14 Adults ‘Functionally Cured’ Of HIV, Study Says

A baby who was “functionally cured” of HIV may have some adult company.

Fourteen adults have also been “functionally cured” after they were given combination antiretroviral therapy (cART) for their HIV infection. They have been able to stop taking the treatment while still keeping their infection under control, according to a new study in the journal PLOS Pathogens.

“Our results show that early and prolonged cART may allow some individuals with a rather unfavorable background to achieve long-term infection control and may have important implications in the search for a functional HIV cure,” the researchers, from the Institut Pasteur in Paris, wrote in the study.

MedPageToday pointed out that while the 14 adults still technically have HIV in their bodies, it’s only barely detectable when using highly sensitive laboratory methods. Therefore, they are considered “functionally cured” instead of being completely rid of the virus.

The New Scientist reported that there were 70 people in the study, all of whom had been treated incredibly early for their HIV infection (anywhere between 5 and 10 weeks of being infected), but whose drug regimens had been interrupted for some reason:

Most of the 70 people relapsed when their treatment was interrupted, with the virus rebounding rapidly to pre-treatment levels. But 14 of them — four women and 10 men — were able to stay off of ARVs without relapsing, having taken the drugs for an average of three years.

The findings suggest that anywhere from 5 to 15 percent of people are able to be “functionally cured” of HIV, the study researcher, Dr. Asier Saez-Cirion, told BBC News.

“They still have HIV, it is not eradication of HIV, it is a kind of remission of the infection,” Saez-Cirion told BBC News.

However, it still remains to be seen whether the virus will be controlled sans drugs forever. Dr. Michael Saag, of the University of Alabama Birmingham, told MedPageToday that he would not recommend people with HIV stop taking treatment, since stopping can actually spur replication of HIV. The adults in the study have been off antiretroviral medication for an average of seven years, and one person has even been off the medication for 10.5 years, the New Scientist reported.

A person with HIV must take antiretroviral drugs every day for the rest of his or her life, according to AVERT. A recent study in the journal AIDS showed that people who are able to well-control their HIV through these drugs have no higher risk of dying than people without HIV.

In the case of the baby who was declared “functionally cured” of HIV, doctors gave the baby — who is now 2 1/2 years old — strong HIV drugs within 30 hours of being born, the Associated Press reported. She was born to a mother who didn’t realize she had HIV until she came into the hospital during labor. The HIV treatment was given to the baby before she was confirmed infected with HIV, but the doctor who treated her — Dr. Hannah Gay, of the University of Mississippi — told the Associated Press that she “just felt like this baby was at higher-than-normal risk, and deserved our best shot.”

However, Dr. Mark Siedner, a postdoctoral fellow in the division of infectious diseases at Massachusetts General Hospital and Harvard Medical School, wrote an opinion piece in the Wall Street Journal, where he pointed out that questions still remain as to whether the child was infected with HIV upon birth, or merely exposed. He wrote:

In the case of the Mississippi baby, we know she was exposed to HIV, had HIV in her blood, and that at least some cells in her blood were found with sleeping virus — though we will likely never know if those cells were from the child or maternal cells that had been transmitted during pregnancy or birth. Was the baby infected with HIV and, thus, cured?To many of the researchers at the conference, the answer is “no.” It seems more likely that her treatment prevented her, after exposure to HIV, from being infected.

 

Before the Mississippi baby, there was another man thought to be “cured” of HIV — Timothy Ray Brown, who is known as the “Berlin patient.” Brown was “cured” when he was given bone marrow stell cell transplants for leukemia that wasn’t related to his HIV infection. But those stem cells he received came from a person with HIV-resistant cells — and after he received the transplant, his virus never came back and he was able to stop taking antiretroviral medication.

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Mixed Messages on Meds and Booze

by Benjamin Ryan                 

Many skip their HIV meds when they drink.  Here’s why this is a mistake.

In the ongoing struggle to improve adherence to HIV medications, alcohol has long been an obvious crux standing in the way of progress. Brian Risley, manager of the treatment education program at AIDS Project Los Angeles, says some of the common refrains he hears from his HIV-positive clients are, “They got drunk, they forgot to take their meds; they went home with somebody and they didn’t bring any meds with them.”
Now cutting-edge research has teased out a new component of booze’s detrimental effects on health outcomes: the fact that many people with HIV skip their meds on purpose when they are drinking because they falsely believe that antiretrovirals (ARVs) and alcohol are a toxic mix.
A team from the Department of Psychology at the University of Connecticut studied 176 HIV-positive Atlanta residents who were taking ARVs and who drank. The group was predominantly male and African American, averaging about a high school education. After interviewing the participants about their beliefs surrounding the supposed hazards of drinking while on ARVs, the researchers monitored their medication adherence, alcohol intake, viral load and CD4 count over a yearlong period.
A stunning 51 percent of the participants reported that when they drank they skipped their ARVs—for a variety of reasons. Some of them would only skip one dose, while others would stop their medications in advance of drinking and wait until the alcohol was cleared from their bodies to start up again.
Richard D. Moore, MD, director of the Moore Clinic for HIV Care at Johns Hopkins Medicine, reports observing this phenomenon among his patient population. “We think it’s unfortunate,” he says, “that patients who are going to be drinking over the weekend would say, ‘Well, since I’m going to do that, I shouldn’t take my antiretroviral medications.’ We encourage adherence to our antiretroviral medications no matter what.”
While the study’s authors state in their paper, which was published in the Journal of General Internal Medicine, that their cohort is not a representative sample of the general HIV population, previous studies have also reported that as many as half of people with HIV who drink alcohol skip their meds on purpose when they’re drinking.
Most notably, this study proves for the first time that purposefully skipping ARVs when drinking is a significant source of the non-adherence problem in the United States. It also shows that faulty beliefs about the danger of mixing alcohol and HIV medications not only significantly motivate people to skip doses, but that these beliefs are actually a greater predictor of non-adherence than alcohol use itself. All of this is particularly troubling given the fact that those who skip medications put themselves at risk for treatment failure.
To these effects, those study participants who held the faulty beliefs were much more likely to fall into the 51 percent who skipped medications while drinking. And those who skipped were significantly more likely drop below a crucial rate of 85 percent adherence, to have detectable viral loads and to experience CD4 counts below 200—all factors that could seriously jeopardize their health.
Robert Gross, MD, an HIV specialist who is a professor at the University of Pennsylvania Perelman School of Medicine and a clinical researcher at the Philadelphia VA Medical Center, says that the misconceptions about booze and HIV meds are likely an extension the early- to mid-20th century era when barbiturate use was common in the United States. These drugs, also known as downers, can be fatal when taken in combination with alcohol, so there was a big push in those days to warn people about the harms of mixing substances.
Seth Kalichman, PhD, a professor of psychology at the University of Connecticut and the study’s lead author, says, “It appears people have generalized the message to their antiretrovirals, although there really is no indication that they shouldn’t be mixed [with alcohol]. With a really big exception: people who have liver disease, including hepatitis C, [for whom] the combination of antiretrovirals and alcohol can actually be very dangerous. They really should not be drinking, period. But, those folks aside, the harm of missing antiretrovirals clearly outweighs the harm of taking antiretrovirals with alcohol.”
Risley, of AIDS Project Los Angeles, reports that many of the clients in his group for newly diagnosed people with HIV ask him questions about drinking.
“They think that their liver can’t handle the HIV meds and the alcohol,” he says. “Basically what I tell them is you’re not competing for the same metabolic pathways that break it down. So you don’t have to worry about it. But, like anything else, you want to try to drink moderately.”
However, some HIV medications do indeed have side effects that make combining them with alcohol inadvisable. But instead of coming to conclusions on their own, people with HIV should discuss the subtleties of their individual drug regimens with their doctors or nurses, Kalichman says. (Pharmacists are also a good source of information about drug-drug reactions of any kind, including in regards to alcohol and street drugs.)
But surprisingly, more than 80 percent of the study’s participants reported that their health care providers had specifically instructed them not to mix ARVs and alcohol, while only 65 percent stated that their providers actually engaged them in a discussion about alcohol use.
In these cases, misinformation and missed opportunities for effective harm reduction appear to be the true toxic mix.
“I think that doctors and nurses and health care providers can be more clear in their communications,” Kalichman says. “I’m sure it’s very common for providers to tell patients, ‘Now, if you’re going to be starting these antiretrovirals, one of the things that you shouldn’t do is drink.’ And that’s good advice. Because drinking is not healthy to begin with. And also, drinking is a really strong predictor of non-adherence. But what some of these participants are hearing is, ‘Don’t drink when you’re taking these medications. So when you start drinking, stop the medications.’”
Risley says that a more nuanced harm reduction message is needed and that it could be promoted by anyone in the HIV field, including psychosocial case managers, nurses who handle HIV caseloads, and even community education groups that participate in health fairs.
Speaking specifically to medical providers, Kalichman says “they need to have a more comprehensive conversation about the role of alcohol in someone’s life, and when they should be drinking and when they shouldn’t be drinking—not just a one-liner: ‘Don’t drink.’”

Baby Born With HIV Apparently Cured, Say Scientists

Newborn baby feet in hospital

 

 

By LAURAN NEERGAARD  03/03/13 07:28 PM ET EST AP

WASHINGTON — A baby born with the virus that causes AIDS appears to have been cured, scientists announced Sunday, describing the case of a child from Mississippi who’s now 2 1/2 and has been off medication for about a year with no signs of infection.

There’s no guarantee the child will remain healthy, although sophisticated testing uncovered just traces of the virus’ genetic material still lingering. If so, it would mark only the world’s second reported cure.

Specialists say Sunday’s announcement, at a major AIDS meeting in Atlanta, offers promising clues for efforts to eliminate HIV infection in children, especially in AIDS-plagued African countries where too many babies are born with the virus.

“You could call this about as close to a cure, if not a cure, that we’ve seen,” Dr. Anthony Fauci of the National Institutes of Health, who is familiar with the findings, told The Associated Press.

A doctor gave this baby faster and stronger treatment than is usual, starting a three-drug infusion within 30 hours of birth. That was before tests confirmed the infant was infected and not just at risk from a mother whose HIV wasn’t diagnosed until she was in labor.

“I just felt like this baby was at higher-than-normal risk, and deserved our best shot,” Dr. Hannah Gay, a pediatric HIV specialist at the University of Mississippi, said in an interview.

That fast action apparently knocked out HIV in the baby’s blood before it could form hideouts in the body. Those so-called reservoirs of dormant cells usually rapidly reinfect anyone who stops medication, said Dr. Deborah Persaud of Johns Hopkins Children’s Center. She led the investigation that deemed the child “functionally cured,” meaning in long-term remission even if all traces of the virus haven’t been completely eradicated.

Next, Persaud’s team is planning a study to try to prove that, with more aggressive treatment of other high-risk babies. “Maybe we’ll be able to block this reservoir seeding,” Persaud said.

No one should stop anti-AIDS drugs as a result of this case, Fauci cautioned.

But “it opens up a lot of doors” to research if other children can be helped, he said. “It makes perfect sense what happened.”

Better than treatment is to prevent babies from being born with HIV in the first place.

About 300,000 children were born with HIV in 2011, mostly in poor countries where only about 60 percent of infected pregnant women get treatment that can keep them from passing the virus to their babies. In the U.S., such births are very rare because HIV testing and treatment long have been part of prenatal care.

“We can’t promise to cure babies who are infected. We can promise to prevent the vast majority of transmissions if the moms are tested during every pregnancy,” Gay stressed.

The only other person considered cured of the AIDS virus underwent a very different and risky kind of treatment – a bone marrow transplant from a special donor, one of the rare people who is naturally resistant to HIV. Timothy Ray Brown of San Francisco has not needed HIV medications in the five years since that transplant.

The Mississippi case shows “there may be different cures for different populations of HIV-infected people,” said Dr. Rowena Johnston of amFAR, the Foundation for AIDS Research. That group funded Persaud’s team to explore possible cases of pediatric cures.

It also suggests that scientists should look back at other children who’ve been treated since shortly after birth, including some reports of possible cures in the late 1990s that were dismissed at the time, said Dr. Steven Deeks of the University of California, San Francisco, who also has seen the findings.

“This will likely inspire the field, make people more optimistic that this is possible,” he said.

In the Mississippi case, the mother had had no prenatal care when she came to a rural emergency room in advanced labor. A rapid test detected HIV. In such cases, doctors typically give the newborn low-dose medication in hopes of preventing HIV from taking root. But the small hospital didn’t have the proper liquid kind, and sent the infant to Gay’s medical center. She gave the baby higher treatment-level doses.

The child responded well through age 18 months, when the family temporarily quit returning and stopped treatment, researchers said. When they returned several months later, remarkably, Gay’s standard tests detected no virus in the child’s blood.

Ten months after treatment stopped, a battery of super-sensitive tests at half a dozen laboratories found no sign of the virus’ return. There were only some remnants of genetic material that don’t appear able to replicate, Persaud said.

In Mississippi, Gay gives the child a check-up every few months: “I just check for the virus and keep praying that it stays gone.”

The mother’s HIV is being controlled with medication and she is “quite excited for her child,” Gay added.

Lack of understanding of treatment benefits may discourage women with HIV from having children – and could increase the risk of vertical transmission

Gus Cairns
  Published: 16 November 2012

Two papers presented at the eleventh International Congress on Drug Therapy in HIV Infection this week in Glasgow suggest that some women with HIV may not have up-to-date information about vertical transmission (HIV being passed on from mother to child) – and paradoxically the risk may be increased if they do not take antiretroviral therapy (ART) as a result.

A study from Italy found that 20% of women with HIV overestimated the likelihood of passing on HIV to their babies if they were on ART, and nearly 10% thought that transmission from a mother with HIV to a child was more than 50% likely.

The study also showed that starting ART was associated with a decrease in the desire to have a child and that fear of mother-to-baby transmission was the strongest predictor that a woman reported not wanting to have children.

Meanwhile, a study from two East London hospitals found that although the majority of women with HIV who gave birth there returned for care after giving birth, some did not return for one or two years and that 37% had a viral load over 100 copies/ml when they did return. This study was done, in part, to inform discussions about the possibility of relaxing breastfeeding guidelines in the 2012 BHIVA guidelines on treatment for pregnant women; in the end these guidelines did not change their recommendation of total avoidance of breastfeeding.

Desire to have a child

Women with HIV are often viewed as potential mothers, so it is quite unusual for a survey to ask women with HIV of childbearing age whether they actually want children. This is what the DIDI study did in Italy.

This survey asked 178 women who were in a steady relationship and under 45 years old, as part of a larger health survey that took place between November 2010 and February 2011, whether they wanted a child, or another child if they were already a mother.

Sixty-one per cent said ‘no’. This is not that surprising given that the mean age of the group was 39, so more women were nearing menopause than not, and 53% of them had a child already.

The women’s own health considerations were not an influence: this was a group with an average CD4 count of 552 cells/mm3, of whom 88% were on ART, with 79% of those (69% of all the women) with an undetectable viral load.

However, answering ‘no’ was far more likely among the 44% of women who had an HIV-negative partner. Thirty-one per cent of women were actively trying for a child, but whereas 44% of women with HIV-positive partners said they wanted a child, only 10% of women with HIV-negative partners did so.

Over half of the women trying to conceive were simply doing so by having unprotected sex with their partner (including half of the small number of women with HIV-negative partners) but about 20% used self-insemination as a technique – even with HIV-positive partners – and another 20% (50% of those with negative partners) were seeking advice from a fertility clinic.

Half of the women said their HIV diagnosis had affected their desire to have a child (or another child), and a third said it “very much” had. Strikingly, women with an undetectable viral load were 69% more likely not to want a child, although this could be because older women might be more likely to be on ART. Nearly a quarter (22%) of the women said starting ART had reduced their desire to have a child.

Women were asked: “If all necessary measures were adopted, how likely do you think your child would be born without HIV?” Most women had a reasonably accurate view of this: 35% said they thought that if everything was done, it was a certainty that their child would be born without HIV and another 35% said there would be a less than 5% chance. However 10% thought the chance was between 5% and 50% and 9.4% thought the chance was over 50% (3.4% thought it was a certainty any child of theirs would be born with HIV).

When it came to predictors of wanting to have a child, Italian-born women and former injecting drug users (who were also more likely to be native Italians) were half as likely to want a child than other women, while women on a low income (less than €800 a month) were four times more likely to want a child, though this reflects the fact that low-income women were more likely to be young and/or African immigrants.

Low income was one of only two factors that had a statistically significant association with wanting to have a child. The other was “fear of vertical transmission”: women who said they were afraid that they would pass on HIV to their child were 3.75 times more likely to not want to have a child, and those who feared they would not live long enough to raise a child were 2.85 times more likely not to want one. Fear of having to disclose their own HIV status to their child was another reason quoted by many women for not wanting a child.

Although this study serves as a useful reminder that women with HIV should not be regarded simply as potential child bearers, it also suggests that among some women, exaggerated fears of infecting either their partner or their child may be inhibiting them from becoming mothers.

Viral loads after giving birth and breastfeeding

The study from Homerton and Newham General Hospitals in London was a more straightforward survey of viral load and follow-up monitoring in pregnant women but was done with a purpose in mind: 80% of pregnant women with HIV attending these two hospitals were of African origin and many of them had expressed confusion about breastfeeding and viral load guidelines. Advice on infant feeding given to women living with HIV is very different in the UK to the advice given in many African countries.

Whereas the British HIV Association (BHIVA) guidelines on pregnancy say that women with HIV should exclusively use formula milk for infant feeding from birth and never breast feed, the international World Health Organization (WHO) guidelines say that, on the contrary, as long as women have an undetectable viral load and are in situations where that can be monitored, then they should breast feed, because there is evidence that in low-income countries it may protect maternal and child health. The hospitals therefore undertook to monitor post-partum viral load in women, partly in order to see if BHIVA could relax its guidelines.

They looked at 151 pregnancies in 140 women. The mean age of the women at delivery was 32, and 27.5% of them were diagnosed during pregnancy. Most women needed ART as treatment: only 20% had CD4 counts above 350 cells/mm3 and took ART to prevent transmission, rather than because they needed it themselves. Viral load at delivery was well controlled, with only 11% of women having a viral load over 100 copies/ml.

All but two women returned for care, but the average time to the next visit at which viral load was measured was 2.5 months – the concern being that if a woman was breastfeeding and her viral load increased in the time between viral load tests, the risk of passing on HIV to her baby would also increase. The longest gap between delivery and follow-up was 26 months.

At follow-up, quite a high proportion of women had a detectable viral load. A third of the women who were on HIV treatment for their own health had a viral load over 50 copies/ml and 21.5% over 100 copies/ml. Only 25% of women who had taken treatment specifically to prevent mother-to-child transmission (and who had then stopped taking it) had a viral load under 100 copies/ml. Altogether, 37% of the women had a viral load over 100 copies/ml at their first test after giving birth.

The authors of the paper suggest that viral load monitoring in nursing mothers needs to be considerably intensified before breastfeeding guidelines can be relaxed.