A Guide to Primary Care of People with HIV/AIDS - Canadian Public ...

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A Guide to Primary Care of People with HIV/AIDS Chapter 5: Antiretroviral Therapy 5 • Intermittent therapy The plan with intermittent therapy is to periodically discontinue treatment on a prearranged schedule, such as 1 week on and 1 week off or 5 days of treatment followed by a weekend off. The theory is that when therapy is discontinued there is usually sustained viral suppression for 10-14 days and treatment is restarted while the virus is still suppressed. This strategy could potentially reduce treatment-associated side effects and cost. Although the initial experience has been limited but promising, the strategy cannot be recommended until more substantial experience is gained. • Pulse therapy With this strategy, therapy is discontinued when the CD4 cell count increases to a level that makes the patient and physician comfortable doing so and is restarted when the CD4 count declines to a worrisome level. Initial experience has generally been that the viral load returns within 2 weeks and the CD4 cell count declines rapidly and then plateaus. Most experts restart therapy when the CD4 cell count reaches 350/mm 3 , but this strategy has not been systematically studied. Nevertheless, it does appear that there is no penalty in terms of resistance and the period off therapy is often 1-2 years, depending to a large extent on the CD4 cell count at the time treatment is discontinued and on the pre-therapy CD4 nadir. The patient must be warned that viral loads will return to pre-therapy levels, with important implications for risk of HIV transmission to others. KEY POINTS The major indicator for the speed of progression in early stage disease is the viral load, which dictates the speed of CD4 cell decline. The major indicator for the risk of HIV-associated complications is the CD4 cell count. ART is directed toward preventing HIV-associated complications and hospitalizations and improving quality of life and survival. ART does not cure HIV infection, is expensive, is associated with substantial risks of short-term and long-term toxicity, and requires a level of adherence that is unmatched with any other antimicrobial therapy. ART is recommended when there are HIVassociated symptoms or when the CD4 count is 25-50/mm 3 at 6-12 months), or clinical (new AIDS-defining OI after >3 months of therapy). Treatment is changed for drug intolerance (substitution) or virologic failure (selection by resistance tests). The 3 factors that consistently predict outcome are CD4 cell count, patient adherence, and provider experience. 34 U.S. Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau
A Guide to Primary Care of People with HIV/AIDS Chapter 5: Antiretroviral Therapy SUGGESTED RESOURCES Deeks SG, Hirschel B. Supervised interruptions of antiretroviral therapy. AIDS. 2002;16:S157-169. Hirsch MS, Brun-Vezinet F, Clotet B, et al. Antiretroviral drug resistance testing in adults with Human Immunodeficiency Virus type 1: 2003 recommendations of an International AIDS Society – USA panel. Clin Infect Dis. 2003;37:113-128. 5 Lawrence J, Mayers DL, Hullsiek KH, et al. Structured treatment interruption in patients with multidrug-resistant human immunodeficiency virus. New Engl J Med. 2003;349:837-846. Mellors JW, Munoz A, Giorgi JV, et al: Plasma viral load and CD4+ lymphocytes as prognostic markers of HIV-1 infection. Ann Intern Med. 1997;126:946-954. Palella FJ, Delaney KM, Moorman AC, et al: Declining morbidity and mortality among patients with advanced human immunodeficiency virus infection. N Engl J Med. 1998;338:353-360. WEBSITES AIDSInfo: http://www.aidsinfo.nih.gov Accessed 11/03 (Several treatment guidelines are continuously updated at this U.S. Department of Health and Human Services website) AIDS information – http://www.aidsinfo.nih.gov for continuously updated treatment guidelines Panel on Clinical Practices for Treatment of HIV Infection. Guidelines for the Use of Antiretroviral Agents in HIV-Infected Adults and Adolescents. Washington DC: U.S. Department of Health and Human Services. Nov 10, 2003. Available at http://www.aidsinfo.nih.gov. Yeni PG, Hammer SM, Hirsch MS et al. Treatment for Adult HIV Infection: 2004 recommendations of the International AIDS Society–USA Panel. JAMA. 2004; 292:251-265. Youle M. Strategies of HIV Management – When to start. AIDS. 2002;16:S145-149. U.S. Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau 35
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