|Undetectable for 2 years
Nov 10, 2004
I am a 39 year old caucasian male in good health. I have been positive now for approximately 25 months. I was fortunately diagnosed approximately one month after infection. Standard tests came back negative. My PCR (viral load test) confirmed HIV infection. My viral load was 750,000 plus. CD4 count 610.
I started treatment September 10, 2002 and have been taking meds regularly since. My viral load dropped to just above 400 in 4 weeks. Shortly thereafter I was nondetectable. My tcells climbed to 800 as well.
During this period I have made many changes in my life. One of them is to become sober and stop using Crystal Meth-- the reason I became positive in the first place. I also moved from NYC to Los Angeles and have reconnected with my family, friends old and new. I have to say I have my down moments regarding my HIV but all in all I am a better person as a result of my experience.
My Los Angeles doctor has recently mentioned the idea of stopping my meds (Viread, Viramune, Epivir). Citing the possibility of me being a slow or non progressor given my caucasian background and good overall blood counts. Well, honestly at first I was completely put off by the idea but that only means I need to better inform myself. I was further confused when my doctor in NYC repeatedly tells me to continue my meds. I want to say again my viral load has been nondetectable since January 2003 and my CD4 count has ranged from 600 - 1100 over that same time.
My main concern for stopping meds is fear of resistance on my current regimen. I fear protease inhibitors and their side effects. I might add other than fatigue. My side effects are basically nill. I also realize I am approaching mid life. So fatigue is something I would encounter regardless of my status I would think. To note, I am also on testosterone supplementation to help with energy.
What I would like to know. Am I a good candidate for stopping? Are their any tests that would give further insight to my health if I were to stop meds? Progressor or non progressor. Should I stop my meds all at once or Viramune one day before because of the half life difference over Viread and Epivir?
Any insight to this question would be beneficial.
Frank (Los Angeles)
| Response from Dr. Pierone
What we do know is that treatment of primary HIV infection with combination therapy works and continued therapy can maintain virologic control and allow preservation of immune function. What we don't know is whether we should stop at some point, and if so, at what point? There are studies that suggest a subset of patients treated early seem to be able to control virus for years after medications are stopped. If so, maybe one does not need to be on therapy long-term. We worry about long-term side effects of therapy and development of drug resistance (especially if adherence is problematic). The benefit of early therapy is unproven at this point in time, but this lack of supportive evidence does not mean that it does not work, time will tell.
Since we don't have definitive data to guide management in your situation, it comes down to individual choice about whether to stop or continue.
You could stop and this would let you know is going on with your body's ability to control the virus absent medication. The viral load off therapy (set point) will give you a general sense of what is happening. But after months to years after stopping this set point may change, as the viral load has a tendency to rise in conjunction with viral escape from immunologic control (the "set point" may not really be that set in the context of primary HIV infection treatment). Another consideration is the chance of developing a retroviral rebound illness several weeks after stopping; the rate of this syndrome varies widely in the STI literature, but typically is less than 10 percent.
You could also continue therapy and this would be entirely reasonable. You are tolerating the regimen well, it is working, adherence is not an issue, and your current doctor is in favor of treatment. These factors certainly influence the decision making process and support the argument to continue. Lastly, you can simply defer the decision about whether to stop to some future time. Studies are underway (like SMART) that will provide us with additional data to inform situations like yours.
In the future we should be better able to tell someone how best to stop NNRTI-based regimens like yours to lower the risk of developing resistance. Right now we don't know the best way to achieve this goal and I simply advise my patients to stop all medications at the same time. Other clinicians recommend stopping Viramune a week (or two) before stopping the nucleosides. Others actually change the NNRTI to a PI, then after several weeks stop everything at the same time. Different approaches abound since we don't have clear data to guide us in this regard.
In any case, let us know what you decide to do and how things turn out. Thanks for posting.
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