- Many patients return to care after treatment interruption when they experience clinical deterioration – screening for opportunistic infections (OIs) should be performed.
- VL measurement should be performed before re-initiation, and repeated 3–6-monthly.
- Choosing the appropriate regimen in patients who return to therapy depends on their previous regimen, their level of treatment adherence prior to disengaging from care, and their current CD4+ count and hospitalisation status.
It is common for patients receiving ART to interrupt their treatment for a variety of reasons (e.g. treatment fatigue, denial, life event, depression, new job, relocation). Many patients return to care after an interruption, often precipitated by clinical deterioration. Patients who have clinical symptoms of an OI when returning to care should be investigated and, if appropriate, started on treatment for the infection before restarting ART. In particular, patients should be screened for headache and for TB symptoms when returning to care. Reasons for delaying ART re-initiation are the same as for delaying initiation in ART-naïve patients (see Module 6). Patients who are asymptomatic when they return to care could be re-initiated on ART the same day with appropriate counselling. A counselling plan should be implemented to ensure retention in care going forward and to address reasons for disengagement.
We recommend performing a VL measurement before re-initiating ART, then 3–6-monthly thereafter. The choice of ART regimen to restart will depend on prior treatment history.
In patients returning to treatment after disengaging from a TDF + FTC (or 3TC) + NNRTI regimen:
- If the patient was treatment-adherent prior to disengaging, with a suppressed VL, and has only disengaged once or twice, then they could either be restarted on the same regimen or restarted on TDF + 3TC (or FTC) + DTG. If a patient restarts an NNRTI-based regimen, then switching to a second-line regimen should be considered if the VL is not < 1000 copies/mL at 3 months after restarting.
- If the patient has a history of poor adherence with multiple episodes of disengaging from treatment, then we suggest re-initiating therapy with a second-line regimen of: AZT + 3TC + DTG; or AZT + 3TC + PI/r; or TDF + FTC + PI/r. We do not recommend TDF + 3TC (or FTC) + DTG in this scenario, as there may be resistance to TDF and 3TC – multiple episodes of treatment interruption, particularly beyond the first year of ART, and poor adherence can result in resistance to all drugs in the first-line regimen.
- Hospitalisation with an AIDS-defining condition and a CD4+ count < 50 cells/μL represents another scenario in which a patient may be restarted immediately on second-line ART when returning to care after disengaging. Such patients are considered to be at high risk of mortality if restarted on first-line therapy to which their virus may be resistant; and they require an ART regimen that is guaranteed to be effective immediately. This decision should typically be taken by the hospital-level clinician.
In patients returning to treatment after disengaging from a DTG-based regimen:
- Restart the same regimen. Assess the VL at 6 months and follow standard guidance in response to the result.
In patients returning to treatment after disengaging from a second-line PI-based regimen:
- Either restart the patient on the same regimen or switch to AZT + 3TC + DTG (if they had failed a first-line TDF + 3TC (or FTC) + EFV regimen). Assess the VL at 6 months and follow standard guidance in response to the result.
In patients returning to treatment after disengaging from a third-line regimen:
- Restart the same regimen and assess VL at 6 months. Follow standard guidance in response to the result.
Common pitfall: Performing a resistance test after an ART treatment interruption of > 4 weeks. Such testing is of limited value. Many resistance mutations are overtaken by wild-type virus when ART is stopped and thus the resistance test may not accurately reflect the true resistance pattern.