Simplification - an emerging theme for management and resistance interpretation

Jonathan Shapiro has twice spoken very compellingly about the needs for simplified, clinically relevant advice to help guide decision making. In the opening debate on Sunday he argued that the difficulties of drug - drug interactions could be ameliorated by better interaction tables and desktop guidance.

He has just presented the lead review talk Resistance: What's new and on the horizon. On this occasion, while clearly indicating the continued relevance of resistance, he made a number of key observations:

• "we now have drugs that allow us to ask patients to adhere" reflecting on the greater tolerability of current regimens
• that resistance testing falls into a number of camps:
  transmitted resistance In this regard he predicted that there was unlikely to be a dramatic change and that transmitted drug resistance would remain between 5 and 15%
  treatment optimisation where resistance profiles are used to determine second and third line therapy; determining which NRTI to use and/or fine tuning PI selection, particularly among heavily pre-treated patients

Again he emphasised that resistance interpretation needs to be made easier. His rationale was that we are no longer in a position where drug changes are as frequent. The majority of the drugs commonly in use now are not the drugs which were being used when resistance monitoring first came into being and that as the capacity to adhere has increased, so too has the development of resistance decreased.

He urged clinicians to tell those who develop assays and their interpretation systems what they want to know. He suggested that it should be possible to provide a virtual phenotype interpretation system which would, for example, indicate what PI options were available and what additional drugs to add to optimise a salvage regimen.

He also described a setting where those with limited resources might be able to purchase a basic analysis to assist in continuation or switch strategies through to a more costly tier for complex pre-treated patients. He referred people to the Stanford database http://hivdb.stanford.edu/pages/poc.html

It is not so long ago we had discussions about using standardised resistance interpretations in Australia and trying to make reports more digestible and useful. This seems to be a recurring theme at this conference. How can we make decision making easier? The webcasts from this conference will be posted some time soon and those with an interest in resistance might be interested in viewing O33 Resistance and Tropism.