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ART Resistance, 1st line, 2nd line
Nov 24, 2005

Hi Doc, I am still confuse about ARV resistance,1st line, and 2nd line. Let's say I am resistance to certain coctail combination on 1st line category,can I take another combination still from 1st line category as a replacement? And if no more option from 1st line, then I should took medication from 2nd line, correct? What happened if the 2nd line also failed? Does it mean my ART opportunitiy has finished? Does it mean no hope anymore and just waiting for AIDS coming? Soory for this stupid question, I am really confuse on this matter.

Thanks, Roy.

Response from Dr. Sherer

These are important questions, and smart ones. I urge you to discuss them, along with my answers below, with your doctor, and don't give up until you're sure that you're clear about the answers.

We speak of 'first line' and 'second line' ART combinations to refer to the order of their use. In fact, most drugs have been used in both first and second line regimens (i.e. combinations), as well as in third and later regimens.

Drugs that tend to be chosen as first line in 2005 regimens are those with the best combination in clinical trials of efficacy, tolerability and side effects, and convenience. Drugs that tend to be chosen as second line regimens in this era are those that are known to have good effectiveness when used in this way, i.e. after the failure of a first line regimen.

Note that we have useful tools to understand why certain ART regimens have failed. One is regular discussion of adherence to medications, which is the one factor that patients control exclusively, and the one that they should work the hardest on. The first key rule is to take all meds, all the time, in the way that they are prescribed, and to communicate regularly with your doctor if questions or concerns arise.

Another important tool is the resistance test, which allows us to determine whether new HIV mutations have arisen that render one or more of the drugs in a regimen (1st line, 2nd line, or later line) are still active against the current majority population of HIV. In order to interpret such a test, your doctor will need to have a complete treatment and treatment response record.

Also generally, HIV physicians will aim for the same outcome, i.e. rising CD4 cell counts and undetectable viral loads, with both the first and the second line regimens. After failures of both of these regimens (if that unfortunately were to occur), it is more difficult to achieve complete viral load suppression, though not impossible, and lesser goals of rising or stable CD4 cell counts and controlled viremia (eg 2,000 - 20,000 copies/ml) may be neccesary.

Even after the virologic failure of two regimens, there are ART regimens with good success at preventing HIV-related opportunistic infections - so a person is in no way 'done' with ART after a second failure.

The best source of information about both your current status and your future is your doctor. Patients can't afford the luxury of being shy with their doctor, so take these questions to him or her, and stay at it until you get the answers you need.


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