Drug holidays aren't for everyone—or forever. But a nice, long break can be like summertime for your body and soul. A POZ guide.
at the long-term toxicities of the overhyped protease “cure,” POZ was
among the first and loudest to cheer when treatment advocates like
Project Inform’s Martin Delaney gave drug holidays cred, calling them
“structured treatment interruptions” (STIs) and demanding the respect
of researchers and doctors. We imagined a utopia of personalized,
precisely calibrated on-off med cycles, minimizing side effects,
turbo-charging regimens and beating resistance at its own game.
us naive. It turns out that drug holidays aren’t the holy grail, able,
as Delaney predicted in our pages in 1999, to reverse resistance and
revitalize combos—except for the lucky few. Still, after two dozen–plus
studies, it’s clear that STIs do belong on your treatment chart. Some
tests have found, for example, that high-triglyceride and
bad-cholesterol levels gradually fall during breaks and that other
HAART horrors can dissipate (though lipo’s look often lingers). Even
the foot-dragging feds got in step last fall when their HIV guidelines
said that STIs may make sense in some cases. As Delaney says, “STIs
continue to challenge the notion that people must take the drugs
constantly and for the rest of their lives.” Joe Brewer, a San
Francisco HIVer who’s done well on four STIs, says, “To live a long
time with HIV, be off meds as much as possible.” Need a med vacation?
Here’s a guide.
Most docs advise you not to start an STI until you’ve been undetectable for a year, with CD4s above 350 for six months. Expect a break to make CD4s drop and viral load rise—sharply but briefly. San Francisco STI taker Timm Dobbins says, “Be comfortable with fluctuating lab numbers—but be monitored.”
Research reveals that STI success has little to do with which drugs are in your combo. Two possible exceptions: Taking hydroxyurea, an immune-suppressing med (used in some bold HIVers’ combos) for several weeks pre-STI may lengthen the break; if 3TC is in your combo, dropping everything but may work better than breaking from the whole regimen—maybe because 3TC-induced resistance puts extra pressure on HIV.
Though on holiday, you’ll still have work to do. Jon Kaiser, MD, a San Francisco AIDS specialist, says “aggressive support of the immune system: healthy diet, vitamins and minerals, stress reduction and exercise” makes a “dramatic difference” in STI results.
Above all, confer with Doc before, during and after to ensure a safe trip.
Planning by Numbers
• CD4s above 350, premeds HIV specialists mostly agree: STI success depends on your lowest-ever premeds CD4s—a.k.a your nadir—not your current labs. Boston HIV pro Paul Sax, MD, says: “Folks whose CD4s have never been below 350 can likely remain off therapy for months if not years.” Three studies conclude that even HIVers with nadirs of 200 can take breaks if carefully monitored. But some supercautious docs suggest CD4s above 500 (on meds) for a year pre-STI.
• CD4s below 350, premeds Your STI prospects are iffier. Cal Cohen, MD, director of Boston’s Community Research Initiative of New England, which is conducting a multiyear STI study, says: “Some low-nadir people may have a rapid fall in CD4s. But about half will have at least six to eight months off before they need to restart.” Sax discourages those with nadirs below 350 from stopping therapy “unless there is bad med toxicity.” He says these folks “have the greatest risk of high viral-load rebounds and rapid CD4 drops when they stop.” But Cohen says, “On effective combos, you can regrow CD4s regardless of the starting CD4 level.”
• Travel Advisory: Treatment Failure Three recent studies rule out STIs between ending a combo that has bred mucho drug resistance and starting a new one. In this case, the STI may cause viral-load rebounds and big CD4 drops—and perhaps other health problems. One study found that HIVers who had tried several combos without reaching undetectable did poorly on STIs.
Cleared for Takeoff
Get tested Experts advise a viral-load test. Undetectable? Let the break begin! 1,000 copies or more? Get a phenotype or genotype test—you might have to cancel your holiday. Set a budget Decide which numbers will trigger a return to your regimen. Expert advice: When viral load exceeds 100,000 or CD4s drop below 200, head home. Or, as Philadelphia AIDS researcher Luis Montaner, DVM, says, set a CD4-count limit about 15 percent above your nadir. And everyone agrees that what Sax calls “all those nonspecific cruddy feelings we used to call AIDS-related complex” should send you back to Doc. Early-bird special The general rule is to drop all your meds all at the same time, but since the non-nukes (Sustiva, Viramune) stay in your body longest, if you’re on them, stop them some days before the rest of your combo to avoid resistance.
Choose from two basic STI timetables.
The first: staying off meds until lab numbers or illness require restarting. Sax calls this the safest, adding that he prefers using lab results, not “waiting for symptoms” to signal the end of the holiday.
More controversial: intermittent therapy. Montaner says, “More times on and off make sustaining viral suppression less likely.” Says Kaiser: “This is a prescription for breeding resistance.”
Intermittent therapy comes in several patterns, including the convenient “weekend” version: five days on meds, two off. But results are mixed. In a six-month study, Cohen found that this pattern worked well for HIVers on non-nuke combos, while some on proteasecombos had viral rebounds.
Staying Healthy on Holiday
Monitoring blood work is essential. Most docs advise checking CD4s and viral load every three months—or monthly for nadirs below 350—until you stabilize. (If your benefits don’t cover extra tests, argue that early detection is cost-effective.)
Tell Doc about any infections or illnesses and avoid vaccines, which can kick HIV into overdrive, ending your STI. Cohen advises spending your first two STI months “with access to care—not heading off on a cruise ship.” And don’t forget what Kaiser calls “common sense: rest, healthy diet, not abusing recreational drugs.”
All good things must end, so before the fall frost creeps in, warm up to your new regimen. Cohen says, “If your viral load was controlled before the break but is high now, you may need a more potent regimen.” Montaner suggests a different combo if you’re not undetectable after 20 weeks back. But every tour guide must admit that you and your medical team are your own best experts. HIVer Jason Wilcox, of Victoria, British Columbia, whose CD4 nadir was a problematic 200, calls his seven-year holiday “the best—not having to worry about adherence or what the next study says about side effects.” He restarted meds when stress drop-kicked his CD4s—but he’s already plotting his next break. Like Wilcox, make sure you take a holiday from meds, not health. Bon voyage!