People with HIV sometimes complain to me about severe side effects from antiviral medications (also known as "drug cocktails"). Some have wondered if the benefits of these drugs were worth the side effects. In many (but not all) people, these drug cocktails have been shown to be very helpful in improving their clinical status. But are these benefits worth the nausea, vomiting, fatigue and other side effects that sometimes occur? People suffering from severe side effects must ask themselves, "Which is more important . . . quantity of life, or quality of life?" Ultimately, this balance between quantity of life and quality of life is a very personal decision.

Some people who suffer from severe drug side effects stop taking their drugs (either temporarily or permanently). They may skip a dose or two, or just stop taking their drugs altogether. This is commonly known as taking a "drug holiday." Depending on the circumstances, clinically speaking, this may be very harmful to someone with HIV. Here are some reasons:

1. When one goes off medications, the viral load can increase substantially, since there would no longer be anything to limit reproduction of the virus. The higher the viral load, the greater the damage to the immune system, and the worse someone's prognosis.

2. The virus can become resistant to the drugs the person was taking. This is especially true if drugs are taken on and off (for example, taking them one day, skipping the next day, resuming the following day, etc.). There may also be problems if one stops taking just one or two drugs of a cocktail, rather than stopping the entire cocktail. We still do not know exactly how long a drug holiday of one or more drugs of a cocktail need be (days, weeks, or months) to cause problems with drug resistance. Generally speaking, if a cocktail is discontinued, it is recommended that all the drugs in that cocktail be stopped, rather than just one to two drugs. Drug resistance can limit someone's treatment options for the future. Sometimes a person may become resistant to multiple drugs at the same time, further limiting their future treatment options.

Generally speaking, once someone starts treatment, it is strongly recommended that they continue treatment indefinitely (although they may be able to switch from one drug cocktail to another). If someone's side effects are so severe that their quality of life is significantly reduced, there are several options:

1. Reduce the dosages of the drugs. One should always discuss this with one's doctor before changing any dosages. It is important to be very careful when reducing the dosages of antiviral drugs. If dosages are too low, HIV can quickly develop resistance to the drugs, making these drugs useless.

2. Change to a different drug cocktail. This should always be discussed with one's doctor before any medications are changed. There may be another treatment cocktail available that has fewer side effects. Usually, when changing drug cocktails, all of the drugs are changed, rather than just one or two.

3. Continue on the same drug cocktail to see if the side effects lessen over time. Sometimes side effects can become less severe over time, as the body gets used to the drugs.

4. Consider alternative/holistic therapies. However, be aware that many alternative treatments have not undergone clinical trials to see whether they are safe or effective. Since alternative therapies may interact with various drugs (both prescription and nonprescription), this should always be discussed with one's doctor ahead of time.

5. Go off all medications and take no treatments at all. This is often the least desirable option, but an option nonetheless.

My best suggestion is for people to discuss concerns with their doctor before making any changes in treatment. Living with HIV is a balancing act between quantity of life and quality of life. Only the person living with HIV can decide where that balance lies.

For more information on treatment guidelines, see the following:

• Guidelines for the Use of Antiretroviral Agents in HIV-Infected Adults and Adolescents

• Guidelines for the Use of Antiretroviral Agents in Pediatric HIV Infection

• Revised Recommendations for Use of Antiretroviral Drugs During Pregnancy for Maternal Health and Reduction of Perinatal Transmission of HIV-1 in the United States

Remember that treatment guidelines are changing very rapidly. Therefore, some information may have already changed by the time they are published. Also, opinions regarding when to change treatment (and what treatments to change to), vary from one HIV expert to another. Simply put, when it comes to treatment issues, this is a topic where one question can have many different answers (and opinions), depending upon whom you ask, so always consult with your doctor.

These same issues, of quantity of life versus quality of life, can be found with any other chronic and life-threatening disease. People with cancer must ask themselves these same questions, especially as they relate to the side effects of chemotherapy, radiation therapy, surgery, etc. So the options discussed above apply not only to those being treated for HIV, but for people with other life-threatening illnesses as well.

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Do you want more information on AIDS, STDs or safer sex? Contact the U.S. Centers for Disease Control AIDS hotline, open 24 hours a day, seven days a week, at 1-800-CDC-INFO. Or visit The Body's Safe Sex and Prevention Forum.

Until next time . . . Work hard, play hard, play safe, stay sober!