Page 112 - HIV/AIDS Guidelines

Discontinuation or Interruption of Antiretroviral Therapy (Last updated January 10, 2011; last
reviewed January 10, 2011)

Discontinuation of antiretroviral therapy (ART) may result in viral rebound, immune decompensation, and
clinical progression. Unplanned interruption of ART may become necessary because of severe drug toxicity,
intervening illness, surgery that precludes oral therapy, or unavailability of antiretroviral (ARV) medication.
Some investigators have studied planned treatment discontinuation strategies in situations or for reasons that
include: in patients who achieve viral suppression and wish to enhance adherence; to reduce inconvenience,
long-term toxicities, and costs for patients; or in extensively treated patients who experience treatment failure
due to resistant HIV, to allow reversion to wild-type virus. Potential risks and benefits of interruption vary
according to a number of factors, including the clinical and immunologic status of the patient, the reason for
the interruption, the type and duration of the interruption, and the presence or absence of resistant HIV at the
time of interruption. Below are brief discussions on what is currently known about the risks and benefits of
treatment interruption in some of these circumstances.

Short-Term Therapy Interruptions
Reasons for short-term interruption (days to weeks) of ART vary and may include drug toxicity; intercurrent
illnesses that preclude oral intake, such as gastroenteritis or pancreatitis; surgical procedures; or
unavailability of drugs. Stopping ARV drugs for a short time (i.e., <1 to 2 days) due to medical/surgical
procedures can usually be done by holding all drugs in the regimen. Recommendations for some other
scenarios are listed below:

Unanticipated Need for Short-Term Interruption

• When a patient experiences a severe or life-threatening toxicity or unexpected inability to take oral
medications—all components of the drug regimen should be stopped simultaneously, regardless of drug
half-life.
Planned Short Term Interruption (>2–3 days)

• When all regimen components have similar half-lives and do not require food for proper
absorption—all drugs may be given with a sip of water, if allowed; otherwise, all drugs should be
stopped simultaneously. All discontinued regimen components should be restarted simultaneously.
• When all regimen components have similar half-lives and require food for adequate absorption,
and the patient cannot take anything by mouth for a sustained period of time—temporary
discontinuation of all drug components is indicated. The regimen should be restarted as soon as the
patient can resume oral intake.

• When the ARV regimen contains drugs with differing half-lives—stopping all drugs simultaneously
may result in functional monotherapy with the drug with the longest half-life (typically a non-nucleoside
reverse transcriptase inhibitor [NNRTI]). Options in this circumstance are discussed below. (See
Discontinuation of efavirenz, etravirine, or nevirapine.)

Interruption of Therapy after Pregnancy
ARV drugs for prevention of perinatal transmission of HIV are recommended for all pregnant women,
regardless of whether they have indications for ART for their own health. Following delivery, considerations
regarding continuation of the ARV regimen for maternal therapeutic indications are the same as for other
nonpregnant individuals. The decision of whether to continue therapy after delivery should take into account
current recommendations for initiation of ART, current and nadir CD4 T-cell counts and trajectory, HIV RNA
levels, adherence issues, and patient preference.

Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents H-19

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