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Is stopping meds good advice?

Apr 1, 2004

My son has been on meds since July 2003 (early detection and started meds right away) -he will remain on them for another 11 months at which time his Doctor is planning on taking him off of them until his numbers say otherwise. At this time his CD4 is 1000 and Viral load undetectable......he feels comfortable on the meds and is tolerating them very well. What would you suggest? Is it better to take him off and look at his numbers or continue with the meds?

Response from Dr. Pierone

The benefit of prompt treatment after early detection has not been proven, so stopping therapy at some time to see what happens is a reasonable approach. However, some people initiated on early treatment choose to continue (especially is they feel well) because they want to maintain viral suppression.

It is a matter of evaluating the potential costs and benefits of therapy. There is a trade off between medication-related side effects and the benefits of medications in suppressing viral replication and preserving immune function. An additional factor is the potential for development of resistance if full adherence is not maintained. If resistance develops, this will limit future treatment options.

If an individual wanted to continue therapy, did not have adherence issues, and was not showing signs of medication-related toxicity, I would have no problem continuing therapy indefinitely. In general though, for those that have had prompt treatment of primary HIV infection I would recommend stopping at some point to see what happens. Some people in this situation end up with very low viral load results and may do extremely well without need for daily medication. Since we don't have good scientific evidence to guide us on how to proceed, a very important study is underway to help address these questions of early treatment.

SMART is a study that will enroll 6000 people worldwide with CD4 counts above 350 cells. Half with be randomly assigned to start or continue therapy with the goal to maintain viral suppression (similar to the situation your son is in now). The other half will be randomized to stop medications or continue off medications until the CD4 count drops to 250 cells. When the CD4 count goes above 350 they will stop antiretrovirals and stay off until the counts again drop below 250. Then back on once again until counts rise above 350, and so on. As data from this study matures we will gain a better sense of the benefits of early therapy versus the risks.

Since we don't have definitive data to guide us, the choice will have to be made based on general considerations, but the individual particulars will drive the decision. There should be a shared decision making process between patient and doctor to arrive at the best individual choice. Good luck and give us an update in the future.

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Immune-Assist 247

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