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medication
Sep 28, 2007

My nephew was diagnosed with HIV around 5 years ago, this week he went to his regular quartely checkops and his CD4 count level was 300, the doctor recommended tostart treatment right away. My questions is after he start his medication he will need to continue meds all his life span, or the count improves to the right levels he can stop. The reason knowing how adverse the side offects could be on him.

Response from Dr. Sherer

In the past few years, there has been a great deal of interest in the idea of stopping antiretroviral therapy (ART) after a good response with CD4 cells above a certain threshold, e.g. 350 or 500 cells/ml, in order to reduce treatment toxicities.

In the largest HIV study ever conducted, the SMART study, one half of patients were taken off ART (or not started if they had never been treated) until their CD4 cells fell below 250 cells, while the other half just stayed on their ART (or were started at >350 if they had not been on ART).

The results were very consistent - the group that stopped their ART were 2 times more likely to get an AIDS opportunistic infection or die than the group that stayed on ART. And a big surprise was that the treatment toxicities and non-HIV causes of morbidity and mortality, like heart disease, stroke, kidney disease, and liver disease, all were WORSE by 2 fold in the group that stopped medication compared to those who stayed on ART.

This latter finding was unexpected, because it was thought that some complications, such as heart disease, were related in part to the impact of treatment, such as lipid elevations and increased cardiovascular risk. As it turns out, ART REDUCED the risk of these events.

There have been some other treatment interruption strategies guided by CD4 cell counts that have worked out better, mainly with higher CD4 cell count thresholds for resuming ART, e.g. over 300 cells/ml (rather than the lower threshold of 250 CD4 cells in SMART).

Nonetheless, my answer to your question is that, once ART is indicated, it is best considered to be life long. Your nephew and his doctor may decide that an exception is possible, with careful monitoring and specific milestones to prompt resumption of treatment, but my advice is to get onto highly potent ART, establish a solid routine to ensure that every dose of ART is taken at the right time, and then stick with it without any interruption.

It is important to note that the newest generation of ART has fewer side effects and greater convenience, so that many of the reasons for considering treatment interruptions are no longer as compelling. Talk to his doctor about your question and this response.


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