The recent news about a baby in Mississippi and 14 French adults said to have been "cured" of HIV infection has fueled excitement that the end of HIV/AIDS could be within sight. Both situations raise more questions than they currently answer.
Although no one can say we now have "the" cure for HIV, these cases show that currently available medical treatment -- if provided early and consistently after infection -- seems capable of driving HIV into remission, achieving what is called a "functional" (that is, for all intents and purposes) cure.
That two-letter word "if" holds a world of significance. The cases of the baby and the French adults suggest that diagnosis within hours or days of infection, and treatment within hours or weeks, can lead to long-term suppression of the virus after a few years on medication.
Today people with HIV can expect to live a normal lifespan if they take their medication, as prescribed, every day. Again the word "if."
To be functionally cured means that after a few years of treatment, someone could theoretically stop their medication. Although HIV would still be found in the DNA of their cells, it would not reproduce, circulate in the blood and bodily fluids, and destroy the immune system. It would be comparable to the remission of cancer -- still present, but held in check.
The case of the French adults and the baby, who scientists say may or may not have had its own HIV infection separately from the HIV-positive mother's, makes one thing clear: Early diagnosis and treatment are key to maximize the chances of achieving a functional cure.
Washington, D.C., one of the 12 U.S. cities in which half the nation's HIV-positive people live, is taking the message to heart. The city is taking advantage of new technology that makes it fast and cheap to detect HIV within a week or two after infection. The new assay detects both the virus antigen, part of the actual virus, and antibodies. If it finds the antigen but no antibodies, it means the infection is very new.
Older testing relies on detecting antibodies that may not appear for months after infection -- too late for medication that could stop the infection and provide a functional cure.
In two Washington clinics, everyone visiting the emergency room or clinic will soon be tested using the new assay. Those who test positive, particularly those with antigens but no antibodies -- that is, newly infected -- are advised to start antiretroviral medication as soon as possible.
Gregory Pappas, M.D., director of the D.C. city program to fight HIV, will work with United Medical Center by providing funds for the assay to get it into use faster. "Starting early to preserve the immune system is better than waiting for HIV to destroy the immune system before starting medication," said Pappas. "Suppressing virus also helps slow the spread of the disease in the community because it lowers the amount of virus in the body and, therefore, in the community. So we want to test and treat early in any case. The chance to functionally cure a few people is worth the effort."
The district's mayor, Vincent Gray, appointed an HIV/AIDS commission to advise the city and put science at the forefront of its efforts. Dr. Pappas, who is executive director of the commission, said, "Pioneers in the epidemic remember the people who did not survive after the protease inhibitors came on the scene, because we were not ready for the science. The commission puts us on alert to look at every scientific breakthrough to see if we can help even a few people."
Important questions will remain: Which medication will work best? Do we need to wait a couple of weeks to find out which strain (genotype) of HIV someone is infected with to guide the selection of medication? Will this delay close the window of opportunity for a functional cure? Will treatment without genotyping lead to viral resistance? Can any resistance be overcome and a functional cure still achieved?
There are many questions for science to answer before we fully accept the reality of a functional cure and how to use it. But people fighting HIV have never waited for 100 percent certainty when something offers real hope of a breakthrough.
"Why wait?" said Dr. Pappas. "We want to treat everyone positive and some of these people may end up cured. We don't know how many we will find, or when to stop medication. Those questions can be answered later. For now, we can go for the functional cure by starting medication right away."
D.C. physicians will have to decide the best course of action to take with each patient. But the option to embrace the new science, to start treatment within a couple of weeks of infection -- and possibly cure a few people -- is a tantalizing prospect, hard to ignore.
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