If you are starting HIV medicines for the second (third, fourth, etc.) time, you are called “treatment experienced.” This is different from starting HIV medicines for the first time. Some people have “failed” their first HIV medicine regimen and have to start again. Some people never failed their HIV medicine and can just pick up where they left off. How can you figure out which category you belong in? Do you have treatment failure?
What is HIV treatment failure?
If you read my earlier sections, I told you to think of being married to your medicines--faithful, trusting, and ever so careful. Choosing a second regimen (or spouse) reminds me of getting remarried after divorce--things are a bit different the second time around. Hopefully, you have learned the reasons your first marriage (drug regimen) failed and will not make similar mistakes. The worst thing you can do is not figure out why the marriage (drug regimen) failed because you will be doomed to learn the same painful mistakes again.
HIV treatment failure is having to choose one or more different HIV drugs because the HIV drugs you are now taking, have stopped taking, or have taken in the past no longer work. This is not a good situation to be in. As of the day I am writing this, there are only 23 HIV drugs available--if you have to scratch one or more drugs off the list because they will never work on your particular virus, it’s not a good thing.
If you have taken HIV drugs in the past, you are considered “treatment experienced.” The person who has never taken HIV medicine is called “treatment naive.”
HIV treatment failure is not the same thing as having an allergic reaction, a “toxic” reaction, or bad side effects with a particular HIV medicine. Treatment failure means you have resistance to the medicine and the medicine will never work for you again.
If you recall from my earlier chapters, resistance develops when HIV is not exposed to high enough doses of medication to keep it from making new virus particles. Resistance causes treatment failure. How do you know you have treatment failure”?Your HIV viral load, which may have been “undetectable,” is now inching upward. Here is an example of treatment failure:
Example #1: Treatment failure
Jim has been taking the three-drugs in one pill, Atripla, for 2 years now. When he started the medicine, his CD4 was 200 and his HIV viral load was 200,000. One year after starting medicines, his CD4 was 450 and his viral load was undetectable (less than 48). The past year, Jim has been taking more out-of-town trips with his job, and frequently runs out of his medicine while he is on the road. He knows he has been getting careless with getting his refills, but he plans to get back on track. Today, Jim is in the clinic and his HIV specialist tells him his CD4 is 454 but his HIV viral load is 750. His specialist recommends Jim get a resistance test--an HIV genotype--to see if Jim has treatment failure. Jim’s resistance test shows that he has a mutation to two of the three drugs that are inside the Atripla pill. His HIV specialist says that Jim must stop Atripla and start taking a different HIV drug regimen.
This is an example of treatment failure--Jim’s drugs must be changed and the two drugs that Jim has resistance to will not be active against Jim’s HIV virus, now, or in the future. Jim is considered “treatment experienced” and has “treatment failure.”
Example #2: Not treatment failure
Marco has been on taking the three-drugs-in one, Atripla, for 9 months. When he started taking the pill, his CD4 count was 100 and his HIV viral load was more than 1 million. During today’s visit with his HIV specialist, Marco learns that his CD4 count is 452 and his viral load is undetectable. Marco tells his HIV specialist that lately, he has been having severe bad dreams--the dreams are so real that he awakens screaming in terror. He and his partner are getting very little sleep at night. He thinks the HIV medicine is causing these bad dreams and knows that this is one of the side effects of efavirenz (Atripla contains the medicine efavirenz). Marco wants the HIV specialist to change his HIV medicine.
Marco does not have treatment failure--his virus is undetectable so there is no need to get an HIV genotype test to check for resistance. If Marco ever decided to take Atripla in the future, he could.
The exact definition of treatment failure is this: HIV viral load (on HIV medicines) more than 400 at 24 weeks; or an HIV viral load (on HIV medicines) more than 50 at 48 weeks, or repeated detectable HIV in the blood after one had previously achieved “undetectable.” (See the previous chapter on HIV viral load tests.) Treatment failure may also include:
- Having undetectable HIV virus but the CD4 count remains quite low
- Getting a new “opportunistic infection” (not an IRIS infection--see chapter on IRIS)
- Having a flare-up of an old opportunistic infection after you have been on HIV medicine at least 3 months.
Who is more likely to get treatment failure?
Those people with HIV who are more likely to get treatment failure are these:
- Starting HIV medicines before 1996 or 1997, when there were not many HIV medicines and they were given one at a time.
- Higher HIV viral load before the first HIV medicines were given.
- Lower CD4 count before the first HIV medicines were started. Your CD4 nadir is the lowest CD4 count you have ever had; this is an important number and should always be considered when making any treatment decisions.
- Those who have been diagnosed with AIDS.
- Those who are depressed.
- Those who are using street drugs (cocaine, methamphetamine, heroin, someone else’s prescription pain killers, etc).
- Those who are drinking more than 1-2 alcoholic drinks in one 4-6 hour time block on a regular basis--even once a week or once a month is a problem.
- A genotype in the past showing resistance.
- Prior HIV treatment failure raises your risk of getting treatment failure again.
- Not taking HIV medicines on a daily basis and at around the same time every day; this also includes taking the medicine incorrectly--for example, some medicine must be taken with food.
- Missing clinic appointments.
- Experiencing drug side effects or a “toxic” reaction to an HIV medicine.
- The HIV medicines you are taking, or have taken in the past, were not prescribed to get the maximum benefit for you. Those with HIV who are not seeing an HIV or infectious disease specialist and are getting their HIV medicine from a family or internal medicine provider may not have received appropriate HIV medicines.
- Those who are taking “difficult” HIV medicine regimens; this includes large numbers of pills, taking medicines more than once a day, or any other factors that cause one to miss or stop taking their medicines.
- Taking medicines, either prescribed or over-the-counter, which interfere with your HIV medicines (see chapter on drug interactions).
- Individual factors that are unique to one person--how the person absorbs and processes their HIV medicines.
You can see that there are many reasons and risks for treatment failure and every one of these reasons should be considered. Do any of these reasons apply to you? What role, if any, did you play in your past treatment failure?
It is important not to blame outside factors for your past problems with taking your HIV medicine. This includes factors like pharmacy, paperwork, insurance, family members, job, transportation, etc. I’m not saying that these factors are not important; however, if you do not look within yourself for the reason you had problems getting or taking your medicine, your next HIV medicine regimen will work as well as the first regimen and you will get treatment failure again. This is something you must try to avoid at all costs.
How do I know if I have treatment failure?
After a person has achieved undetectable HIV levels, it is not unusual for them to have an occasional “bump” in their viral load--anywhere from 50 to 1000. The person may have been ill, had an infection, a recent vaccination, all things which may cause a temporary rise in the HIV viral load. The lab may have made an error or used a different test. If the person has been quite careful not to miss any doses of HIV medicines, one can ignore this blip. If, on the other hand, the person has been careless with their medicines, this blip can serve as a wake-up call to get back on track. Another warning sign to pay attention to is how often these blips occur--once a year is okay--more than that, one must be careful that they are not getting careless with taking their medicine.
If the person having these blips is not missing doses of medicine, then they should look at the time they are taking their medicine. Are they taking the medicine at the same time every day--within one to two hours of the time they took it the day before? I see this quite commonly in my HIV clinic; many times the patient rushes to get to their morning clinic appointment and didn’t take their “breakfast” time HIV medicines. When I ask them when they will get home, the person tells me that he gets to the clinic by taking several buses so he won’t be home until 2 o’clock in the afternoon. That means that his medicines will be 6 hours late that day; in other words, the blood levels of the medicine are quite low from 8 a.m. until the person takes the medicine at 2 p.m.
The medicine should be taken at around the same time every day. If not, the virus is exposed for several hours to low levels of medicine, which will eventually cause the virus to mutate (change) and eventually be able to multiply even when exposed to high levels of the same medicine. See the previous chapter on resistance.
If the person is taking the medicine on time, every day without missing doses, is the person taking any other medicines that interfere with their HIV medicines? An example of this is atazanavir (Reyataz) and heartburn medicine--heartburn medicine lowers atazanavir levels. See the chapter on common drug interactions for more information. You can also ask your pharmacist, your HIV specialist, your nurse or read about the medicine yourself--either online, or in drug handbooks.
If the person has been taking their medicine quite carefully and not missing their doses, a blip may be ignored. If, on the other hand, the person says they have been missing quite a few doses of their medicine, and their HIV viral load is more than 750 to 1000, another HIV viral load should be measured. If the viral load remains above 750 to 1000, an HIV genotype test may be done to check for resistance “mutations.”
Restarting HIV medicines
An HIV genotype should be done if your HIV specialist thinks you are failing your HIV medicines. You should have an HIV viral load of at least 750 to run a genotype test; less than this and the test may not be able to be run. The best time to get the HIV genotype is while you are taking the medicine. If you have been off your HIV medicine for more than a month, the genotype may not be able to detect virus resistance.
Adding one new drug to the “old” HIV medicines
In some cases, if your HIV virus is more than 50 but less than 1000 and your HIV genotype is not showing resistance, your HIV specialist will add one more drug to your 3-drug HIV regimen. In other words, your HIV drug regimen is made stronger. Restarting the “old” HIV medicines
The best thing to do if you have been off HIV medicines for more than one month and your HIV specialist is not sure you have resistance is to restart the last HIV medicines you were taking. This is provided that you are able to restart the same medicine and do not have a reason why this would not be a good idea. For instance, if your last medicine regimen included zidovudine (AZT), and you now have anemia (a low red blood cell count), your HIV specialist may want you to avoid zidovudine.
After restarting your last HIV medicines, wait patiently. If, after several months, you achieve “undetectable” HIV, you can be assured that you do not have treatment failure and you can either stay on these medicines or you can ask your HIV specialist to change to a new HIV medicine regimen--perhaps one that is once a day, or less pills, or doesn’t cause as many side effects, etc.
If you have treatment failure, your HIV specialist will need to choose new HIV medicines. The HIV specialist will need to know the results of all your old genotype tests, if possible. If you have had genotype tests in the past but do not know the results, and are unable to get the results, your specialist may have to make an educated guess about what type of resistance mutations you have. For example, if you once took the drug efavirenz (Sustiva), and stopped taking the drug for whatever reason, there is a good likelihood that you have a resistance mutation to efavirenz and you will not be able to take this drug again. The efavirenz mutation is the K103N and it is famous for causing treatment failure in those who are the least bit careless about taking their HIV medicine on a strict daily basis.
Along with resistance, your HIV specialist should consider your past HIV medicines. Always keep a record of what HIV drugs you have taken in the past as these medicines are important to know when choosing your next regimen.
You should know about something called “archived” resistance mutations. Archived means “filed away” or hidden. Your new genotype may show no resistance but you do have resistance--it is just hidden. These mutations will usually show up only when your virus is exposed to the same drug.
Let me give you an example of someone who has archived mutations. From 2004 to 2007, Shirley took the HIV drugs zidovudine (Retrovir, AZT), lamivudine (Epivir, 3TC) and nelfinavir (Viracept). Before starting the medicine, Shirley had an AIDS diagnosis with a CD4 of 58, an HIV viral load of 600,000 and she felt bad. She had thrush (white patches in her mouth) and had lost 30 lbs. She took the 3 drugs correctly the first several months, then on and off for 3 years. Her CD4 went up into the 300s, and her HIV viral load went to undetectable after 3 months time. Shirley regained some of her lost weight and no longer felt sick. Shirley became careless about taking her medicine and frequently skipped her evening medicines and ran out of medicine for 1 or morej days every month. Eventually, Shirley decided she was sick of taking HIV medicines and stopped them altogether in 2007. At the time she stopped the drugs, Shirley’s CD4 was 301 and her HIV viral load was 2500. Now, in 2010, Shirley comes back to the HIV clinic and wants to restart her HIV medicines. Her CD4 is 205, her HIV viral load is 101,000, and she has started to lose weight again. Her HIV specialist runs a genotype test to see if she has any resistance mutations and the test shows no resistance. The HIV specialist is worried about hidden (archived) mutations but decides to restart Shirley’s old HIV regimen. Shirley restarts zidovudine, lamivudine, and nelfinavir and she is seen in the office 2 months later. Her HIV viral load has gone down only slightly, to 78,000, certainly not what her HIV specialist had hoped for. Shirley gets another test for HIV resistance, and the test shows that she has resistance mutations to two of her 3 HIV drugs. Shirley had archived, or hidden mutations, which did not show until the virus was exposed to the old HIV medicines.
This is one benefit of restarting your old HIV medicines--”teasing out” archived or hidden mutations. It’s good to know upfront exactly what type of mutations you have, if any.
Choosing new HIV medicines
The goal of the new HIV medicine regimen is the same as the goal of the first HIV regimen: to suppress the HIV viral load to undetectable (less than 50) and to keep it undetectable over the long run. The new medicines are chosen from the US Department of Health and Human Services (DHHS) and the International AIDS Society (IAS) adult treatment guidelines just like the first medicines were, keeping in mind that the drugs you have resistance to must be avoided. For example, if you have the mutation K65R, you will not be able to use the drug tenofovir (Viread).
An HIV viral load is checked around 2 to 4 weeks after starting new HIV medicines. If your viral load is moving toward undetectable, great. If not, you are either not taking your medicines every day, are taking them incorrectly, or a mistake was made in choosing your medicines. You may have HIV resistance mutations that were not picked up on your HIV genotype test. Resistance mutations show up when the virus is “under pressure” from the HIV medicines. If the virus is not “under pressure” because you are off medicines, the resistance mutations will not show until you take HIV medicines again.
The best “new” HIV regimen will include 3 “active” drugs. By active, I mean that each drug is fully effective in maximally suppressing your virus. Let me explain. Sometimes, your HIV specialist will recommend you remain on an HIV drug, even though you have resistance to the drug. There is some benefit to doing this; however, the drug is not considered to be “active.” The drug is not fighting the virus but is helping in other ways.
For example, many people have the M184V mutation which is associated with lamivudine (Epivir, 3TC) and emtricitabine (Emtriva, FTC) resistance. Their HIV specialist nearly always recommends that they continue this drug because it still has a benefit, but it is not considered an “active drug.”
My CD4 count and HIV viral load are good. Can’t I just stay off medicine for now?
What about those who have taken HIV medicine in the past and want to stay off HIV medicines--perhaps because they have a good CD4 count and a low HIV viral load? The results of much recent research shows that HIV treatment, once started, should be continued forever. Even with a high CD4 count and a low HIV viral load, HIV causes damage and inflammation to the body’s organs and keeping the virus suppressed is of great benefit.
My HIV genotype shows no resistance, but my provider says I am failing my HIV medicines. What does that mean?
Usually, an HIV genotype that is done when a person is on a failing regimen will pick up HIV resistance mutations. If the resistance test shows no mutations, most HIV specialists think it’s just a matter of the person is not taking their HIV medicines. For example, a person has an HIV viral load higher than 100,000 and the resistance test shows no mutations. Ninety-nine times out of 100, the person is not telling the truth about taking their medicine.
Why would a person be dishonest about taking their medicines? Usually, the dishonesty is for a reason--sometimes the person fears upsetting or disappointing their HIV specialist. I once had a patient swear up and down to me that he was taking his medicine, even though his HIV viral load was in the 600,000 range and his genotype showed no resistance. Thirty minutes later, he told the nurse he was taking his medicine only once a week. When the nurse asked him why he had not told his HIV provider, he said, “I didn’t want any drama.” I laughed when the nurse told me about this, but then I thought about it. I do give out “drama” when patients tell me they aren’t taking their medicine and perhaps I was getting dishonest answers because of this drama. Perhaps I need to go easy on the drama.
