Bansi, L.K.; (2011) Treatment strategies in HIV. Doctoral thesis , UCL (University College London).

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Abstract

The introduction of highly active antiretroviral therapy (HAART) has led to significant improvements in survival and morbidity for HIV-positive patients. Though HIV can now be well managed with treatment, interlinked barriers to successful treatment are still prevalent. In particular, low adherence to therapy, resistance to drugs and drug toxicity can have a considerable impact on the success of HAART. The potential of HAART is limited from the outset if patients are infected with a drug-resistant virus. Evidence suggests that a small minority of patients are starting HAART with drugs that the virus is resistant to, and consequently, are less likely to achieve virological suppression. A large proportion of resistance tests performed after patients‟ start HAART are not followed by a switch within 4 months of the result being received. This raises questions as to why the test was performed and whether limited future drug options are of concern. A single abnormal laboratory value may be the result of random fluctuations and may not necessarily be a reason for concern over drug toxicity. I derive a more stringent definition of an ALT flare and compare this definition with that commonly found in the literature. Treatment interruptions, perhaps due to drug toxicity, should not take place when the viral load is detectable. Patients who have achieved viral suppression after interrupting treatment and who have failed a higher number of HAART regimens are at a greater risk of viral rebound, though this risk is reduced substantially as duration of suppression increases. A score to characterise laboratory abnormalities is derived and used to predict mortality. Several methods were used; I felt the most appropriate was that based on the estimates from a regression model in which the current laboratory measurements were fitted; only three routinely measured laboratory measures were needed to calculate the score.

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