Hi, I started a combination of Combivir and Viramune about 3 years ago, and I've had an undetectable viral load (<25 copies) and gradually increasing CD4 cells since (currently about 700). At baseline, my viral load was about 30,000 and my CD4 cells were around 480. I had probably been positive for 2 years before testing. I have had no significant side effects from treatment.

However, lately I've been wondering whether I should have started therapy as soon as I did. Perhaps it would have been better to wait until my CD4's dropped more. The problem, I guess, is that no one knows whether treating early is a good idea (except perhaps for primary infection). Would it be reasonable for me to go off therapy at this point, so as not to risk long-term side effects and to save medications for later? Would it be reasonable to take a break from treatment if and when my viral load rebounds, rather than switching therapies right away? I'm not expecting immune control over the HIV, but I'm not sure therapy at this stage is really necessary.

Thanks

You obviously understand some of the difficult issues involved. The attitude and the "conventional wisdom" on when to start treatment has changed from one of certainty to a more complicated admission that we don't really know the exact time to start therapy. More importantly, there is probably a right time for each individual, rather than a formula we can use. You started with a viral load that pretty much everyone would agree warranted therapy, but at a CD4 count that gave you some time before treatment was essential. How much time? Perhaps 2 to 3 years.

So, you are doing great, able to take your meds well, but are wondering what to do. The long term side effects are still something we don't full understand. You don't mention any body shape changes. Viramune has not been associated with increased cholesterol or insulin resistance, which decreases the possible worry about heart disease or diabetes, but we don't have 10 years of experience to be able to tell you what the 10 year safety looks like.

You could stop everything, and probably would rebound with wild type virus. That means that when you decide to go back on treatment, you could use the same regimen. If you chose that option, you should pick a CD4 count that you would restart at, perhaps 350 to 400. The second option, waiting till your viral load rebounds and then taking a break, is something we don't have any real data on. I don't suppose it would be a bad option, but I don't see an advantage.

Having said all that, my sense is that, given a great response, a non toxic regimen, and no problems taking all of your doses on time every time (I am assuming this part…) it doesn't make sense to mess with success. That is the, "what would I do if it were me" answer that I think honest docs should ask themselves. Good luck

ATP