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drug holiday
Jul 6, 2005

I started taking meds (videx+retrovir) on april 1997 and I've never stopped until april 2005. My viral load has always been undetectable and my cd4 were between 400 and 600 (between 18% and 31%). My initial viral load in 1996 was 5,000. Now after 2 months holidays my viral load is 2626 and my cd4 443 (13%). What can I do now? thank you

Response from Dr. Sherer

Your story is interesting, in that you achieved control with only two NRTIs for 8 years. Most people who had this level of success with 2 NRTIs had higher CD4 cells and viral loads below 10,000, as you did. Current guidelines recommend against using this type of regimen because it is significantly less potent that 3 drug regimens, and in the majority of people with lead to regimen failure and drug resistance. You are an exception.

However, your question concerns me, as it suggests that you and your physician did not have a clear plan for what you would do if and when your viral load increased and your CD4 cell fell, as you both should have expected they would. Was there no plan?

For the readers, I will make the point that drug holidays are not a good idea if the options for management are not considered in advance. Was this a drug holiday taken without your doctor's knowledge and consent? I would also discourage this kind of independent act. Your doctor is your best ally in your efforts to stay healthy and keep HIV under control, and drug holidays should be considered and undertaken in consultation with your doctor.

So, what can you do now? I would suggest that you return to your doctor and ask him or her what to do, and you are welcome to share these suggestions as well, understanding that he or she may have important information in your case that I lack. There are several options:

1) You can perform a resistance test now, knowing that a result that shows 'no mutations' might be misleading, because your virus has not been under the pressure of your past regimen for 2 months, and mutant virus that may be present in a minority of clones may have since been overwhelmed and overgrown by the wild type viral clones. But you also might find a resistance mutation that would be useful in considering your next regimen (if any).

2) You and your doctor could also simply resume your past regimen and observe whether the outcome is again positive, as it has been for the past 8 years. If good control is re-established, then you could simply continue this regimen. If there is viremia, then you could do a resistance test to guide the choice of the next regimen.

3) You and your doctor could choose to resume ART with a simple and potent 3 drug regimen that includes a new class of drug, such as an NNRTI like efavirenz (Sustiva), in order to ensure that you receiving the current standard of care. The choice of drug would best be guided by the result of the resistance test in #1.

4) And, finally, you could choose to extend the drug holiday until the CD4 cell count was closer to 350 cells/ml, and then resume ART.

Personally, I would favor # 1, and then #3 based in part upon the outcome of the resistance test. Talk to your doctor and come to an agreement about your next steps, both in the short term and the long term.


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