What to Do When Initial HIV Antiretroviral Therapy Fails to Suppress Viral Load
This protocol addresses people with HIV whose first-line antiretroviral regimen has not achieved or maintained adequate virologic suppression — specifically when HIV RNA remains detectable above established thresholds during or after initial treatment.
Previous Treatment — Failure Condition
When Initial ART Did Not Reach Its Goals
Initial antiretroviral therapy — which may include BIC/TAF/FTC, dolutegravir plus TXF/XTC, or DTG/3TC — is considered to have failed when HIV RNA does not fall below 200 copies/mL within 12 to 24 weeks of therapy, or when ongoing virologic suppression below 50 copies/mL is not maintained after prior suppression.
Next-Line Approach
When virologic failure is confirmed, the approach begins with HIV resistance genotype testing to characterise specific resistance mutations — the targeted regimen switch that follows depends on those findings and is fully detailed in the structured protocol.
Treatment Goal
Virologic suppression to HIV RNA below 50 copies/mL
References
DOI: 10.1001/jama.2024.24543
- If HIV RNA level is above 200 copies/mL on 2 consecutive measurements, then an HIV RNA reverse transcriptase–protease genotype should be obtained, and if the person is receiving an InSTI, an InSTI genotype assay should be ordered (evidence rating: AIII).
- In aggregate, these studies demonstrated that use of dolutegravir along with TXF/XTC provided rates of virologic suppression comparable or superior to those of a boosted protease inhibitor plus 2 NRTIs.
- If an HIV RNA level above 50 copies/mL is detected during ART following previous suppression (<50 copies/mL), a repeat measurement of HIV RNA level is recommended in 2 to 4 weeks, and adherence to medication and tolerability should be assessed (evidence rating: AIa).
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