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From Crisis to Cure: How Antiretroviral Therapy Changed How We Look, Talk, and Think About HIV

Does viral load suppression mean that HIV is cured? The reality is subtle and complex.

Someone recently asked me if there was a cure for HIV. My initial answer was no. HIV infection doesn’t go away and people infected with HIV have to take antiviral medications for the rest of their lives. But after thinking about it for a bit, I started to consider what it means to actually “cure” someone, and I realized that the answer is not so clear cut. Increasingly, people in the field of medicine have been talking about the U=U idea, or that undetectable equals untransmittable.

In the 1980s, AIDS was essentially a death sentence and senior colleagues tell me about the times when medical wards were filled with people dying due to AIDS-related complications. With the discovery that AIDS was caused by a virus and the development of antiretroviral medications to treat it, the reality of HIV changed completely. Today, people treated with HAART (Highly Active AntiRetroviral Therapy) can suppress the virus to the point where it is no longer detectable in their blood. With no virus detectable in their blood, they cannot transmit HIV to their sexual partners.

This might not be a “cure” in the traditional sense. People with HIV cannot stop their medication, or else the disease will progress — so in that sense it is not a cure. But with therapy, they can avoid all the complications of AIDS and avoid AIDS-related illnesses that have killed so many in the past. If their viral loads are suppressed, they can essentially live normal lives without fear that they will pass the virus on to someone else through sexual contact.

You may remember stories from 2013 about the “Mississippi baby” that was cured of HIV. There were, in fact, two babies: one in Mississippi and one in California, both born to mothers that were HIV-positive but didn’t receive any treatment while pregnant. These two case reports are interesting although neither was exactly a “cure.” In the first case, the mother and baby were lost to follow-up, and treatment was interrupted. When the child was seen again at 2 years old, HIV tests were negative. However, some low levels of non-functional virus were still detectable in the blood. So, the child wasn’t “completely” cured but seems to have been “functionally” cured, meaning that the remaining virus didn’t seem capable of causing clinical infection. Unfortunately, by 2014 the child's viral levels had risen and all hopes of a cure were dashed.

Meanwhile, the second child is still on HIV therapy, so the label of a “cure” can’t be applied unless the therapy is stopped and the tests remain negative. For ethical reasons, and because it would not be in the interests of the patient to do so, there are no plans to actually test that theory.

The initial reports of cures in these two children were premature. This was made more tragic by the fact that HIV transmission from mother to fetus is largely preventable. Standard practice is to start pregnant women who are HIV positive on antiretroviral medications. At the time of delivery, a Cesarean might be considered if the mother has not achieved adequate viral suppression, and after the baby is born, the infant should be given six weeks of HIV prophylaxis treatment. Bottle-feeding is also preferred over breastfeeding to minimize the risk of viral transmission. All this would have reduced the risk of HIV transmission from mother to fetus from around 45% to below 5%.

This is still not a cure, but the passage of HIV from mother to fetus can be essentially prevented if proper medical care is available. Unfortunately, cost and availability are a problem. The issue occurs not just in the developing world but in resource-rich countries as well. The CDC recently reported that the US falls short in its treatment of HIV, with less than two-thirds of HIV-positive individuals achieving viral suppression.

HIV cannot be cured in the traditional sense, but in the span of about 30 years we went from a deadly epidemic that killed thousands of people per year to what is now a chronic condition that can be managed with medication. With proper treatment, people infected with HIV can lead essentially normal lives and not pass the virus on to others. It may not be a cure, but it is close.


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