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3–18 | Clinical Manual for Management of the HIV-Infected Adult/2006 Table 1. Resistance Testing Recommendations Clinical Setting/Recommendation Rationale Recommended Acute or primary HIV infection, if treatment is to be started Chronic HIV infection before starting ART • Determine whether drug-resistant virus was transmitted, to help design an initial regimen or to change a regimen accordingly. • Consider resistance testing in all, even if treatment is deferred. • Determine whether drug-resistant virus was transmitted to help design an initial regimen. • Transmitted drug-resistant virus is more likely to be detected earlier in the course of HIV infection; consider resistance testing early. Virologic failure during ART • Determine the role of resistance in drug failure and maximize the number of active drugs in the new regimen, if indicated. Suboptimal suppression of viral load after starting ART • Determine the role of resistance and maximize the number of active drugs in the new regimen, if indicated. Not Usually Recommended After discontinuation of drugs • Drug resistance mutations may decrease in number and become undetectable on assays. Plasma viral load
Resistance Testing in Patients with Virologic Failure As discussed in the chapter Antiretroviral Therapy, factors other than nonadherence and resistance may cause failure of ART; these include drug-drug interactions and malabsorption. Therefore, before assuming that drug failure is due to resistance and ordering a resistance test, it is important to assess the causes of antiretroviral regimen failure. If resistance is still suspected after assessing all possible causes, resistance testing should be done while the patient is taking the failing regimen, for the reasons noted above. Key Points ♦ ♦ ♦ ♦ There are 2 major types of resistance testing currently available: genotype and phenotype tests. In general, a patient's viral load must be at least 1,000 copies/mL for either test to be reliable. Both genotypic and phenotypic testing can detect resistance only if it exists in at least 20% of the viral species present in a patient (known as the dominant species). Minor species may harbor resistance that remains undetected by either test. Resistance tests are most reliable when performed while a patient is still taking a failing regimen, or within 4 weeks after stopping. Neither test predicts which drugs will be active in a particular patient, only drugs that are not likely to be active. Nevertheless, studies comparing the use of resistance testing to expert opinion alone have shown that resistance testing can improve virologic control of HIV. Most treatment guidelines recommend resistance testing in certain circumstances. References ♦ ♦ ♦ Section 3—Antiretroviral Therapy | 3–19 Bartlett JG, Gallant JE. 2005-2006 Medical Management of HIV Infection. Baltimore: Johns Hopkins University Division of Infectious Diseases; 2005. Available online at hopkins-aids.edu/mmhiv/ order.html. Shafer RW. Genotypic Testing for HIV-1 Drug Resistance. In: Peiperl L, Coffey S, Volberding PA, eds. HIV InSite Knowledge Base [textbook online]; San Francisco: UCSF Center for HIV Information; April 2004. Accessed February 7, 2006. U.S. Department of Health and Human Services. Guidelines for the Use of Antiretroviral Agents in HIV- 1-Infected Adults and Adolescents. October 10, 2006. Available online at aidsinfo.nih.gov/Guidelines/ GuidelineDetail.aspx?GuidelineID=7. Accessed July 7, 2007.
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Clinical Manual for Management of t
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Table of Contents Clinical Manual f
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Clinical Manual for Management of t
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Preface—About this Manual | Clini
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Previous Editions Atlanta Contribut
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♦ ♦ ♦ ♦ ♦ | Clinical Manu
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1-2 | Clinical Manual for Managemen
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Initial Physical Examination Backgr
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Genitals/Rectum • Inspect the gen
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Initial and Interim Laboratory and
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Section 1—Testing and Assessment
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Patient Education ♦ ♦ ♦ ♦ D
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Section 2—Health Maintenance and
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References ♦ ♦ ♦ ♦ ♦ ♦
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Page 67 and 68: Occupational Postexposure Prophylax
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Page 81 and 82: contact with the patient. Patients
Page 83 and 84: tablet daily of trimethoprim-sulfam
Page 85 and 86: Opportunistic Infection Prophylaxis
Page 87 and 88: Discontinuing Primary Prophylaxis P
Page 89 and 90: Latent Tuberculosis Background Late
Page 91 and 92: INH may cause liver toxicity and it
Page 93: Patient Education ♦ ♦ ♦ ♦
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Page 117 and 118: Reducing Maternal-Infant HIV Transm
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Page 123 and 124: Section 3—Antiretroviral Therapy
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Section 4—Complications of Antire
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♦ ♦ ♦ Toronto General Hospita
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Adverse Reactions to HIV Medication
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♦ ♦ ♦ ♦ ♦ Vital signs: No
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egimen, symptoms of fatigue could i
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Recreational Drugs and Antiretrovir
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Section 4—Complications of Antire
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LSD, Mescaline, Psilocin, and Methy
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Immune Reconstitution Syndrome Back
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A: Assessment In the appropriate cl
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♦ ♦ ♦ ♦ ♦ Navas E, Martin
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Eye Problems Background The immunos
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of
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Fever Background Although fever may
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Headache Background Headache may ha
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Lymphadenopathy Background Lymphade
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Treatment Treatment will depend on
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Neurologic Symptoms Background The
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Pulmonary Symptoms Background Short
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Treatment Once the diagnosis is mad
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Candidiasis, Oral and Esophageal Ba
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Maintenance therapy Use caution whe
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Cervical Dysplasia Background Cervi
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Patient Education ♦ ♦ ♦ ♦ P
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Cryptosporidiosis Background Crypto
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Patient Education ♦ ♦ ♦ ♦
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Gonorrhea and Chlamydia Background
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Treatment of Gonorrhea Treatment op
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Hepatitis B Infection Background He
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♦ ♦ ♦ ♦ ♦ Some patients t
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Hepatitis C Infection Background He
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pregnancy. Ribavirin is teratogenic
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Herpes Simplex, Mucocutaneous Backg
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References ♦ ♦ ♦ ♦ ♦ Cent
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Kaposi Sarcoma Background Kaposi sa
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Treatment Treatment of KS is not co
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Molluscum Contagiosum Background Mo
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Mycobacterium avium Complex Backgro
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Table 1. Interactions between Rifab
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Mycobacterium tuberculosis: Treatme
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P: Plan Diagnostic Evaluation Durin
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Table 1. Regimens for Treatment of
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Rifabutin may be substituted for ri
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Patient Education ♦ ♦ ♦ ♦
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Non-Hodgkin Lymphoma Background Non
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Patient Education ♦ ♦ ♦ ♦ S
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Toxoplasmosis Background Toxoplasma
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♦ Atovaquone 1,500 mg orally twic
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Linear Gingival Erythema Background
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Background Necrotizing ulcerating p
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Oral Health Background Examination
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Maxillary Tori; Mandibular Tori S:
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Periodontal Disease Background The
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Oral Hairy Leukoplakia Background O
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Oral Ulceration Background Oral ulc
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Oral Warts Background Oral warts ar
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Anxiety Disorders Background Anxiet
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Patient Education ♦ ♦ Behaviora
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Insomnia Background Insomnia is a c
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Suicidal Ideation Background Transi
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Section 8—Neuropsychiatric Disord
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P: Plan ♦ ♦ ♦ ♦ ♦ Check t
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Correctional Settings Background Ca
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Adherence Adherence is one of the m
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Karnofsky Performance Scale Backgro
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