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Viral load increasing while on HIV therapy

When monitoring a patient's viral load during treatment, it is important to realize that increases in the amount of virus can occur for several reasons. One reason might be that the person is not taking the medications appropriately. In this case, the reason for failing to follow treatment must be established. If the poor adherence is a result of drug side effects, efforts should be directed towards managing the side effects or changing to a better-tolerated regimen. If the reason is difficulty with the dosing schedule, new strategies should be discussed. Such strategies might include placing medications in a pillbox, associating the dosing with certain daily activities such as brushing teeth, or possibly changing the regimen. Finally, if the reason for poor adherence is depression, substance abuse, or another personal issue, these issues need to be addressed and managed. If necessary, the antiviral medications can be withheld until the issue has been resolved.

It is important to remember that sometimes, for reasons not entirely understood, the viral load can briefly increase. Unexpected increases, therefore, necessitate repeated testing of the viral load before any clinical decisions are made. If, however, the viral load is continually elevated despite proper adherence to the prescribed therapy, serious consideration must be given to the possibility that the virus has become resistant to one or all of the medications being given. The best strategy for dealing with this situation has not yet been defined. It is suffice to say, that this situation is complex and methods for managing the problem are evolving. Accordingly, these patients should be referred to a clinician with expertise in antiviral therapy. Generally, the specialist will change the regimen to one that is likely to be active and then closely follow the virologic response. There is now an abundance of data showing that the use of drug resistance tests can improve the response to a second regimen. Testing can be used to determine if an individuals HIV has become resistant to one or more of the drugs that are being taken. Drug resistance testing is expensive and at times can be difficult to interpret. Therefore, it is best used by those with expertise in this area. Drug resistance testing is currently recommended for all subjects experiencing increases in viral load while on therapy as well as in the setting of pregnancy. Guidelines also are increasingly recommending that such testing be performed in those recently infected who have never been on antiviral therapy because of the increasing frequency with which people are being infected with HIV virus that already is resistant to drugs.