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Implications for Clinical Management

Martin S. Hirsch, MD; Brian Conway, MD; Richard T. D'Aquila, MD; Victoria A. Johnson, MD; Françoise Brun-Vézinet, MD; Bonaventura Clotet, MD, PhD; Lisa M. Demeter, MD; Scott M. Hammer, MD; Donna M. Jacobsen; Daniel R. Kuritzkes, MD; Clive Loveday, MD, PhD; John W. Mellors, MD; Stefano Vella, MD; Douglas D. Richman, MD; for the International AIDS Society–USA Panel

JAMA. 1998;279:1984-1991.

Objectives.— To review current knowledge of the biology and clinical implications of human immunodeficiency virus (HIV) resistance to antiretroviral drugs, describe assays for measuring resistance, and assess their use in clinical practice.

Participants.— The International AIDS Society-USA assembled a panel of 13 physicians with expertise in basic science, clinical research, and patient care relevant to HIV resistance to antiretroviral drugs.

Evidence.— We reviewed available data from published reports and presented at national and international research conferences. Basic science research, clinical trial results, and expert opinions were used to form the basis of this report. Data on methods for and characteristics of specific genotypic and phenotypic assays were obtained from manufacturers and service providers.

Consensus Process.— The panel met regularly between October 1997 and April 1998. Panel subgroups developed and discussed different sections of the report before discussing them with the entire panel. Conclusions and suggested approaches to the use of resistance testing were determined by group consensus.

Conclusions.— Plasma HIV RNA level and CD4⁺ cell count are the primary values that should be used to guide the initiation of antiretroviral therapy and subsequent changes in therapy. Possible causes of treatment failure other than development of drug resistance that should be considered are adherence, drug potency, and pharmacokinetic issues. Genotypic and phenotypic testing for HIV resistance to antiretroviral drugs may prove useful for individual patient management. Assays under development need validation, standardization, and a clearer definition of their clinical roles. Possible current roles of resistance testing for choosing an initial regimen or changing antiretroviral therapy, as well as possible implications of the presence or absence of phenotypic resistance and genotypic changes, are discussed.

From Harvard Medical School, Boston, Mass (Drs Hirsch, Hammer, and D'Aquila); St. Paul's Hospital, Vancouver, British Columbia (Dr Conway); University of Alabama at Birmingham School of Medicine and Birmingham Veterans Affairs Medical Center, Birmingham (Dr Johnson); Hôpital Bichat-Claude Bernard, Paris, France (Dr Brun-Vézinet); Fundacio irsaCaixa and HIV Unit, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain (Dr Clotet); University of Rochester, Rochester, NY (Dr Demeter); The International AIDS Society–USA, San Francisco, Calif (Ms Jacobsen); University of Colorado Health Sciences Center, Denver (Dr Kuritzkes); The Royal Free Hospital Medical School, London, England (Dr Loveday); University of Pittsburgh Medical Center, Pittsburgh, Pa (Dr Mellors); Istituto Superiore di Sanità, Rome, Italy (Dr Vella); and University of California San Diego and San Diego Veterans Affairs Medical Center, San Diego (Dr Richman).

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