Stopping therapy in this setting has been shown often, although not always, to result in a drug susceptible virus becoming the predominant strain in blood. In all likelihood, the resistant virus persists, but only as a minor population that may not be measurable with the assays available to test for resistant virus. Whether this switch in the predominant virus will allow for enhanced viral control upon reinitiating therapy is being studied. At this time, the amount of experience demonstrating benefit from this approach is too small to draw any conclusions.
In the two settings described above, interruption of therapy is done at a time of full viral suppression, and the potential for developing drug resistance, therefore, is very real. By contrast, in this situation, where the patients already have multi-drug resistant virus, they are not likely to develop increased drug resistance. However, since these patients often have more advanced HIV disease, with lower CD4 cell counts, they may experience precipitous declines in CD4 cells during the interruption of treatment. The resulting weakening of the immune system may place them at increased risk for developing opportunistic infections or other complications of AIDS. Thus, if therapy is discontinued in this setting, the immune status should be monitored closely, and patients should receive appropriate prophylaxis (preventative medications) for infections.
In conclusion, STIs have become a fascinating new strategy to deal with several aspects of HIV disease. Many studies are now underway to address the role of STIs in various clinical situations. As a clinician my objective is to make sure that patients are fully informed of the status of this research and the potential risks and benefits of such interventions. It remains important that people distinguish between therapeutic strategies under investigation and those that have been proven to be safe and effective. For now, STI clearly falls in the former category.
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