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Decline in immune function/Increased risk of infection: When antiretroviral therapy (ART) is stopped, the amount of HIV in the blood, called the viral load, increases dramatically. A low viral load is about 200–500 copies per milliliter of blood. A high viral load can be anywhere from 5,000–1,000,000 or more copies. A high viral load indicates that HIV is replicating and the disease will most likely progress quicker than if the viral load is low. The increased viral load leads to a decline in CD4 cells. This is because HIV primarily infects the CD4 cells, which are white blood cells that help coordinate the immune system's response to infections and diseases. Healthy individuals have a CD4 cell count between 600 and 1,200 cells per microliter of blood. HIV patients have less than 600 CD4 cell counts per microliter of blood. Patients progress to AIDS (acquired immune deficiency syndrome) when their CD4 cell counts drop below 200 cells per microliter of blood. When CD4 counts are this low, there is a high risk of developing serious, sometimes deadly infections. Research has shown that patients who stopped ART had an increased risk of developing opportunistic infections. Opportunistic infections occur in individuals who have weakened immune systems. The organisms (bacteria, fungi, or viruses) that cause these infections do not cause illnesses in patients who have healthy immune systems because healthy patients are able to fight off the infection. HIV and AIDS patients are vulnerable to opportunistic infections, such as Pneumocystis jiroveci pneumonia (formerly called Pneumocystis carinii pneumonia or PCP), mycobacterium avium complex (MAC), toxoplasmosis, and tuberculosis. Certain infections are considered AIDS–defining illnesses. This means that when HIV–infected patients develop the infection, their condition has progressed to AIDS. Patients who had low CD4 cell counts before stopping treatment have the greatest risk of experiencing these infections. Also, when ART is discontinued, patients may develop flu–like symptoms, which most patients experience when they first become infected with the virus. This is because the virus is actively multiplying in the body. Symptoms may include fatigue, enlarged lymph nodes, sore throat, fever, and fatigue. Once ART is restarted, the amount of HIV in the blood decreases, and the CD4 counts increase. However, these levels may not return to levels achieved before the interruption, and the risk of infection may remain higher than before treatment was stopped. Drug resistance: Stopping and restarting ART increases the likelihood that the virus will become resistant to medications. Current research has shown that in order for anti–HIV drugs to work correctly, they must be taken exactly as prescribed. Taking breaks in treatment can cause the amount of an antiretroviral drug to decrease in the bloodstream. If the drug level becomes too low, HIV can begin reproducing at a more rapid rate. The faster HIV reproduces, the more mutations occur, including those that may be resistant to drugs. According to several studies, HIV patients must be more than 95% adherent to their treatment plans in order for the drugs to remain effective. In other words, missing more than one dose a month can reduce the drug's effectiveness. Healthcare providers evaluate the effectiveness of treatment by measuring the patient's CD4 cell count. If the CD4 cell count is maintained, the likelihood of virus mutating into a resistant strain is reduced. Resurgence of side effects: When patients continually take antiretrovirals, many side effects of treatment gradually lessen over time. However, when therapy is discontinued for a period of time and then restarted, patients are more likely to experience a resurgence of initial side effects, such as dizziness, confusion, fatigue, headache, difficulty sleeping, nausea, vomiting, and diarrhea. Superinfection: According to studies, there have been cases of patients becoming superinfected, or re–infected, with a different strain (type) of HIV while they are taking a break from treatment. This is because low or nonexistent levels of antiretrovirals in the bloodstream allow HIV to reproduce rapidly. The faster HIV multiplies, the more mutations occur.
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