The Diagnosis and Management of Second-line Antiretroviral Treatment Failure

The Diagnosis and Management of Second-line Antiretroviral Treatment Failure

A 35-year-old female is referred to the clinic due to persistently elevated viral load. She has been on antiretroviral therapy for almost six years in total and for the past two years has been on second-line therapy. Her latest viral load performed three months ago was 125,391 copies/ml, having been 9,770 copies/ml eight months previously. Adherence counselling was intensified between these two viral load measurements. Her latest CD4+ cell count was 237 cells/µl. As she transferred into the programme one year previously from another programme in the province, details of previous laboratory monitoring are incomplete but her treatment history is outlined in the tables and the graph below [Note the initial second-line regimen was based on previous guidelines recommending zidovudine (AZT) + didanosine (ddI) + lopinavir/ritonavir (LPV/r) rather than current guidelines which recommend tenofovir (TDF) + lamivudine (3TC) + lopinavir/ritonavir (LPV/r) in the case of failure of d4T-based first-line regimen].



Reason for switch/substitution


April 2005 – August 2008

Virological failure


August 2008 – March 2010

Intolerance to didanosine (vomiting)


March 2010 – Feb 2011


d4T – stavudine; 3TC – lamivudine; EFV – efavirenz; AZT – zidovudine; ddI – didanosine; LPV/r – lopinavir/ritonavir 


Question 1: Which one of the following would be the most appropriate action to take now?






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