Mar 05 2013

HIV Cure “Game Changer”

The story of a young patient apparently cured of HIV infection, making them only the second case of an HIV cure ever, is buzzing around the internet. It is an interesting and important story, but as is often the case the details are complicated and need to be put into context.

The case was recently presented at a conference, on Retrovirus and Opportunistic Infections. The child was born of an HIV infected mother who did not receive pre-natal care. The mother had high viral loads when she presented for delivery. Not surprisingly, the child was found to be infected shortly after birth, indicating that they were likely infected in utero.

Hannah Gay, a pediatric infectious disease specialist, consulted on the case and decided to treat the infant with higher doses of anti-retroviral therapy (ART) than are typically given. She gave therapeutic doses of ART rather than prophylactic (preventive) doses. She also started the ART drugs earlier than they are typically given, at 31 hours of life.

The child was treated for about 18 months and followed closely. At 18 months, however, the mother had some undisclosed life stress leading them to stop medical follow up for their child. The child was no longer given ART or brought in for medical follow up.

Gay, who was still following the patient, eventually tracked her down (now at about 24 months of age) and made a surprising discovery. Despite 6-7 months of no ART, tests revealed no sign of HIV in the child’s system. Gay was surprised at the result, so double checked everything- the child was truly infected early in life and is truly virus free now.

Follow up detailed examination also revealed no sign of the virus, except for a few tests that reveals tiny amounts of viral RNA and DNA, but no “replication competent” virus. They also demonstrated that the HIV is a typical wild type of the virus, and not a mutated weakened strain. Also, neither the mother nor the child have mutations known to confer HIV resistance.

In the abstract they call this outcome a “functional cure,” which means that the virus has not set up shop anywhere in the body, is not replicating, and will not rebound despite being off ART.

What typically happens with HIV infection is that the virus hides out in reservoirs that are impossible to eradicate. Even when viral loads in the blood are reduced to undetectable levels, the virus remains in these hideouts and can rebound the moment ART is stopped.

What the doctors in this case believe is that the early aggressive therapy with ART reduced the virus to very low levels before it could establish these persistent reservoirs. Therefore when ART was stopped, the virus did not rebound. The immune system was able to keep the virus in check by itself.

This is an exciting case that has significant implications. It seems likely that this will result in a change in the standard of care to early aggressive ART for newborns who were infected at or before birth. Further research is needed to assess the overall safety and efficacy of this approach, but it seems hopeful.

This is not, however, a new cure for HIV or AIDS. I always get a little concerned when I see the word “cure” in the headline of news articles, paired with some serious disease like HIV or cancer. This is not a new treatment for HIV and will not affect most people infected with HIV.

It can have a huge impact on infants infected with HIV, however, and this cannot be underestimated. While only about 130 children per year in the US are infected in this way, in developing countries as many as 1000 children per day are born with HIV.

This approach also could prove hugely cost effective – 1-2 years of ART vs a lifetime of ART and possible complications from HIV. An investment in early treatment would certainly be one worth making.

13 responses so far

13 Responses to “HIV Cure “Game Changer””

  1. Ori Vandewalleon 05 Mar 2013 at 8:44 am

    Interesting. I wonder, if someone were infected with HIV and then immediately got aggressive ART, would they be cured in the same fashion? I know that’s a very speculative question given that all we have right now is a hypothesis explaining a single incident, but HIV is a subject I know very little about except in the broadest strokes. I also know that people generally don’t find out that they’re infected with HIV until much later when AIDS presents, so even if such a treatment were effective, it wouldn’t get used very often.

  2. Chad Joneson 05 Mar 2013 at 9:54 am

    Thank you for framing this story properly. It seems that a lot of the headlines say things like:

    Doctors “cure” HIV

    without explaining the quotation marks.

    Also, it seems to me there is an ethical dilemma in this story- remember, this “treatment” was basically a mother who (for one reason or another) stopped bringing her HIV infected child in for treatment. How can you ethically design a study that is basically the gold standard treatment for 1.5 years and then no treatment at all. The details of the case need to be rigorously dissected before that can be done.

  3. ccbowerson 05 Mar 2013 at 11:09 am

    “Interesting. I wonder, if someone were infected with HIV and then immediately got aggressive ART, would they be cured in the same fashion?”

    There is something called post exposure prophylaxis (PEP) which is really similar what you are describing. Most commonly this is described in healthcare when a person has potential exposure to HIV inadvertently through a “needle stick,” for example, although it could be used in other situations in which a person is exposed to the HIV virus outside of healthcare. Regimens vary, but generally a person is on a given regimen for 4 weeks. This does significantly reduce the rate of infection. An important difference is that PEP is viewed as preventing an infection from taking hold rather than treating an infection early as in the case described above, although the mechanism described may be the same.

  4. jreon 05 Mar 2013 at 12:56 pm

    Excellent post: clear explanation, good context, important points highlighted.
    Please forgive one nit-pick: suggest sed s/”cannot be underestimated”/”should not be underestimated”/

  5. PharmD28on 05 Mar 2013 at 2:13 pm

    exactly! as soon as I read it, I quickly went over to facebook and put up some basic cautionary statement about the NPR article to this basic degree…

    its so damn annoying these headlines…do they not know that many people pretty much only read headlines and short blurbs….argh

    I think the analogy to PEP makes more sense than “cure”…as I understand, it is thought that this early, the virus has not set up in CD4 cells fully establishing what Dr. Novella calls “resevoirs”….thus allowing the “cure”… wondering if this will now become a standard of care for kids being born from mothers with HIV, even in addition to current prenatal care standards for HIV infected mothers?

    The real “cure” will be when we can take an average patient and treat them in some way to “functional cure”….then we will have a “cure”….this is however a breakthrough for alot of children, particularly in Africa…

  6. petrossaon 05 Mar 2013 at 2:52 pm

    And what if later (assuming the child indeed is ‘cured’) the antiviral treatment at that age causes cancer? If i had the choice i’d take hiv over cancer anyday.

  7. HHCon 05 Mar 2013 at 3:00 pm

    How can you be sure that the tiny viral strands of RNA or DNA might not become neoplasms in the blood at later stages of life?

  8. PharmD28on 05 Mar 2013 at 3:17 pm

    “And what if later (assuming the child indeed is ‘cured’) the antiviral treatment at that age causes cancer? If i had the choice i’d take hiv over cancer anyday.”

    ***If*** you had that choice….

  9. Sawyeron 05 Mar 2013 at 3:29 pm

    I’m curious if anyone heard the Talk of the Nation coverage of this story on NPR. It was good discussion overall until the last five minutes of the program when a caller informed the host that megadoses of Vitamin C could cure AIDS but it wasn’t being published. I didn’t bother listening to the response but now I’m curious what I missed.

  10. PharmD28on 06 Mar 2013 at 10:37 am

    being that we have only 2 documented “cures” and neither of which as I recall had anything to do we know of with Vitamin C….

    PS – a facebook friend (old high school buddy) who is a chiropractor (a “straight”) told me about groundbreaking experience in africa these days with chiropractors treating and even curing cancer….even had a website to “prove” it 😀

  11. Berlinesqueon 09 Mar 2013 at 3:55 pm

    While I’m pretty sure ART doesn’t cause cancer, I was under the impression that the neurological effects of ART on adults still haven’t been ferreted out. Painful peripheral neuropathies, motor coordination difficulties and mild to moderate cognitive dysfunction all seem to crop up in adult patients maintained on ART, and I thought there was some debate as to whether these symptoms were a result of early infiltration of HIV into the CNS or some nasty side effect of the drug. Given that the child/test case is already difficult to follow up with, how can long term effects of high doses of ART early in life be tracked? Was this even remotely ethical to try in the first place?

  12. QuiteDragonon 11 Mar 2013 at 12:19 am

    “It was good discussion overall until the last five minutes of the program when a caller informed the host that megadoses of Vitamin C could cure AIDS but it wasn’t being published. I didn’t bother listening to the response but now I’m curious what I missed.”

    The topic of vitamin C introduced by the was completely ignored by both interviewer and interviewed. I was disappointed there wasn’t an immediate slap-down.

  13. norrisLon 11 Mar 2013 at 12:58 am

    What is it with vitamin C? We all know that it does not cure a cold (sorry Linus). Here in Australia we have quack vets who insist that vitamin C will cure snake bite. Given the toxicity of our snakes, I certainly would prefer an appropriate antivenom than vitamin C if I was bitten. Sadly there is a long list of diseases that are cured very effectively by vitamin C, in the world of woo that is!

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