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HIV cure: a game changer or just a lucky little girl?

Commentary: Many obstacles remain for those who need interventions and care.
Hiv aids civil disobedience 382013Enlarge
Activists participate in a campaign of civil disobedience outside the White House after a march from the Walter E. Washington Convention Center on July 24, 2012, in Washington, DC. AIDS activists from organizations all around the world participated in the march to "demand rights and resources to confront and cure HIV/AIDS." (Alex Wong/Getty Images)

DENVER — This week’s scientific report on the “functional cure” of a HIV-infected infant has set the world’s media ablaze with discussion and speculation. Is this truly a “game-changer,” as media outlets like NPR have reported?

In the long run, perhaps. The researchers themselves pointed out that this was a “proof-of-concept” case and that we need to learn much more about why this baby’s virus appears to be eradicated before we generalize the results into medical or public policy.

While we wait for scientific confirmation of the treatment, this little girl’s case crystallizes the continued challenges of delivering interventions already proven to prevent pediatric HIV/AIDS.

The baby girl was born to an HIV-infected woman in Mississippi who was unaware of her HIV status. Of the 4 million children born each year in the United States, just 100 are born with HIV/AIDS. This impressively low number is thanks to a combination of widespread antenatal care, regular HIV/AIDS testing of high-risk mothers, and pharmacological advances in combination therapies for preventing mother-to-child transmission (PMTCT) in utero, before the virus has a chance to take hold in the fetal immune system.

Although this package of interventions is incredibly low-cost, about 330,000 babies will be born with HIV/AIDS in less developed countries, primarily in Sub-Saharan Africa. This is due to stigma and discrimination, but most of all due to the lack of resources for these interventions.

The aforementioned 330,000 children born with pediatric AIDS represents about 25 percent of babies born to HIV-positive mothers around the world, whereas 100 such cases of pediatric AIDS in the US accounts for roughly .25 percent. While the baby girl in Mississippi was truly unlucky to miss the initial window for preventing HIV, her situation would have been typical in many parts of Sub-Saharan Africa.

Even after more than six years of a concerted global campaign to end HIV/AIDS, great swathes of Sub-Saharan Africa lack the facilities, the personnel or the drugs to carry out simple PMTCT interventions. While countries like South Africa and Zambia now provide PMTCT to 75 percent of HIV-infected mothers, others like Angola and Ethiopia remain below 25 percent.

Having missed the window for prevention, the girl’s astute pediatrician recognized the risks of infection and promptly started the girl on an aggressive three-drug antiretroviral treatment for HIV.

HIV infection was confirmed in repeated tests just hours later. Eventually, the girl’s medications reduced the quantity of the virus in her blood to undetectable levels. Amazingly, the girl’s “cure” didn’t require a pie-in-the-sky Buck Rogers solution or a yet-to-be discovered vaccine.

The antiretroviral medications she was treated with have been available around the world for many years. Indeed, her care shows us once again that HIV treatment medicines can also prevent some HIV infections. But the costs of standard three-drug treatments for children infected with HIV can be out of reach in many countries.

More importantly, this aggressive intervention was only possible because the little girl was delivered in a hospital by skilled attendants knowledgeable about HIV/AIDS. It is widely recognized that hospital delivery is essential to reduce maternal and neonatal mortality due to many causes, but the world has flinched at paying the costs. If this were ever to be achieved, then hospital deliveries would be a great opportunity to administer such a treatment.

Like many families affected by HIV, the child and her mother did not stay connected to the medical clinic. The child’s mother continued treatment for about 18 months, but then stopped medications.

Studies generally show that populations in developing countries are more reliable at complying with the rigorous drug protocols facing HIV-infected populations and better at staying in contact with their health providers.

Yet their path to recovery is beset with numerous perils, including the departure or absenteeism of qualified health care workers, continual supply shortages for needed drugs and diagnostic equipment, nutritional deficiencies and other diseases that impede their recovery, migration, and disruptions in treatment due to local or national conflict.

In the US and abroad, ensuring drug adherence and referring patients to a wide range of social, health and nutritional services requires considerable organizational resources, information technology and passion.

Normally, HIV comes roaring back to high levels a few weeks after treatment is stopped. But in this case, detailed laboratory testing showed that HIV never reappeared in her blood — suggesting that this very lucky girl had indeed been cured of her virus infection.

While it remains possible that there was something unique about this little girl that allowed her to recover, current reports suggest that there was nothing about her genetic profile that made her uniquely capable of recovery. At the same time, in many populations non-adherence is accompanied by malnutrition, exposure to other infectious diseases, and poverty, all factors that may make the pathway to recovery quite different.

Substantial numbers of people living with HIV in the US and elsewhere are either unaware of their HIV status, or not engaged in medical care. There are many reasons for this situation, including stigma, discrimination and fear of the unknown.

These issues won’t be solved with new medicines, but rather a critical reassessment of community beliefs about HIV/AIDS and some deeply held prejudices. However effective they may be, life-saving or curative medications cannot work if those who need these interventions face obstacles to receiving care.

The Obama Administration has set as its goal an AIDS-free generation. If the outcomes of this case are confirmed, the strategy revealed this week could transform HIV treatment practices around the world and advance this policy objective.

Yet the promise of curing the 300,000 babies born with HIV each year cannot be achieved unless babies are delivered in a healthcare facility with the necessary funds, diagnostic tools, medications and well-trained healthcare providers.

Randal Kuhn is an associate professor and the director of the Global Health Affairs Program at the University of Denver's Josef Korbel School of International Studies.

Benjamin Young is the chief medical officer of the International Association of Providers of AIDS Care and an adjunct professor at the University of Denver's Josef Korbel School of International Studies.

http://www.globalpost.com/dispatches/globalpost-blogs/commentary/hiv-cure-science-health-technology-US

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