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Do I need to continue treatment?
Mar 17, 2002

I have been positive for just over 2 years. Initially, my viral load was 750 with a cd4 count of 500. For the last year and a half, with treatment, my viral load has always been under 50 with a cd4 count greater than 800. Should I continue treatment? I have heard many conflicting statements. Thank you....

Response from Dr. Aberg

This is an excellent question and one we are in the process of trying to find what are the best options for individuals like yourself. Personally, I encourage my patients with similar scenarios to enter a clinical trial in which we are studying "pulse therapy". Let me first define some terms and then let me breifly discuss some options.

Drug holiday: This is when one stops for a unspecified amount of time up front because the person needed a break for personal reasons, side effects, medical reason such as surgery, etc. The plan would be to go back on when the person was able and stay back on.

Structured Treatment Interruption: This is when one decides upon a set schedule to stop and start. It may be a 7 day off/on cycle or a 2month on/1 month off, etc. The bottom line is that the time off and on is pre-determined. There are many clinical trials evaluating this. I have not had any patients do this except in the context of a study. I do not think there is enough information yet to know what the best cycle is.

Pulse: This is when someone has a CD4 count > 500 cells and then they stop their HIV medications and get serial CD4 counts regularly (usually every 2 months or so). The plan is to restart HIV meds when the CD4 count drops somewhere between 300-350. This break may only be a few months for some and maybe even years for others. I also encourage my patients to enter a study looking at this but I do have several patients who have done this without being in a study. In fact, a few have been off more than 18 months and still have CD4 counts above 500.

The guidelines do not address individuals like yourself who went on HIV meds before we would currently recommend starting therapy. I don't know what the best strategy is. It is really up to you and your health care provider. We do know that these medications are associated with some long term complications. The question is really what would be most beneficial to you. I discuss the risks and benefits of going off therapy with my patients and together we make a decision. Some people feel fine on their meds and do not want to take a risk of the CD4 falling and seeing the virus rebound. Some people even feel ill when the virus rebounds.

So, you have the following options: 1. Continue your therapy 2. Do a pulse or pulse trial. Just stop and restart when your CD4 count is between 300-350. 3. Do a Structured Treatment Interruption (Trial would be best) 4. Stop your therapy for a short period of time and if you decide this is not what you wanted to do, go back on. Make sure you do this with your healthcare provider. You do not want to intermittently miss doses as this can lead to resistance.

This is not an easy decision and unfortunately none us can tell you what is best for you.



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