Highly active antiretroviral therapy should continue even if immune restoration syndrome develops

Although it is not common, HIV-infected patients may develop an inflammatory reaction after initiating highly active antiretroviral therapy (HAART). According to physicians from Thomas Jefferson University in Philadelphia, Pa, HAART should not be discontinued in patients who develop this condition, which they term immune reconstitution syndrome.

Dr Timothy J. Babinchak and associates conducted a literature search regarding inflammatory reactions that occurred in patients who had immunologic and virologic responses to HAART. Their descriptions of the varying manifestations of this syndrome are reported in the September 19th issue of the Annals of Internal Medicine.

“We were surprised by the fact that this condition was not as widespread as it might have been, given the number of severely immunocompromised patients,” Dr Babinchak told Reuters Health. On the other hand, most physicians seeing these patients “have probably seen 1 or 2 cases, but didn’t tie it all together,” he added. Exacerbations of opportunistic infections commonly seen in HIV infection have been described, the reviewers found. Onset has been reported in as little as 10 days after beginning HAART for a reaction to Cryptococcus neoformans or as long as a median of 43 weeks for cytomegalovirus vitreitis. “The speed with which immune reactivity recovers is an indication of how soon a patient may experience one of these inflammatory responses,” Dr Babinchak said.

The researchers also encountered reports of exacerbations of noninfectious autoimmune diseases and malignant conditions, such as Graves disease, systemic lupus erythematosus, and Kaposi sarcoma.

“The thing that characterizes [immune restoration syndrome] most,” Dr Babinchak said, “is that these are infections and conditions you would expect in people who are not doing well that are now being manifested in people who are doing well and who are presenting atypically.” Without well-controlled studies, therapy has to be individualized to the patient. Dr Babinchak explained that “Some cases clear with no therapy, just continuation of HAART. Some patients have undergone specific therapy directed at the infection, while for others, therapy was directed at the inflammatory component.” “The main thing to emphasize is that HAART should not be stopped in these situations,” he concluded.