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scheduled interuptions and minimal viral rebound
Apr 13, 2005

Dear Dr's:

My daughter was born HIV +ve and been on HAART since birth. She has always been undetectable with good CD4. At 2 years 4 months old, we decided to giver her a break off meds (AZT, 3TC and nelfinavir). Tested again after 3 months off, her VL was high at 471,000 and CD dropped to 15% (1,916). Restared meds and within 4 months VL was undetectable and CD back up to 34% (1,670). Now at 3 1/2 years old we gave her another break off meds. Just before going off she had VL of 98 with CD at 33% (1,221). We just tested her again after being off 2 1/2 months. Here's the shocker (good shock), VL is 104 with CD4 36% (1,620).

Our doctor is currently away involved in the retrovirus conferences in the US, so I was hoping that one of you experts could comment on this trend i.e. why first interuption had so high a drop in CD4 and high VL, with second interuption having virtually no VL and even an increase in CD4.

Best regards, AO in Thailand

Response from Dr. Pierone

A prolonged "honeymoon" in viral load return is not that uncommon after treatment interruption. It is a good thing of course, and I hope that this trend continues for your daughter.

We are involved in the SMART study and have stopped therapy in many patients with controlled viremia within the context of this trial. A small, but significant, proportion of them remain undetectable or have very low level viral levels for many months after treatment discontinuation. We are treating adult patients but I would expect that children would also sometimes have the same response.

The reasons why there are sometimes long delays in viral rebound after stopping treatment are not well understood. The "auto-immunization" theory is all but dead, but clearly immune-responsiveness to HIV plays a central role in the control of HIV off medications. The best data in the studies of STI comes after treatment of acute infection and if your daughter was treated promptly after birth she may fit into this category.

Please let us know what the next set of labs show. Thanks for posting and best wishes.



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