Treatment interruption: a real choice
Simon Collins, HIV i-Base
At the end of the last day of the Workshop an important discussion provided a controversial focus concerning clinical management of lipodystrophy.
A presentation from Emmanuel Trenado of results from a prospective cohort study of 725 HIV patients, almost 600 of whom had answered a questionnaire distributed by the French community organisation AIDES, and of the 80% on treatment almost 40% said that on their ‘stable’ combination they experienced mild to moderate side effects.  Sexual dysfunction, sleep disorders, lipodystrophy and fatigue were each reported in 17-20% of the questionnaires.
Perhaps unsurprisingly, people reporting side effects were three times more likely to be interested in taking a treatment interruption, but 10% of the cohort were already taking a break from treatment and half of these people were doing this without consulting their doctors.
Perception of body shape changes in a multivariate analysis from the APROCO cohort was also a significant predictor of adherence failure at month 20 in patients who had previously reported excellent adherence (the only other two factors being daily alcohol use and age).
A summary of management of lipodystrophy by Christine Katlama excluded stopping treatment as an option that clinicians should recommend (for the treatment of metabolic alterations), but this is clearly an approach taken by people in real life. Whatever the exact mechanisms for the body shape changes, HIV treatment is now recognised as a significant contributory factor – and a wealth of studies at every lipodystrophy workshop attests to direct effects on mouse, rat or human cells other than purely targeting of HIV.
Risk factors from a treatment interruption in numerous studies include previous CD4 nadir and history of opportunistic infections, and also perhaps severity of original seroconversion symptoms.
Martinez and colleagues from Barcelona reported effects of a treatment interruption in 10/15 patients with symptoms of lipodystrophy and 5/8 without lipodystrophy. After one year there was a trend to fat gain and fat-free mass loss with minimal change in bone mineral density. Patients who interrupted treatment both with and without symptoms of lipodystrophy had greater increases in weight, BMI, total fat and spine BMD and lower decreases in fat-free mass compared to patients who continued HAART. 
While this is not a straightforward option for many patients, that it is always an option that some may choose highlights the real difficulties and urgency of discovering alternative treatment and management options.
Unless otherwise stated, all abstracts refer to the programme and abstracts from the 5th International Workshop on Adverse Drug Reactions and Lipodystrophy in HIV, 8-11 July 2003, Paris and are published in Antiviral Therapy Volume 8 issue 4.
- Martinez E, Milenkovic A, Vidal S et al – Impact of structured treatment interruption on body composition of chronically infected patients: preliminary one year results. Abstract 88.