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Treatment vacations
Dec 4, 2000

I am a long term survivor of HIV. I had pcp in 1986 and 88. I have been on aggressive antiretroviral therapy since the initial clinical trials for azt. I am in what I consider good health with a t'count of 150 and an undetectable viral load. I am a unique patient according to my physician. I have never had a viral load detected. I was always under 200 with the older tests and under 20 with the new ones. I have been extensively tested for variant strains of HIV and only hiv-1 has been found

I recently went through my best friends pancreatitis with him morphine pump and all. It was not a pretty thing! I can honestly say that I am now more afraid of Pancreatitis then a detectable viral load. It was caused by Kaletra which I do not take. I have removed protease inhibitors from my cocktail for the last 2 years. I am on Trizivir, Sustiva and acylovir.

With all the wonderful information on Treatment holidays for undetectable persons, what is your opinion on such a Vacation from pills for someone like myself. If I was ever to take a "holiday" I would insist on continuing Acyclovir since I get disseminated Zoster when I stop.

Thank You for your insight

Response from Dr. Pavia

The area of treatment interruptions, or drug holidays is causing a lot of discussion before we really know much about the benefits, and we are learning about the risks. It is an important area of research, but I fell strongly that it is not ready for clinical use, and we should not be trying it outside of careful studies.

It is important to realize that there are very different situations and possible reasons to think about treatment interruption as a possible strategy. One is a person who was treated during acute infection (say within 60 days of being infected) whose viral load was fully controlled in order to try and improve the body's own immune control of the virus. There is very preliminary, but exciting research suggesting this might just work. Another is to try and do the same in someone that was infected for a long period of time before starting treatment (such as yourself). In this setting, there is very little if any evidence yet that it is of any benefit to your immune system. What we do know, is that you can end up with a loss of CD4 cells while you are on "holiday". If someone had a very high CD4 count it is possible that it could reduce the amount of time you are on treatment without a major risk, and this is another area of research. With a CD4 count of 150, you may not be able to afford much of a loss. There are two other reasons to consider treatment interruption. One is for people who have highly resistant virus who stop treatment for a while before switching to a new regimen. The theory here is that without selective pressure the resistant virus will be replaced by wild type virus. This has been shown to provide almost no benefit at the cost of rapid loss of CD4 cells.

The last reason is to simply take a break because you are having side effects and need to take a break. That does not sound like the situation you are in either. In general my advice to most people is to let the research on treatment holidays continue, but in the meantime, "don't try this at home"

You should feel very blessed as a 14-year survivor after PCP, and I hope others who might feel that their lives are over after being diagnosed can look at you and be inspired. Congratulations, and good luck

ATP

Andrew T. Pavia, M.D.



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