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Most clinicians are aware that HIV treatment outcomes have improved over time, but by how much? A new report gives us a sense of just how impressive the progress has been.
Using longitudinal data, investigators tracked rates of virologic suppression and newly detected resistance among all patients who received antiretroviral therapy in British Columbia between 1996 and 2008. Of the 8016 patients, 7730 had at least one plasma viral-load measurement, with nearly 25,000 resistance tests performed.
During the study period, the incidence of newly detected drug resistance dropped dramatically — from 1.73 to 0.13 cases per 100 person-months of therapy. A similar trend was seen across all three major drug classes. Furthermore, the proportion of patients who achieved virologic suppression (viral load, <50 copies/mL) increased each year — from 65% in 2000 (the first year that the assay with this lower limit of detection was available) to 87% in 2008.
Gill VS et al. Improved virological outcomes in British Columbia concomitant with decreasing incidence of HIV type 1 drug resistance detection. Clin Infect Dis 2010 Jan 1; 50:98.
Comment
People sometimes say that HIV treatment outcomes in clinical cohorts can never match those seen in clinical trials, because the trials enroll ideal patient types not typically seen in the “real world.” What the astounding results of this study clearly demonstrate, however, is that our currently available regimens are so good that even with the heterogeneity (and potential chaos) of clinical care, nearly everyone with HIV infection can be treated successfully. The decline in newly detected resistance indicates that HIV drug resistance — especially multiclass resistance — is largely a relic of the pre–potent therapy era. The question remains what to do with the residual 10% or so of patients who are not treated successfully; one suspects that treatment failure in these patients arises mostly from psychosocial (rather than medical) challenges.