HIV-positive individuals who take a break from their anti-HIV treatment for medical reasons have different motives and characteristics to patients who are motivated to temporarily stop HAART because of their lifestyles, according to an Australian study published in the January 2004 edition of HIV Medicine.
Investigators from the HIV Futures 3 survey, a nationwide study into the clinical and social aspects of the lives of HIV-positive individuals in Australia, wished to determine the medical and lifestyle factors associated with patients’ decisions to take a break from HIV treatments. The investigators noted that although there was a substantial body of research looking at the clinical consequence of treatment breaks, relatively little attention had been devoted to the reasons why individuals opted to interrupt HAART in the first place.
In late 2001/early 2002 a total of 894 HIV-positive individuals (6% of the total number of people with HIV in Australia) completed a questionnaire providing details of their demographic background, health, HIV treatments, relationships, and sexual and drug use behaviours.
The investigators restricted their analysis to the 640 patients using anti-HIV therapy at the time of the survey. Of these, 263 (41%) had taken a break from HAART at some time.
Individuals were asked to identify the primary reason for taking a treatment break and these were fitted into two different categories by the researchers: clinical and lifestyle. It was established that 378 individuals had never taken a treatment break, 99 had clinical reasons for interrupting therapy and 76 had opted for a treatment holiday citing lifestyle factors as the primary factor.
The investigators found that there were subtle, but significant, differences in the characteristics of patients interrupting therapy for clinical and lifestyle reasons. Breaks for clinical reasons lasted longer than those due to lifestyle (mean 165 days versus 108 days, p=0.039), and patients citing medical reasons for their treatment break were more likely to have discussed interrupting treatment with their doctor before (p<0.001) and during (p<0.001) the break.
Health differences were also observed between the two groups. The clinical break patients were more likely to say that their health improved or fluctuated as a result of the break, and the lifestyle break patients were more likely to report that their health stayed the same or deteriorated (p<0.001). Similarly, the self-reported well-being of the clinical break patients was more likely to have improved or fluctuated than those taking a break for lifestyle reasons, who were more likely to report their well-being remaining stable or deteriorating (p=0.005).
There was no significant difference in the viral loads of the patients as the result of the break, and the slight difference observed in CD4 cell counts after the treatment break was not statistically reliable.
The mean time since HIV diagnosis was slightly longer for patients opting for a lifestyle break than for those taking a clinical break (11.3 years versus 10.9 years, p=0.02), and lifestyle break patients had been taking anti-HIV therapy for a mean of almost ten months longer than individuals citing clinical reasons for interrupting HAART (67.8 months versus 57.3 months). However, the lifestyle break patients were significantly younger than the clinical break patients, having a mean age of 41.5 years versus 44.5 years, p=0.16.
At baseline, self-reported health was poorer in the clinical break patients (p<0.001), and this group of patients was also more likely to report having an AIDS-related condition (p=0.065), another major health problem (p=0.049), mental health problems (p=0.045), and to be taking medication other than antiretrovirals (p=0.003).
Significant differences were also found between the pleasure-seeking behaviours of the clinical break patients and the lifestyle break group. Lifestyle break patients were more likely to report taking recreational drugs in the past year (75% versus 65%, p=0.023), to have injected drugs (24% versus 7%, p<0.001), and to have had penetrative sex with a casual partner without a condom (40% versus 15.6%, p=0.005). As individuals on treatment breaks are likely to experience a rebound in their HIV viral load and potentially become more infectious, this finding could have important implications for HIV prevention.
“These findings offer some insight into the relationship between the motivation to take treatment breaks, the outcomes of that break, and the health and social contexts that these breaks are taken within,” comment the investigators. They add that clinical break-takers were more likely to report poor health, both HIV and non-HIV related, and that lifestyle break-takers were more likely to have engaged in potentially risky pleasure-seeking behaviour.
The investigators conclude that “these findings… should provide some guidance to clinicians and health educators. Given that the motivation for treatment breaks may not include clinical considerations, and that they may be taken with little clinical monitoring, suggests that conceptualising treatment interruptions as a purely clinical experience may be highly unproductive. Understanding the social motivations and correlates of treatment interruption offers new challenges to maximinsing the efficacy of health maintenance and support of [HIV-positive individuals]."