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STI options
Mar 25, 2001

My STI appears to be working. After six months my vl was <50 and cd4 1155. I am doing a week on/off cycle. I have a few questions regarding my options, and curious as to which seem appropriate.

1) Discontinue meds and do regular labs? 2) Continue the STI until a vaccine is available? 3) Stop meds until my viral load reaches my setpoint then restart therapy? Thanks for your thoughts in advance. This website is second to none.

Response from Dr. Cohen

Well, it is great to hear that your week on/week off cycle is working for you. So far, the few data we have from a small study being done at the NIH in the US has shown similar success in the 10 or so people participating for about as long as you have been doing this. For this response, I will assume you started meds after you had been HIV positive for some years - since there are different issues involved when treatment is started shortly after initial infection. I'll defer that for this response.

You don't mention how you feel about being on meds - and this could help decide among the proposed options. Since if part of what is triggering your question is some desire to be off meds for more than a week - this would sway us in one direction. And two of the three options you propose involve stopping meds - but I'll assume that staying on is OK by you... for now.

It is not clear from your question how you'll decide on your proposed options - you don't give me any clue to what you are thinking, or what goal you have with your own treatment. So here are some considerations. With a CD4 count of over 1000, it is controversial if you need to be antivirals at this point. So, as you mention, one option to consider is to just discontinue meds and monitor with labs such as CD4 counts and viral load testing. The likely outcome is that your viral load will go back up towards your pretreatment set point, and your CD4 count will probably drop. The few studies already done suggest that your lowest CD4 count in the past has some role in predicting how low you might drop once you stop - so you can figure this into your thinking as well. But if your viral load and CD4 count off meds allows you some time to be off meds entirely - this is an option that some are exploring - given that you have identified at least one combination that can work well for you in the future. Deciding on the trigger to restart - a viral load back to your setpoint, or waiting until a drop in the CD4 count to some number - is one of the factors you'll need to consider as you decide what to do next - since each approach has pros and cons, and are interrelated as well. And studies are planned to take these issues on in a more formal way - since they are some of the most important questions we face in deciding what to do for those doing well on meds.

One consideration is ensuring that whatever you are now on will work in the future if you did stop it now. And there is at least some theoretical concerns about stopping a regimen that contains a nonnucleoside - as these are agents with longer "half lives" in the body that the others we use - so some clinicians have done a variety of things to minimize the risks to you when stopping such combinations.

As for staying on - you certainly can do so if you are feeling well and doing well. Your response sounds ideal in terms of CD4 count and persistant viral control. And we don't have a vaccination strategy yet known to boost your own immune system to control HIV off meds - staying on until we do is certainly one way to protect your current CD4 count from any loss at all that would be expected if you stop meds and allow HIV to reemerge.

These are some of the factors we consider in deciding what is next to do. Without knowing you, and knowing more, it is not possible to recommend one over another - but hopefully these are thoughts you can think more about with your HIV clinicians.

CC



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