Question
Access to ARVs if the flu epidemic closes clinics? What about stopping treatment?
6 August 2009. Related: All topics, Changing treatment, Opportunistic infections, Resistance, Stopping treatment.
Would it be possible for i-base to publish a guide to stopping treatment? Not to encourage people to do so, but to inform on the various drugs that need to be stopped in a certain order and over a certain time. People may stop taking medication for many reasons and of course one would hope under the advice of a suitably qualified medic. However at a meeting last evening there seems to be no clear information in a readily digestible form for people to refer to. If people at stopping medication without prior medical advice, it may help if they knew “how to do it” so they could avoid any issues should they re-start.
In the current climate of flu – and this being the first wave – although many clinics will have contingency plans, if there should be any impact to the provision of drugs, this information may prove useful also.
Many thanks
Answer
Thanks for your questions which cover two important issues that overlap:
i) What are the plans for ARVs access throughout the flu epidemic
and
ii) How to reduce the risk of resistance if you ever need to stop treatment
It is probably best to separate the answers.
i) Information about flu
The are several sources of information about the implication of flu for HIV-positive people. i-Base published an on-line Q&A factsheet, that we are updating as new information becomes available.
Luckily the main point is that, based on the available evidence both in the UK and other countries, HIV-positive people are not at increased risk of catching flu or of getting more serious complications, particularly if they have a CD4 count over 200 and/or are stable on treatment.
The main risk is for people with CD4 counts below 200 is when symptoms of a more serious illness or infection are missed because they are assumed to be flu. People in this situation need their HIV clinic to be aware of flu-like symptoms.
The other complication, as for any person on chronic treatment, is maintaining a continuous supply of medication. This is because, in a serious epidemic or emergency, there may be a period when transport, schools and hospitals etc either close or run extremely limited services.
In London, and likely the rest of the UK, people will be advised to never have less than a minimum of one month of HIV drugs that are kept separately in case this happens – at least until next January when the main risk period will hopefully be over. Some clinics will prescribe an additional month with your next prescription (to have enough meds to last until January), and others to return for their next prescription a month or so earlier than they previously planned.
The most likely time for the flu epidemic is October/November so people are being asked to planning clinic visits and drug supply so you do not need to attend during these months.
Treatment interruptions are not recommended in any patient.
These measures are being taken so that drug supply does not make this an issue.
ii) How to limit resistance if you stop treatment
Given that no patients are being advised to stop treatment, it is still important to answer about how to stop treatment as this is an important question that will often get asked.
The main concern with stopping treatment is that if you stop treatment, as drug levels slowly drop, there is a period when you are at risk of resistance. This may be a few hours, a few days, or with some of the most-widely used combinations, potentially a few weeks. If some of your drugs leave your body more quickly than other, then the slowest drug would be at the highest risk of getting resistance.
Research from doctors in Birmingham have looked at this question in depth and, although there is little data, think that the best way to protect against resistance, theoretically, is to switch people on NNRTI-based combinations (ie using efavirenz, nevirapine or etravirine) to four weeks of a ritonavir-boosted protease inhibitor only, on the day they stop their current combination.
Protease inhibitors are less likely to generate resistance, and when the last ritonavir dose runs out the boosted PI level drop quickly, reducing the potential period of being at risk of resistance.
The technical review of this approach was published in the journal AIDS last year, and is available free online here.
The non-technical summary is:
– don’t stop meds unless there is a medical reason, and not without your doctors knowledge
– if you use NNRTIs, then switch to a boosted PI (with no nukes) for 2-4 weeks (while your NNRTI and nukes levels slowly drop)
– if you are on a PI-based combination, stopping the nukes a week or two before you stop the PI will limit the risk of resistance to the nukes.
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