There are exciting new data on 14 French patients who were treated during the first weeks of infection and who have successfully remained off of antiretroviral (ARV) therapy for an average of 7.5 years after interrupting prolonged treatment. These cases are exactly the kind we need to better understand the possibility of a “functional” cure for HIV, whereby people still have detectable virus, but don’t lose control of the virus or see their immune system’s bottom out. That said, the media is going just a tad crazy about these new data and heralding “14 cured HIV patients,” or “Functional Cure of 14 HIV-infected.”
It’s perhaps a bit early to use even the term, “functional cure,” and cooler heads are now using the term remission. We know that these individuals are controlling their HIV for now, but don’t know whether that control will remain in place permanently.
Here’s the skinny: Seventy people who were infected with HIV and caught it during the first weeks of infection were started on ARV therapy and then later went off therapy for a variety of reasons. Of those, 14 maintained viral control after stopping therapy. Most stayed on their medication for at least three years. Then, for a variety of reasons, all of them stopped their drugs, but virus levels never came back up. Though all who have data available still have enough virus to be detected on the most sensitive tests, they are essentially controlling HIV without the need for continued treatment, and all have been off therapy for at least 4.5 years.
When these patients were first reported to other researchers there were questions about whether they might actually have controlled HIV on their own without ever having needed to start ARV treatment in the first place. In other words, whether they were actually part of a very small proportion (less than one percent) of people with HIV called elite controllers. These individuals do get infected with HIV, but their immune systems keep the virus from doing damage. Most have genetic advantages over the average human being that helps them control HIV naturally.
What’s interesting about this new group of 14, dubbed the Visconti Cohort, is that they don’t have any genetic protections the way elite controllers do. In fact, their genetic make up is actually most similar to people who progress through HIV disease quite rapidly. As well, elite controllers typically have robust anti-HIV immune responses, which is not the case with the Visconti group. Also, elite controllers do such a good job of squashing viral mayhem, that they don’t typically have symptoms of infection during the “acute” phase of HIV infection. This contrasts with the fact that 12 of the 14 Visconti patients had symptoms of acute infection.
Thus, it seems like these individuals look a lot more like the average person with HIV. Yet, after prolonged HIV treatment started very early during infection, they now are able to control the virus for long periods. Are they cured? No they aren’t exactly, at least not by the definition of getting rid of the virus completely. However, they are not completely unlike the recent report of the baby in Mississippi who has, according to some researchers, achieved a “functional” cure, meaning that the virus is still present, but unable to do much damage to the immune system.
Are these data exciting and encouraging? Absolutely. Given the incredible challenge of finding people during their first weeks of infection, however, this isn’t likely to be easily reproduced. Also, the majority of people in the original cohort who stopped treatment were not able to later control it. That said, it does point to the potential benefits of getting people on treatment as early as possible.
Many in the blogosphere are asking whether anything like this will ever be possible for the majority of people with HIV who weren’t treated until much later in their disease process. The answer is that researchers are working furiously to reduce the size of the viral reservoirs in such individuals to the point where they might look more like the fortunate Visconti patients. It’s going to take time, and there will be failures along the way, but Project Inform and its most ardent supporters have always been motivated by hope.