1A 7.2 In patients on ART:   A single VL 50–400 copies/mL preceded and followed by an undetectable VL is usually not a cause for clinical concern. GPP We recommend a single VL >400 copies/mL is investigated further, as it is indicative of virological failure. 1C We recommend

find more in the context of repeated viral blips, resistance testing is attempted. 1D 7.3 We recommend patients experiencing virological failure on first-line ART with wild-type (WT) virus at baseline and without emergent resistance mutations at failure switch to a PI/r-based combination ART regimen. 1C   We recommend patients experiencing virological failure on first-line ART with WT virus at baseline and limited emergent resistance mutations (including two-class NRTI/NNRTI)

Epacadostat cost at failure switch to a new PI/r-based regimen with the addition of at least one, preferably two, active drugs. 1C   We recommend patients experiencing virological failure on first-line PI/r plus two-NRTI-based regimen, with major protease mutations, switch to a new active PI/r with the addition of at least one, preferably two, active agents of which one has a novel mechanism of action. 1C   We recommend against switching a PI/r to an INI or an NNRTI as the third agent in patients with historical or existing reverse transcriptase (RT) mutations associated with NRTI resistance or past virological failure on NRTIs. 1B 7.4 We Tolmetin recommend patients with persistent viraemia and with limited options to construct a fully suppressive regimen are discussed/referred for expert advice (or through virtual clinic referral). GPP   We recommend patients with triple-class resistance switch to a new ART regimen containing at least two and preferably three fully active agents with at least one active PI/r such as DRV/r or tipranavir/ritonavir (TPV/r) and one agent with a novel mechanism (CCR5 receptor

antagonist or integrase/fusion inhibitor) with etravirine (ETV) an option based on viral susceptibility. 1C 7.5 We recommend accessing newer agents through research trials, expanded access and named patient programmes. GPP   We suggest continuing/commencing NRTIs as this may contribute partial ARV activity to a regimen, despite drug resistance. 2C   We recommend the use of 3TC or FTC to maintain a mutation at codon position 184 of the RT gene. 1B   We recommend against discontinuing or interrupting ART. 1D   We recommend against adding a single, fully active ARV because of the risk of further resistance. 1D   We recommend against the use of maraviroc (MVC) to increase the CD4 cell count in the absence of CCR5 tropic virus. 1C 8.1.