Question:

I have been positive for at least 14 years, I began HAART 7 years ago when my VL was 14,000 and CD4 was 450. For the last couple of years, my VL has been <50 and CD4 average 1,500+-. My doc, who I think is very good and very experienced, seems to think I may have developed some immunity to the HIV and has talked with me about stopping the antivirals (sustivia, zerit & epivir). I am hesitant to do so because I am tolerating the drugs well and am afraid of developing resistance should the load start climbing. What are your thoughts?

Answer provided by:

Peter Shalit, M.D.
Internal Medicine

Congratulations on your excellent response to antiviral therapy and on your excellent tolerance of the medications. Here are my thoughts on your situation:

I don't agree that you "have developed some immunity to HIV." It is clear that even when people respond very well to anti-HIV therapy for a long time, the meds are only keeping the virus from multiplying and showing up in the blood stream. There is still a lot of HIV in your body, lurking in the background, and waiting to come out if you stop the medications.

If you stop therapy, your viral load and CD4 will ultimately return to where they were when you started. This may happen rapidly, over a few months, or slowly, over a few years, but it will happen. From that point, the disease process will continue from where it left off 7 years ago. That might not be too big a risk for you, because it might be some time before your numbers reach the 300 +/- 50 CD4 range, the zone where treatment is now recommended in someone who has never had treatment. In other words, I would guess that if you stopped treatment now, you would continue to do well and be relatively safe from AIDS-related problems for a year or two or even more. This holiday from medication would potentially save you some of the longer-term toxicities of the medications, it would reduce the cost of your medical care for a period of time, and might simplify your daily routine. You would need to view this as a temporary holiday from medication, because eventually you would need to resume treatment. I would not worry that stopping your meds would promote the development of resistant virus - this is unlikely.

However, there are some arguments against stopping therapy at this time. You may feel comforted and empowered too know that your virus is well suppressed by medication. You are probably somewhat less infectious to others while your virus is suppressed, a consideration if you are sexually active with an uninfected person. And you may be one of those people who just plain feels healthier with their HIV suppressed.

Ultimately the choice is yours. I suggest you weigh the pros and cons. Whatever decision you make, it is important that you continue to be closely monitored. If you remain on treatment, you need to be monitored for the continued effectiveness and possible long term toxicities of the medications. If you take a break from treatment, you need to be monitored closely for progression of your HIV disease, so that treatment can be resumed before you enter a zone of health risk from this infection

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