Question
If I started treatment soon after infection, should I continue or stop after 8 months?
15 July 2008. Related: All topics, Cure, Starting treatment, Stopping treatment.
Hi
I was diagnosed in February and had very bad flu like symptoms. I was of course seroconverting. My western blot was still evolving and my viral load was 100,000.
I decided to start treatment early and have been on Kaletra and Truvada.
My viral load is now under 100 copies/mL and CD4 count is 900.
In October I have to decide whether to come off my treatment and I’m not sure what to do. Would this be considered a treatment break? I have read somewhere that these breaks are not advisable.
Have you any data on early interventions or treatment breaks which could help me?
thank you
ps I am 42 years of age
Answer
In talking about your situation, the most important thing to remember is that is an individual decision, based on how you weigh up certain advantages and disadvantages. There is no one right answer.
There is some data from research to support both continuing treatment, or stopping, but very little direct research in people in your situation, who started early treatment.
Probably the most important factor in your decision is how you are coping with treatment and how you feel about it. If you have no side effects, are finding adherence ok (ie not missing any doses) then this would make it easier to continue. Scientifically, there may be some benefits to continuing treatment, you will have an undectable viral load for a longer time which may be important for long-term risk of some illnesses, and you will be less infectious.
Also, if your seroconversion symptoms were more severe (ie severe enough to rquire early treatment), this may mean that even if you do stop in October, you may only get a year or two off-treatment, before needing to restart. About 25% patients in the UK seroconvertors register started treatment within 2 years of their diagnosis, showing that it is not uncommon to use need treatment earlier than the average 5 years that is usually discussed.
An additional benefit from staying on treatment may be that you may be more likely to benefit from future research (ie vaccine and other research), in terms of being able to come of treatment for a longer period in the future. (This is based on research in the US, but which until now has not lead to any clinical benefits).
On the other hand, if you are having problems with treatment, either physically because of side effects, or psychologically because you are still dealing with your diagnosis, then you might want to stop treatment and see how long you can go before your CD4 drops again.
Although treatment interruptions are not generally recommended, most doctors would think your immediate risk from anything HIV-related would still be very low off-treatment, especially as your CD4 count now is high. Routine monitoring would give you plenty of time to know when to restart.
The caution against treatment interruptions comes mainly from the SMART study, that showed the comparative benefits from being on treatment with an undetectable viral load.
This is part of the reason behind the recent change to starting treatment earlier (at a count of around 350 rather than before it falls below 200) in the UK treatment guidelines.
The START study is looking at treatment at counts above 500 cells/mm3.
I think that people who started treatment in recent infection and not covered to the same extent by the caution against stopping.
If you do decide to stop, then your viral load would be expected to rebound fairly quickly (usually to detectable and then to several thousand within the first few weeks). There is an approximate 5-10% chance you could experience similar seroconversion symptoms to after your initial infection as for some people stopping treatment produces a reaction similar to an initial infection.
In summary:
– this is a very individual choice, and the answer depends on how you are coping with treatment now
– there are generally likely to be medical benefits from staying on treatment, BUT only if you have an undetectable viral load and no side effects. If you are not finding treatment easy, then any medical benefit is unlikely to be important enough to cause you to need to stay on treatment.
– the caution against treatment interruptions mainly covers people in chronic infection who needed to start treatment when their CD4 count dropped, and not for people who started treatment shortly after a recent infection.
Please let me know if you have other questions.
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