French scientists recently published the tantalising prospect of having ‘functionally cured’ people with HIV. Eight of the
14 people observed have consistently maintained undetectable viral load for more than 4 years without needing to take any more HIV medication.
The study called VISCONTI (Viro-Immunological Sustained CONtrol after Treatment Interruption) estimate that one in seven people (15%) with HIV could become ‘post treatment controllers’. Meaning they are able to maintain an undetectable viral load without medication, effectively becoming “functionally cured”. The study suggests this could be achieved by treating people with HIV medication within 10 weeks of primary infection and keeping them on medication for a median of 3 years (the shortest period observed was one year ).
The benefits of early HIV treatment after primary HIV infection now seem overwhelmingly favourable. Some of the benefits include; the potential of being functionally cured, a more intact immune system for longer, a reduced latent HIV reservoir and a massive reduction in infectiousness. Naturally achieving this requires individuals and the community to be informed and have the early treatment discussion with their up to date Doctor. As with many health issues, articles (like this one) have limits in their capacity to fully communicate the complexity of individual circumstances, so a good relationship with your Doctor is essential.
With the tremendous benefits of early treatment in mind, the U.S. Preventative Services Task Force (an independent volunteer panel of national experts in prevention and evidence-based medicine) has embraced the early testing and treatment paradigm. On the 30th of April Dr Doug Owens was quoted saying that “Nearly a quarter of people with HIV don’t know that they have it, and they’re missing out on a chance to take control of their disease. Universal screening will help identify more people with HIV, allowing them to start combined antiretroviral therapy earlier and live healthier and longer lives.” Increasingly the conservative Australian HIV response runs the risk of being out of date and out of step with the most compelling evidence based medicine from around the world, more often playing a game of catch up. An example would be the slow uptake of rapid HIV testing opportunities (New Zealand has been doing them for years).
Most of us though, would probably be content at the steady and cautious approach by the Australian HIV sector. This lesson was learnt at the early stages of the HIV epidemic. When first generation HIV medication became available in the 1990’s a “hit hard hit early” approach was adopted by many. However some people with HIV today still live with the negative long term consequences resulting from pill toxicity and suboptimal pill adherence from that era, others are very grateful to be alive. This historical legacy deserves our compassion and understanding.
Gradually though times of changed, with third generation HIV medication now being simpler to take with little or no side effects for most. Critics of the Australian HIV response believe the conversation of when to start HIV treatments has moved on and would like to see less reliance on a individuals CD4 count and a greater emphasis on, preserving immune function, the role of treatment as prevention, and now the opportunity to be ‘functionally cured’. Community members who have most to gain from new medical evidence and strategies are eager to exercise their right as well informed individuals to choose what is in their best interest; without interference from paternal policy (we know what’s best for you) and overly conservative gate keeping doctors.
If the VISCONTI study holds true, and a much larger study would need to confirm the results, then the course of HIV in Australia could fundamentally change permanently. Now buckle up for a ride into speculation and an opinion of a possible future. HIV testing regimes would be normalised, rapid (under an hour) and convenient (home based testing is already available in the U.S.A.). Sexually active individuals would know of their HIV status early (within 10 weeks of infection) and be treated immediately. Leading to many of them taking HIV medication for a minimum of a year. After which their own immune system will keep any residual HIV virus in check, below the level of detection and infectiousness, no more pills, no more side effects, no more expense to the government through the Pharmaceutical Benefits Scheme. Too soon, too rosy a vision? Perhaps.
What about the 85% who are not functionally cured? Indeed, for people who have to remain on HIV pills, the side effects will for most remain benign, your immune system remains intact, you maintain an undetectable viral load and so have the benefits of being dramatically less infectious. Plus as a result of starting early treatment you may have reduced your latent HIV reservoir, making it more likely that when a cure arrives, you will clear HIV from your body completely.
No one can predict the future, however the seeds of a new trend have been planted by the VISCONTI study and what implications it will have for HIV policy, public health laws, and community responses to HIV. Yet what humanity as learned from HIV could live on forever. Like how to respond humanely to a new or emerging infectious disease, application of resources upfront and early so as to avoid despair and death, how to coordinate global health responses and funding, empowering a community centred response, and global coordination and collaboration on cure research. Is it game over for HIV? You decide.
Cipri Martinez
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Find Cipri’s previous article here.
