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current issues

or no detectable drug level. In the case these patients, a negative drug level lopinavir level is detected, the chance of
of no detectable drug level, the clinician test predicted the absence of resistance drug resistance to lopinavir is far higher. 4
can assume that the medication has not with 95% certainty. In other words, if a This shows us that drug level testing can
been taken for at least one day, and in patient has a high viral load and their provide easy-to-interpret information
most cases for longer. 8 drug level test reports that the patient on patient adherence, and can enable
has no detectable lopinavir level, the healthcare workers to decide which
This test was then implemented in patients chance of drug resistance to lopinavir patients require drug resistance testing
with a VL >1000 copies/mL during is very low, and an adherence problem and which would benefit from intensified
second-line (lopinavir-based) ART. In is far more likely. In patients where a adherence counselling.

Key messages: How can nurses improve the standard of care based on these lessons?

Key message 1: Low level viraemia does not equal treatment success.
Patients with low-level viraemia (a viral load between 50 and 1000 copies/mL) should be followed up closely as they
have an increased risk of virological failure. Adherence counselling should be performed in these patients. If the low-level
viraemia persists or if virological failure develops, the patient should be switched to second-line ART in accordance with
guidelines. If you do not have authorisation to switch therapy, discuss the case with someone who does.

Key message 2: There is a delayed clinical response to viral rebound.
Patients with viral loads above 1000 copies/mL need to be flagged. The viral load should be repeated within three
months after the initial viral load, and adherence counselling should be performed in the meantime. If the second viral load
remains above 1000 copies/mL, a switch to second-line ART should be performed without delay.

Key message 3: Diagnostic tools can be used to generate insight in virological failure.
When in doubt about patient adherence, a drug level test could be a useful and cost effective screening option prior to
doing a resistance test. If the drug level test is negative, it shows that the patient has suboptimal adherence and a resistance
test is redundant.

References
1. Andrew Boulle , Peter Bock, Meg Osler, Karen Cohen, Liezl Channing, Katherine Hilderbrand, 5. Hermans LE, Steegen K, Ter Heine R, Schuurman R, Tempelman HA, Moraba R, et al. PI drug level
Eula Mothibi, Virginia Zweigenthal, Nevilene Slingers, Keith Cloete, Fareed Abdullah, Antiretroviral testing as a screening tool for drug resistance in 2nd line ART failure [Poster]. CROI. 4-7 March
therapy and early mortality in South Africa, Bulletin of WHO, 2008, https://www.who.int/bulletin/ 2019.
volumes/86/9/07-045294/en/
6. Arnsten JH, Demas PA, Farzadegan H, et al. Antiretroviral therapy adherence and viral suppression
2. Hermans LE, Carmona S, Nijhuis M, Tempelman HA, Richman DD, Moorhouse M, et al. Virological in HIV-infected drug users : comparison of self-report and electronic monitoring. Clin Infect Dis.
suppression and clinical management in response to viremia in South African HIV treatment 2001;33:1417–23.
program: A multicentre cohort study. PLOS Med. 2020 Feb 25;17(2): e1003037. 7. Sangeda RZ, Mosha F, Prosperi M, Aboud S, Vercauteren J, Camacho RJ, et al. Pharmacy refill
3. Hermans LE, Moorhouse M, Carmona S, Grobbee D, Hofstra ML, Richman DD, et al. Effect of adherence outperforms self-reported methods in predicting HIV therapy outcome in resource-limited
HIV-1 low-level viraemia during antiretroviral therapy on treatment outcomes in WHO-guided South settings. BMC Public Health. 2014;14(1035):1–11.
African treatment programmes: a multicentre cohort study. Lancet Infect Dis. 2018 Feb; 18(2): 188-
197. 8. Point-of-care drug level testing for adherence assessment of first and second line antiretroviral
treatment in resource-limited settings Hermans LE, Nijhuis M, Kasper KC, O’Malley R, Oh SJ,
4. Hermans LE, Steegen K, Ter Heine R, Schuurman R, Tempelman HA, Moraba R, et al. Drug Schuurman R, Tempelman HA, Venter WDF, Burger DM, Wensing AM, ter Heine R. Poster
level testing as a strategy to determine eligibility for drug resistance testing after failure of ART: a presentation at the International AIDS conference, Amsterdam, The Netherlands, 2018.
retrospective analysis of South African adult patients on second‐line ART. JIAS. 2020 Jun 9; 23(6):
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