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Managing Side Effects of HIV TreatmentManaging Side Effects of HIV Treatment
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Question about STIs
Aug 30, 2000

Dear Expert,

In the recent article, "Gimme a Break", in the August Poz online (, there was some information in the blue table I was unclear about. It said: "[point]2. Your HAART-suppressed anti-HIV immune response may return." Does this mean that my HAART regimen may be currently suppressing my natural immunity to HIV? I thought the whole point of HAART was to <counter> HIV. Could HAART be making me less able to battle the virus (while the HAART battles the virus for me??). I am confused. Please clarify this for me, I am quite concerned. I am trying to figure out if a STI is right for me. I know that I should only do this with my doctors surveillance, and will only use this information when discussing this with him. I'd like to be clear on the latest theories though: I believe in being well informed about the current meds. Sincerely, Rob PS, I LOVE your magazine, it is really informative.

Response from Dr. Boyle

Dear Rob:

In progressors (unlike long-term non-progressors), the immune system is not very effective at control of HIV replication. HAART, which can effectively control HIV infection, is essential in these patients to suppress viral replication and stop progression or allow reconstitution of immune function to pathogens which cause opportunistic and other infections.

The immune system response to pathogens is somewhat dependent upon the amount of pathogen replication that is taking place. Therefore, as HAART decreases HIV replication and viral burden, the immune response to HIV tends to wane somewhat, with CD4+ and CD8+ cells reverting from a highly activated (but not necessarily effective) state to a resting state. This does not mean that the CD4+ or CD8+ cells are "lost" or that HIV-immune response is damaged, it simply means that the cells involved are not as active since there is not as much pathogen (i.e., HIV) around to drive them to high activity levels. Several studies have shown that if HIV is re-presented to the immune system in this "resting" state, it has the capacity to respond appropriately. So, the "decrease" in immune response to HIV with HAART is expected and simply related to an effective HIV suppression, which has been shown to be associated with long-term success and immune improvement to other important pathogens.

The largest STI trials reported to date have not shown any consistent improvement in immune response to HIV. There are significant unknowns and significant risks regarding STIs and I currently advise my patients to wait until we have more information. I recently wrote an article about these issues in the May issue of the AIDS Reader, which may be available at BB

Brian Boyle, M.D., J.D.

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