[Management of antiretroviral treatment in HIV-infected patients exhibiting virologic failure].

THE BASES OF THERAPEUTIC FAILURE: In view of its varying clinical, immunological and virological components, therapeutic failure during HIV infection is debatable. It relies on monitoring the patient during treatment, taking into account prior therapy and the initial level of CD4 and HIV viral charge, and their evolution. Immuno-virological failure can be defined as a detectable viral charge and CD4 lymphocytes lesser than 200 elements/mm3. Therapeutic failure can be related to various factors: poor compliance to treatment, insufficient dosing, poor absorption or drug interactions reducing its efficacy and HIV resistance to antiretrovirals. THE MANAGEMENT OF PATIENTS EXHIBITING CONFIRMED THERAPEUTIC FAILURE: Requires assessment of patient's compliance and the search for drug or nutritional interactions. Pharmacological doses of antiretrovirals are useful in explaining the onset of failure or in adapting the dose. A genotype resistance test will orient the choice of new molecules in patients with reduced therapeutic options. THE CHOICE OF A NEW COMBINATION: Relies on knowledge of prior treatments and the reasons for their withdrawal (failure or intolerance) and the profile of in vitro cross-resistance to antiretrovirals. The optimal prescription combines at least two new molecules and/or a new class of antiretrovirals to which the patient has not yet been exposed. IN PATIENTS IN WHOM THERE IS NO THERAPEUTIC RESOURCES: An association of three classes of antiretrovirals with a total of 5 to 8 molecules are proposed in high-dose therapies. The use of suspension of therapy, to permit re-sensitivity, is presently being studied. THE OBJECTIVE OF TREATMENT: In non-responding patients, it is essential to retain an number of CD4 protectors depending on the clinical progression of the disease, while awaiting new therapeutic options, contrary to first or second line treatment, the priority aim of which remains reaching a undetectable viral charge.