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another treatment interruption question
Jun 26, 2003

First, thanks so much for all your help and work answering these questions ...

I've been HIV+ for 5 years and was on Viracept/Combivir the whole time until last October. My VL started to creep up (just barely) to the 100 range so my doctor suggested going off in order to be able to do a genotype test and see if I was developing resistance.

I'm not resistant to anything, we found out, and my VL never really spiked again (well, it did in the first couple of weeks but then went back down to 6K), so he suggested staying off meds for a while to get a break from the toxicity.

My numbers now are 18K VL and 406 T cells. My highest VL ever was 37K before treatment and I think I've showed 550+ T-cells at some point.

I know there's no clear answer to whether treatment interruption is good, bad or ugly, but at what point should I insist on resuming meds? Or should I just appreciate the break and stop trying to overanalyze it!

Thanks again ...

Response from Dr. Pierone

It sounds like you have done very well with treatment over the last 5 years and viral loads in the 100 range are generally not a cause for major alarm. The problem is that with a viral load of 100 it is usually not possible to do a resistance test, and once you stop HIV medications and allow virus to rebound you may not find the mutations (if any were present) because of ascendance of "wild type" virus. This is a classic "catch 22"- at low viral loads we worry about early mutations and resistance, but are stymied because resistance testing can not be performed at low virus levels (usually less than 1000). There are resistance tests in research labs that do allow for testing at very low levels of viral replication and hopefully will become available in the future.

The decision to stay off medications for a while is not unreasonable, it really depends on the type and severity of toxicity that was present. This speaks to the larger issue of whether HIV treatment should be continuous, or allow treatment interruptions in order to reduce medication-related side effects. There is a large international study named "SMART" underway that will attempt to improve our understanding of treatment strategies. This study is open to persons with HIV and viral loads above 350. Half are randomly assigned to continuous treatment of HIV with the goal of getting viral load undetectable. The other half are observed off treatment until CD4 cells drop below 250. At that point treatment is begun and goal is get CD4 cells above 350. When this occurs, treatment is again stopped until CD4 is below 250, and then restarted, and so on. Unfortunately, we will not have answers from this study for quite some time.

When should you resume medications? That depends on your comfort level and personal feelings about treatment. The range in which treatment is generally started (or restarted) is 200-350 CD4 cells. Other factors are viral load, symptoms, previous tolerance of medications, and previous ability to adhere. Having said that, definitely appreciate your break and see how things go.



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