Letter From the Editor

Dear Colleagues,

Many of our correctional patients experience recurring cycles of excellent viral suppression followed by interruption of therapy (in parallel with their cycles of release and reincarceration). These cycles of therapy are a form of "unsupervised and unstructured treatment interruption" (USTI). Since USTI is a recurring theme of correctional HIV care, we chose to describe recent studies of Strategic Treatment Interruption (STI) and the interactions between T cells, HLA, and HIV for our main article this month. This article also gives our Chief Editor an opportunity to wear her immunology hat. When not providing care to incarcerated women in the Connecticut prison system, she is involved in the development of HIV vaccines for prevention and treatment of HIV at Brown University.

Our main article in this issue describes the components of immune response to HIV and explains why STI is more likely to provide benefit in acute HIV infection and less likely to benefit patients who have chronic HIV infection, at least until more effective forms of STI, such as STI given in conjunction with effective therapeutic HIV vaccines, are developed. Our "HIV 101" lists vaccines that are currently under investigation for use with STI. The "HEPPigram" describes the course of immune response to HIV infection over time, and in response to HAART.

In this issue, the "Ask the Expert" piece is on HIV-1 non-clade B infections. The case discusses the specific issues of recognizing, testing for, and treating HIV-1 non-clade B infections. This month's expert is our own Chief Editor, Dr. Anne De Groot.

Since correctional HIV patients frequently experience what may be called USTI, correctional HIV providers have an opportunity to contribute some information on the effect of USTI on our patients. How would we expect USTI to compare to STI? Poorly. For example, many of our patients do not achieve suppression of viral replication of long enough duration prior to interrupting therapy (typically, in STI, treatment is continued for at least 8 months before STI is attempted). Secondly, the duration of HAART cessation may occur over periods of months (sometimes years), much longer than the duration of treatment interruption evaluated in STI studies. Furthermore, our patients frequently resume therapy, when they are reincarcerated, with viral loads vastly exceeding the limits used in STI studies. In addition, our patients usually resume illicit drug use when they interrupt their HAART. Resumption of injection drug use and the associated life circumstances may adversely impact the immune response to "autologous immunization." In short, USTI has none of the features that may contribute to the success of STI in acute HIV infection. Experts in the field caution against the application of STI until more information can be obtained on the optimal duration of the individual cycles, the role of HLA, the role of T cell epitopes, and the role of adjunctive treatments such as vaccines.

As always, we encourage your feedback and submissions for future issues of HEPP News!

Sincerely,

David P. Paar, M.D.

Back to the HEPP News October 2001 contents page.