure that you will get at least two active ARVs in the trial.
In some trials it is possible to get assigned to an arm of the study in which you do not receive the new ARV. More information on clinical trials is available here: http://www.clinicaltrials.gov/
The best option for people who need salvage therapy is to use an ARV in a new drug class (see Fact Sheet 401) along with one or more other active ARVs. Your virus is less likely to have resistance to an ARV from a new class of drugs.
There are more treatment options today for people living with HIV than there have been at any time in the past. Treatment can have excellent results, even for people whose virus is resistant to most existing ARVs. A health care provider who is experienced with HIV treatment is very important in helping you decide when to change treatment and when to wait.