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Q&A: ‘The fight is not over’ for HIV
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WHO estimates that approximately 36.7 million people worldwide were living with HIV at the end of 2016, but only 70% were aware of their infection. The epidemic has cost more than 35 million lives since it began 3 decades ago. Although advancements in treatment have contributed to a global decline in new infections and deaths, only 54% of adults and 43% of children with HIV are currently receiving lifelong ART.
Infectious Disease News spoke with W. David Hardy, MD, senior director of evidence-based practices at Whitman-Walker Health in Washington, D.C., and adjunct professor of medicine at the Johns Hopkins University School of Medicine, about progress toward eradicating HIV/AIDS and the obstacles that still need to be overcome. Hardy, who is also an Infectious Disease News Editorial Board member and chair-elect of the HIV Medicine Association, has cared for patients with HIV since 1982 and conducted HIV/AIDS research since 1984, shortly after the virus was discovered.
If there was unlimited funding for HIV/AIDS, where would you focus your energy and why?
What continues to be a critical area of focus both here in the United States and around the world is making HIV testing a routine part of health care so that all persons are given the opportunity to be diagnosed as early as possible and engaged in care with ART. Until we diagnose and treat the great majority — at least 90% to 95% — of individuals who are HIV positive, the epidemic will continue to spread, primarily from those who are infected and do not know it, but also from those who are aware of their infection but are not receiving medication.
There are numerous significant obstacles to the eradication of HIV/AIDS. If you had the power to remove just one of those obstacles today, what would it be?
I would remove the ever-pervasive and destructive stigma that surrounds HIV because it is the number one obstacle that is slowing down progress in eradicating HIV/AIDS. The social and cultural stigma people feel about HIV is related to its transmission, because it is primarily spread through either sexual contact or drug use. Too often, stigma dissuades persons from getting tested, from acting on their test results if they are found to be HIV-positive, and from starting and staying on medication that maximizes their health and prevents further transmission to others.
When do you predict a safe and effective HIV vaccine will be ready, and how would the availability of a vaccine impact HIV eradication efforts?
History has taught us that the ability to cure chronic viral illnesses is very difficult. The only current exception to this is hepatitis C. For all other chronic viral illnesses, especially retroviral chronic infections like HIV, prevention is the most important way to protect people. That is where a vaccine comes into play.
Efforts to create an HIV vaccine have been ongoing since 1983, when the virus was first discovered. Unfortunately, over this 34-year period, progress has been minimal and slow. However, after encountering many obstacles and going back to the drawing board on multiple occasions, researchers have made important progress in better understanding how we can create a vaccine. It will most likely require at least 5 to 10 years before we see scientific evidence that proves that we can create protective immunity against the virus. Vaccinating people would be a highly cost-effective way to counter HIV and protect individuals broadly enough to stop it from spreading. Having a vaccine will certainly be necessary to end the epidemic.
What are some important advances recently made in cure research?
The most important advance that has been made in cure research occurred around 1999 when it was discovered that our current and very effective antiretroviral agents, which durably suppress the virus, cannot eliminate HIV in long-lived, latently infected CD4+ T cells. This latent viral reservoir exists in all HIV-infected people, even after their virus has been suppressed for many years. Early studies have shown that clinically available medications called latency reversal agents can reactivate the latent virus but, so far, have had no effect on reducing it. Further ongoing research is needed to find new ways to protect uninfected CD4+ T cells from this newly reactivated HIV. ART alone is not enough. Another important advance is the recognition that to cure HIV, we will need to create new immunity against the virus. Once someone is infected with HIV, it is very difficult to “teach” their immune system how to fight against a virus that has already caused chronic infection. This is where advances in areas such as cellular and gene therapy will become very important in curing HIV infection.
Only one person has been cured of HIV in the world today. He is an individual who underwent two stem cell transplants for life-threatening leukemia. Some very smart doctors in Germany gave him cells from another person that not only cured his leukemia but were genetically programmed to be HIV resistant. That was about 10 years ago now, but it has given us some hope that a cure is possible.
What is the take-home message?
There is a lot of good news to talk about. We are seeing a significant decline in the number of new HIV infections in many cities around the U.S., including San Francisco, New York City and Washington, D.C. That tells us that our efforts to test people for HIV, get them on treatment, suppress their viral load and keep it undetectable and protect HIV-negative persons with pre-exposure prophylaxis are working. However, there is still a lot more work to do. It is important to remember that the fight is not over. There are more people living with HIV in the U.S. today than ever before. We need to continue to recognize HIV/AIDS as a critical health issue until we can better control and eventually end the epidemic.
Disclosure: Hardy reports no relevant financial disclosures.