Dr. Sherer, I apologize if this is the wrong forum for this question, but being newly diagnosed with HIV I have spent many hours reading this site and I was wondering if resistance is less of a problem today then it has been in the past. I recognize that resistance is still a major issue in HIV care but it seems that there is less activity in the resistance forum then there is in some other sections of the site. Is this indicative of the efficacy of HAART?

Thank you for all of the good work you do here, it has been comforting to know how far HIV treatment has come and that there are clinicians as compassionate and knowledgeable as you.

It is true that fewer people with HIV who started their treatment with 3 drug modern HAART regimens are developing multi-class resistant in this era than in the past. Several large cohort studies have demonstrated this fact. In one recent one from Eurosida, 15% of all patient who were treated with sub-optimal single and double nucleoside regimens before the current HAART era developed multi-drug resistance after 5 years, compared to 4% of patients who started their ART with 3 drug HAART.

Similarly, there is evidence that early virologic failure is a less frequent event now that even 5 years ago, with <5% of people per year in some cohorts failing the more recent regimens that are more convenient with fewer side effects, such as atripla and the second generation PIs like atazanavir and lopinavir.

As good as that sounds, no one should be complacent about resistance. The data above are in cohorts of highly motivated and adherent patients. Data from other cohorts with higher percentages of poorly adherent patients, such as active IDUs, people living with AIDS in high stigma countries with unstable access to ART, or people with AIDS with high rates of adverse drug effects, show much higher rates of virologic failure and new drug resistance.

There is other evidence of rising drug resistance in the studies of newly infected and chronically infected people living with HIV who have never been treated worldwide. In the largest collaboration from 33 countries worldwide, rates of transmitted drug resistance ranged from 5% to 15% or more, including countries on all continents (other than antartica).

So the good news is that the newer HAART regimens are better tolerated and more convenient, and more people are able to remain fully suppressed for longer....AS LONG AS THEY STAY FULLY ADHERENT!

The bad news is that resistance is still a serious threat to each individual, and is increasingly being transmitted worldwide. It is a threat to the health of people with HIV who have never been treated, as well as people on HAART, and it should never be forgotten or ignored.

As long as people living with HIV respect the threat of resistance and do everything that they can with their doctors to prevent it, they give themselves the best chance for long life of good quality on a single and tolerable regimen.