I attended the recent IAS Durban Conference and the preceding two-day HIV Cure symposium hoping to learn of significant advances in the search for interventions that could place HIV infection into remission with durable immune system control of virus without the need for lifetime antitretroviral therapy (ART). That’s one working definition, among several, of what HIV cure might mean for the 37 million people who currently have HIV. My appetite for progress was not substantially rewarded although a few studies were important as was some of the planning for research going forward.
My lack of reward was not unique among attendees seeking major advances in their HIV fields. Undeniably tremendous progress has been made in the global fight against HIV/AIDS and incremental progress will continue because of the sheer will of the IAS community and others. The number of children born with HIV in programs addressing mother to child transmission has decreased dramatically to less than 5000/year in South Africa at last count. Since 2000, when barely a fraction of people with HIV had access to any medicine at all, the number now getting ART is estimated at 17 million. A fantastic result.
" In some pockets, great advances to good healthcare; in others, serious constraints. Without progress, the epidemic could expand again."
Yet everyone should have such access and the attendant healthcare to make it work and reduce co-infections like the killer epidemic twin of tuberculosis. The prospects for achieving that goal over the next several years are dimmed by alarms over global and national funding, weakening economies and a problem with new infections, which for the first time recently have stalled. Babies are born free of HIV from vertical transmission but grow up to acquire the virus in sexual contacts. In some pockets, great advances to good healthcare; in others, serious constraints. Without progress, the epidemic could expand again.
In 2016, there was a good reason to return to Durban – the center of one of the worst places in the epidemic – after the game changing conference in 2000. Outside the conference venue, the municipality of eThekwini, the Zulu name of Durban, suffers. Over 600,000 residents have HIV; women have a life expectancy of 58 and men, 53, i.e. below the national average of more than 60 achieved when ART made some dents in the epidemic. AIDS and TB are primary reasons many with HIV die in some African countries, not ischemic heart disease or other noncommunicable diseases as is true in other parts of the globe.
In that context, the need for safe, accessible and scalable interventions to put HIV in remission without ART is greater than ever. And that’s true also in so-called wealthy countries like Canada where life expectancy can be extremely low among vulnerable populations.
The biennial IAS conference is not regarded as the most important venue for hard hitting basic and clinical science. That occurs at the meeting to take place next year in Paris.
From eThekwini here are some highlights of HIV cure/remission research:
Other gene/cell therapy study. To bring the benefits of a gene therapy approach to those without cancer, new biotech techniques are in play to edit a person’s own immune system without a dangerous transplant, maybe to cut the HIV out of cells where it lies dormant or to inactivate it altogether. CRISPR/CAS9 is the name of one of these editing techniques, also the subject of the prestigious Canadian Gairdner awards in biomedicine in 2016. But this technique may have drawbacks due to developing resistance to the edits. At IAS, Monique Nijhuis, also from the Netherlands, proposed resistance can be overcome using combination “guide” RNA to make these edits hold.
Learning more from cancer treatment. Olivier Lambotte delivered a survey talk describing lessons HIV cure researchers can learn from new immunotherapy and cell therapy treatments tested in cancer patients. These include ways to remove blocks on the natural powers of the immune system and ways to engineer the system to attack tumors or cells containing HIV. The talk was important because this theme – learning lessons from new cancer study – will dominate the IAS cure program to be held in Paris in 2017. A recent New York Times series on the cancer advances (July31 and August 1, 2016 editions) provides good background on these treatments, which are not without serious side effects. We need to keep in mind the question of burden perhaps. A late stage inoperable cancer patient has a higher tolerance for experimental risks than a HIV patient whose drugs keep them in relative – albeit precarious – good health. Still, these treatments may be significant to help achieve an HIV cure.
Best talk at IAS. The work of Deborah Persaud and her colleagues in the IMPAACT trials group to study means to cure pediatric HIV infection with immediate use of ART and/or possibly new antibody strategies never fails to impress. Although a small number of HIV cure studies are starting to take place in Africa, the IMPAACT group’s effort is the widest. A portion of the IAS cure symposium and a smashing conference plenary talk from Dr. Persaud surveyed the differences between infant and adult immune systems as well as the important connections between treatment responses that may make pediatric cure research critical to finding safe, accessible and scalable cures for all. Although these talks were not significant new data, the argument for blending adult and pediatric cure agendas further cooperatively cannot be denied.
In other news . . . .
Other talks and studies on treatment advances and new drug studies were also important. For example, some adults who start ART immediately within days of infection may not test positive for HIV antibody even though the virus resides in their system. Attempts to reduce the size of the hidden HIV reservoir with combinations of ART and some compounds thought to release the virus from hiding were not successful.
Despite the cautions and reminders of how progress can be stalled in the face of realities we often deny, optimism comes from individual people who inspire. The new head of the IAS, Linda Gail-Bekker, is one of those incredibly powerful and compassionate HIV scientist/advocate/activists. Numerous community members given platforms to speak like Juliana Odindo, International Community of Women Living with HIV in Kenya, are another source.
The most significant outcome of the conference in my opinion was not a scientific breakthrough. It was the spotlight shown on the importance of tackling new infections among adolescents – especially girls in Kwazulu-Natal. At one point they took over a conference plenary session where Canada’s Minister of Health, Jane Philpott, was also delivering brilliant information, as she did in more than one instance during the week. But will research and healthcare programs answer their questions? That remains to be seen.
About the author: Robert Reinhard is the Community Liaison, Canadian HIV Cure Enterprise (CanCURE)