April 9, 2013
The first in a series examining the reports of a pediatric "functional cure" and its implications across Black America.
In early March, the news that a newborn baby in Mississippi had been treated with a potent cocktail of anti-HIV drugs was presented as the "first documented case of a child being cured of the virus." Only days after the pediatric case made international news, French investigators reported their "functional cure" of 14 patients who had started treatment within 10 weeks of infection and continued on ARVs for, on average, three years.
When researchers use the term "functional cure" (pdf), they mean that the virus is still present in the person's body, but at such low levels that it doesn't require treatment or progress or transmit to others -- a state that Anthony Fauci, M.D., director of the National Institutes of Health's National Institute of Allergy and Infectious Diseases, describes as a "sustained remission that doesn't require therapy." This is different from the traditional use of the word "cure," or "sterilizing cure," meaning that the virus has been eradicated from the person's body altogether.
So could a cure for HIV be on the horizon?
Probably not. In the weeks since then, some have suggested that the Mississippi findings may have been exaggerated -- and the infant may not have been infected with HIV but merely exposed to the virus.
The infant girl was born in rural Mississippi in July 2010 "to a mother who did not receive prenatal care or HIV treatment," ABC News reported. Around the time of her delivery, the mother was tested and was informed that she was HIV positive. Her infant was found to have some HIV antibodies in her blood and was "started on antiretroviral treatment about 30 hours after birth. Doctors took the unusual step of prescribing three aggressive drugs at once."
Having antibodies to HIV means that you've been exposed to the virus and your immune system is trying to fight it off; it isn't the same as actually having HIV.
The infant's viral load, or the amount of virus in her bloodstream, reportedly became undetectable, and the baby received regular ARV treatment for 18 months, until the mother and child dropped out of care and treatment for almost one year.
Widespread HIV testing for pregnant mothers and increased access to ARV treatment has dramatically reduced mother-to-child transmission (MTCT) in the United States to about 162 cases per year today from an estimated 1,500 cases in 1992, according to the Centers for Disease Control and Prevention. Of those 162, more that 60 percent occur among Black people.
The epicenter of the domestic HIV/AIDS epidemic remains in Black America. Blacks represent only 13 percent of the nation's population but account for about 45 percent (pdf) of all new HIV infections. Almost 40 percent of Mississippians are Black. Blacks also represent 78 percent of the state's new HIV infections, so it's highly likely that the mother and infant were Black.
A critical article in The Wall Street Journal questioned whether the infant was infected with HIV or merely exposed to the virus. "We will likely never know if those cells were from the child or maternal cells," wrote Mark J. Siedner, M.D., a postdoctoral fellow in infectious diseases at Massachusetts General Hospital and Harvard Medical School. "Was the baby infected with HIV and, thus, cured? To many of the researchers ... the answer is 'no.' "
Dr. Gaddist echoes Dr. Siedner's concerns. "Several physicians that I have consulted with have asked, 'How did they know the child was HIV positive in the first place?' " she says. "There are so many questions."
Dr. Siedner suggested that the infant was treated to a very aggressive postexposure prophylaxis, a cocktail of usually three or four ARVs that must be taken immediately after possible exposure to HIV and for up to 30 days. "The reason we give medicines to both pregnant women and their newborns is precisely to prevent HIV exposures in children from becoming established infections, an intervention that can decrease the rate of transmission from about 30 percent to less than 1 percent in optimal conditions," he wrote.
Regarding the French investigators who reported their functional cure, "all 14 French patients reported have low levels of detectable HIV after treatment was stopped," Tim Lahey, M.D., an HIV specialist and associate professor of medicine at Dartmouth's Geisel School of Medicine, wrote in The Atlantic.
The only other documented HIV cure has been that of Timothy R. Brown, the so-called Berlin Patient, who was cured of HIV infection after a radical stem cell transplant.
The French results are not likely to be replicated easily across Black America -- in part because many Black people are not diagnosed until after they've been HIV positive for years.
Much of the media narrative around the Mississippi pediatric cure was "hype," says veteran HIV/AIDS activist Sean Strub, the founder of Poz magazine and the Sero Project. "The phenomenon has been observed several times before. The use of the word 'cure' was misleading."
Indeed, apparently people have been functionally cured before. The presenter documenting the Mississippi pediatric case at the 20th Conference on Retroviruses and Opportunistic Infections reported that "80 percent of U.S. children treated for HIV before 3 months of age and achieve suppression of virus are HIV-negative," wrote Shenell Evans, Ph.D., a postdoctoral fellow at the HIV Center for Clinical and Behavioral Studies at Columbia University.
The fact that the baby was HIV negative "was something they discovered by accident because the mother took the child off treatment. [Possibly] this was hyped by some to highlight the research funding at risk from the [budget] sequester," says Strub.
Rod McCullom has written and produced for ABC News, NBC and Fox, and his writing has appeared in Ebony, The Advocate, the Los Angeles Times and many others. Rod blogs on politics, pop culture and Black gay news at rod20.com.