Sarah began with questioning whether a cure was even necessary in an age where we have excellent treatment, and funding could instead be focussed on science towards prevention, PrEP, Vaccines and long-acting ART. She pointed out that access to ART has already reached over 21 million, which is over half the global need. However, those with access require lifelong ART and this cannot be guaranteed in areas of economic and political instability. This, in addition to drug resistance and toxicity of ART was argued as a case for continuing with cure research. Sarah continued with some of the practical issues, such as ‘How to design an HIV remission/cure trial’, ‘Analytical Treatment Interruption designs’ and finally 4 of the ‘Different approaches to cure HIV’.
Research towards cure currently is targeted 4 ways. We know that the “Shock & Kill” approach like that in cancer immunotherapy is in trial, and of gene therapy. Something I gained from this session was learning about the immune modulation properties of bNabs which can provide a “vaccinal effect”. Small (n=14) ongoing proof of concept studies on combination bNabs in humans have so far been safe. The other, a search for novel drug classes which can push viral reservoir levels to below a “threshold” therefore inhibiting residual replication may be reliant upon an individual. Very early ART initiation may be counterintuitive as this inhibits antibody development.
Individually, Sarah explained, we are unlikely to find a cure - but utilising multiple approaches in combination towards HIV remission, in addition to early or long-term ART to limit the size of the measured HIV reservoir look encouraging. Cure therapy may require a cancer treatment model approach such as induction, remission then maintenance therapy before removing the need for daily ART. The risks of viral rebound for the individual are minimal, but the risks of inadvertent onward transmission maybe significant
It is important to consider when talking to our patients about a cure that for many, they will need to commence PrEP following cure until the virus is completely eradicated. Patients are realistic, and most know that a cure will not come in their lifetime, but it is encouraging to know that this research continues. In a clinical trial setting, I must remain vigilant to participants of treatment interruption studies, that they are ensuring partners (including casual partners) are protected during the trial period. When responding to patients about the possibility of a cure, this may consist of a post-treatment viral control of 5-10 years of combination medication and ART, however the possibility of a sterilising cure is a long way away.
Author bio: A nurse with varied Public Health experience - from managing malaria and measles outbreaks in the Congo, a Tuberculosis Hospital in PNG or research into healthcare delivery with the Australian Institute of Health Innovation; to care of HIV patients in Sydney, and now HIV and Immunology research at St Vincent’s Hospital Translational Research Centre. I am passionate about health systems strengthening, health education and promotion, infectious disease control and research. I am currently studying an MSc in Public Health.
