title: Treatment switches after viral rebound in HIV-infected adults starting antiretroviral therapy: multicentre cohort study.
abstract: OBJECTIVE
  To describe the time from first viral rebound on highly active antiretroviral therapy to first treatment change, identify factors associated with more rapid switching, and investigate whether treatment changes are in line with treatment guidelines.
  
  
  METHODS
  A multicentre cohort study.
  
  
  METHODS
  We described the time to first treatment switch among individuals experiencing confirmed virological rebound after initiating highly active antiretroviral therapy; factors associated with more rapid switching were identified using proportional hazards regression and predictors of a switch in line with guidelines were identified using logistic regression.
  
  
  RESULTS
  Thirty-four percent of the 694 patients experiencing virological rebound remained on a failing regimen for more than 6 months. Factors associated with more rapid switching were lower CD4 cell count (hazard ratio, 0.84 /100 cells/mul higher, P < 0.001), higher viral load (1.29 /log10 copies/ml higher, P < 0.001), older age (1.06 /5 years older, P = 0.07), and changing/adding drugs to the regimen prior to rebound (1.16, P = 0.16). Two hundred and eighteen of the 394 treatment changes (55%) were in line with guidelines; those receiving nonnucleoside reverse transcriptase inhibitor-containing regimens were more likely to make changes in line with guidelines (adjusted odds ratio, 2.80, P < 0.001), whereas those who had previously added drugs to their regimen were less likely to make changes in line with guidelines (0.15, P = 0.001).
  
  
  CONCLUSIONS
  A substantial minority of patients remain on a failing highly active antiretroviral therapy regimen for periods of 6 months or longer without adding new drugs. Changes made are often not in line with treatment guidelines, raising concerns about the development of resistance and long-term clinical outcomes in these individuals.
authors.forename: Katherine J
authors.initials: KJ
authors.lastname: Lee
authors.forename: David
authors.initials: D
authors.lastname: Dunn
authors.forename: Richard
authors.initials: R
authors.lastname: Gilson
authors.forename: Kholoud
authors.initials: K
authors.lastname: Porter
authors.forename: Loveleen
authors.initials: L
authors.lastname: Bansi
authors.forename: Teresa
authors.initials: T
authors.lastname: Hill
authors.forename: Andrew N
authors.initials: AN
authors.lastname: Phillips
authors.forename: Caroline A
authors.initials: CA
authors.lastname: Sabin
authors.forename: Achim
authors.initials: A
authors.lastname: Schwenk
authors.forename: Clifford
authors.initials: C
authors.lastname: Leen
authors.forename: Valerie
authors.initials: V
authors.lastname: Delpech
authors.forename: Jane
authors.initials: J
authors.lastname: Anderson
authors.forename: Brian
authors.initials: B
authors.lastname: Gazzard
authors.forename: Margaret
authors.initials: M
authors.lastname: Johnson
authors.forename: Philippa
authors.initials: P
authors.lastname: Easterbrook
authors.forename: John
authors.initials: J
authors.lastname: Walsh
authors.forename: Martin
authors.initials: M
authors.lastname: Fisher
authors.forename: Chloe
authors.initials: C
authors.lastname: Orkin
mesh_terms: D000328:Adult; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D023241:Antiretroviral Therapy, Highly Active / Q000379:methods; D018791:CD4 Lymphocyte Count; D015331:Cohort Studies; D024882:Drug Resistance, Viral; D005260:Female; D019983:Guideline Adherence / Q000706:statistics & numerical data; D015658:HIV Infections / Q000188:drug therapy* / Q000276:immunology / Q000821:virology; D006801:Humans; D008297:Male; D017410:Practice Guidelines as Topic; D019562:Viral Load
chemical_list: D019380:Anti-HIV Agents