red-ribbon-aids-4It is an exciting time to be working in HIV prevention, writes Mark Tyson of Yorkshire MESMAC.  Its becoming a full time job just to keep up to date with progress: new innovations and opportunities are emerging all the time.  The evidence is now overwhelming that ‘test and treat’ is not only the right public health response to the HIV epidemic; but that it could, so long as there isn’t any slippage with regard to condom use, actually win us the war.  HIV medications have been proven to prevent infections when used by HIV negative people both pre and post exposure. They have also been shown to render an HIV positive person 96% less infectious. We have the tools, now we must all use them.

Even the mainstream media is buzzing with articles announcing that scientists are significantly closer to producing a cure for HIV/AIDS. ‘An American in Berlin, a baby in Mississippi and 14 patients in France are all alive without treatment’, said the New York Times last month.  This was followed by an article in the Telegraph reporting that scientists in Denmark are just months away from unveiling a breakthrough treatment that could functionally cure HIV.  A cure, seemingly impossible just a few years ago, is now being sought on multiple fronts.  Should we be getting our hopes up?  And what does it mean for the fight to prevent new HIV infections in the here and now?

First to hit the headlines was the ground breaking news of Timothy Ray Brown, known as ‘the Berlin patient’, who became the first person ever to be cured of HIV infection through a bone marrow transplant.  Although it became obvious quickly that replicating this on a large scale was impossible, it did lead to a sea change in research including the development of gene therapy which aims to make a patient’s immune system resistant to HIV.  Brown, who now lives in San Francisco, is something of a superstar in the AIDS community.  He has made himself endlessly available to researchers, who regularly bleed and biopsy him to learn as much as possible about his cure.

More recently in the headlines was the story of a baby born in rural Mississippi to a mother who was not aware she was HIV positive.  Her baby was treated aggressively with antiretroviral drugs soon after birth and remained on them for 18 months, at which point the mother stopped attending clinic and stopped giving her baby the drugs.  When the mother and child returned five months later all HIV tests for the baby returned negative results.  A battery of sophisticated follow up tests found tiny amounts of viral genetic material but no virus able to replicate, even lying dormant in the so-called ‘reservoirs’ where HIV hides within cell DNA.

This story is reminiscent of the ‘Functional Cure’ headlines we saw last year about a group of 14 unusual patients in France, known as ‘the Visconti cohort’.  They were all given antiretroviral drugs soon after becoming infected and remained on them for three years, but then stopped.  Usually, the levels of virus in the body will rise without drugs; ‘drug holidays’ worked out badly when they were tested in clinical trials.  But the Visconti cohort has remained well with extremely low levels of virus in their system.

The existence of people who do not become ill even though they are infected with HIV, the so called ‘HIV controllers’, is already known.  The excitement felt by scientists over the Mississippi baby and the Visconti cohort is because it appears that in some cases at least, medical intervention has been able to bring about similar results.  The virus’s march into the body now looks less unstoppable.

Finally, and perhaps most exciting of all, on 27th April this year the Telegraph reported that Danish scientists currently conducting human trials are hoping for results that will show that ‘finding a mass distributable and affordable cure for HIV is possible’.  In their ‘novel strategy’ the HIV virus is ‘reactivated’ from its ‘reservoir’ hiding place within human DNA and brought to the surface of the cells.  Once there the researchers believe that the body’s immune system, boosted by a vaccine, can kill it.

Lead researchers studying the treatment told the Telegraph that initial signs are “promising.”  “I am almost certain that we will be successful in releasing the reservoirs of HIV,” said Dr. Ole Søgaard, a senior researcher at Denmark’s Aarhus University Hospital.  “The challenge will be getting the patients’ immune system to recognise the virus and destroy it. This depends on the strength and sensitivity of individual immune systems.”

The technique is also being researched in Britain, where five universities have joined forces to form the Collaborative HIV Eradication of Reservoirs UK Biomedical Research Centre group (CHERUB) which is dedicated to finding an HIV cure.  “When the first patient is cured in this way it will be a spectacular moment,” says Dr John Frater, a member of CHERUB, “It will prove that we are heading in the right direction and demonstrate that a cure is possible.  But I think it will be five years before we see a cure that can be offered on a large scale.”

So what does all this mean to the person on the street at risk of HIV and to those of us who are already employed in the war against HIV/AIDS?  Well, we have been fine tuning our messaging of late based on currently available treatments and research.  ‘It Starts with Me’, the new national HIV Prevention England campaign launched recently, expresses where we are at quite succinctly:

·        We are at the start of a new era in HIV prevention: we now have more tools then ever before to help us stop the spread of HIV.

·        Treatment has never been better, and can reduce the levels of virus in someone’s body to an undetectable level. This means it’s very unlikely they would pass the virus on.

·        However, 1 in 4 people living with HIV in the UK don’t know they have HIV, and so aren’t on treatment.

·        And 8 out of 10 men get HIV from someone who didn’t know they were HIV positive.

·        So, through testing, treatment and using condoms, together we can stop the spread of HIV.

I suppose the danger is that some will look upon the good news regarding an HIV cure as a green light to take more risks.  Experts warn that even a small reduction in condom use could wipe out the gains hard earned by ‘test and treat’.  We will need to keep a close eye on this one, particularly with the spectre of drug resistant Gonorrhoea on the horizon.  However, the advances with regard to possible cures do raise some other interesting questions and may provide yet more reasons why individuals at risk should test early and be treated promptly.

The New York Times reported in April that several experts say the reported cures — if confirmed by others — do suggest that some AIDS policies in the States should change in at least two ways.  First, instead of waiting for the infected to wander into testing clinics, health authorities should be aggressively seeking them out. Second, those who test positive ought not to hold off on starting medication.

In fact, early testing and treatment already have two established benefits for individuals:

1.      They may live longer, healthier lives.

2.      They can be 96 percent less likely to infect anyone else.

It seems that we may now be able to add two additional benefits to the list:

1.      They may turn out to be among the lucky few who can stop treatment later.

2.      Early diagnosis and treatment will protect their immune system, and a healthy immune system may prove essential if they are to benefit from an HIV cure, should one become available in the future.

Services locally seem well aware of the changing situation and have been restructuring accordingly to provide convenient HIV testing services available to everyone and targeted at those most likely to be affected.  Yorkshire MESMAC, for example, have embarked on a rapid expansion of its award winning HIV testing service ‘Testing Times’ into community venues throughout West and North Yorkshire.  Local Sexual Health Clinics are also building partnerships and working creatively to reach out further.  Its becoming quicker and easier to test and you can find your local HIV testing centre easily using a number of bespoke search engines, including the HIV test finder on Yorkshire MESMAC’s home page

In terms of future developments, I’m a count your chickens once they have hatched sort of guy.  No one really knows if a cure is possible, how long it will take to become widely available and who will benefit.  Medical research by its very nature is impossible to predict.  What we do know is that we have the tools we need to win the war against HIV today, if we can persuade enough people to adopt a regular testing regime.  If a cure does come along it will not necessarily work for everyone, and it might depend on the health and vitality of the individuals’ immune system.  The reasons to test have never been so compelling.  Testing services have never been so convenient.  The wait for your result has never been shorter (often just 20 minutes).  And our belief that collective human effort can and will defeat one of the most challenging and ingenious viruses ever to attack us, has never been stronger.

Categories: Features

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