How do we know if someone’s in HIV remission?
In July, the HIV community heard a new report of a child, born with HIV, who appears to be in HIV remission. (HIV remission refers to the situation when people with HIV have interrupted antiretroviral therapy and have no evidence of HIV replicating in their body for some period of time.) Even though the nine-year-old child is not taking HIV medications, researchers are unable to find HIV in their body.
The South African child had a very high viral load at about nine weeks of age, and was given HIV medications which suppressed their viral load to undetectable. When the child was a year old, they were taken off of their HIV medications. The child has maintained an undetectable viral load after almost nine years off of medications. How is this possible? Has this child been cured of HIV?
It is not yet known if this child has been functionally cured of HIV, although researchers certainly believe it might be possible.
Researchers have studied the South African child to figure out if they are functionally cured of HIV. They were able to find virus DNA integrated into a very small number of immune system cells (5 copies per 106 cells), but otherwise did not find any evidence of HIV replication or HIV infection. Because the child does not have genetic characteristics of so-called “elite controllers,” the researchers believe the early HIV therapy given to the child shortly after birth was enough to achieve HIV remission.
“You can’t detect any virus—there seems to be no virus left in the body. This is what people think of when they think of an HIV cure,” said Jonathan Li, MD, ACTG Network Investigator, and Assistant Professor of Medicine at Harvard Medical School and Brigham and Women’s Hospital.
This isn’t the first time that a child born with HIV, treated very early on with HIV medications, has been in remission. The “Mississippi baby” had no virus detectable in her viral load for 27 months after aggressive HIV therapy was given soon after birth. (The “Mississippi baby’s” virus did resurface, just before the girl’s fourth birthday.)
“Right now, one of the major goals of the field is to find strategies that can lead to sustained HIV remission. HIV remission is a goal that our patients are interested in and want to achieve. I’ve heard of patients saying that while HIV is not a death sentence anymore, it is still a life sentence,” said Li.
One of the challenges in the field of HIV cure and remission is that researchers are not able to predict what will happen when a person living with HIV stops HIV medications.
“After pausing HIV medications, most patients experience viral rebound, and this occurs relatively quickly—typically within a few weeks. But then there are lots of individuals who have more delayed viral rebound. There are some rare individuals whose viral rebound is delayed for months and even years. Unfortunately, we don’t have a good way to predict when HIV will become detectable in the blood after a patient stops HIV therapy,” said Li.
A clinical trial is now underway that will help researchers predict when and if someone’s viral load will bounce back if that person is taken off of antiretrovirals. Li said that the information learned from the study, called ACTG A5345, will also be used to devise new strategies for HIV remission.
Below, find more information about the ACTG A5345 study including how to get involved.
About the ACTG A5345 study
ACTG A5345 is an HIV remission study that is currently enrolling people living with HIV.
What will be learned from the study?
The study will identify biomarkers that can be used to predict when HIV will become detectable in the blood after an individual stops HIV treatment. Once validated, these biomarkers will be used to predict the likelihood of viral rebound and create strategies to achieve long-term HIV remission.
What will people in the study do?
People in the study will have a large volume of blood drawn at the beginning of the study. Then, they will undergo an intensively monitored antiretroviral pause. They will stop HIV treatment under the close supervision of their study doctor, returning to the clinic twice a week for the first two weeks after stopping therapy so that their viral loads can be monitored.
Once people’s viral loads go up to over 1,000 copies/mL, they re-start their HIV medications and they’re monitored until their viral loads become suppressed. Many people might expect to have their viral loads go back up after a couple of months off of medications, but some people might be post-treatment controllers whose viral loads are suppressed long-term without HIV therapy. Post-treatment controllers will be followed for a prolonged period of time.
Is this study safe for people living with HIV?
Safety is a primary concern for the ACTG A5345 study research team. While some people might be concerned about the potential risk of stopping therapy, Li emphasized that the kind of treatment interruption studies being done today and in this study are not the same as those that were done 10 or 20 years ago. In those studies, people were taken off of therapy for long periods of time and exposed to very high levels of virus. In this study, participants are monitored very closely and re-starting therapy as soon as the virus becomes detectable.
How do I get involved?
Study sites across the U.S. are enrolling participants (click here for more information).
People in the San Francisco Bay Area may enroll at the University of California San Francisco study site. Contact firstname.lastname@example.org for more information.
How is HIV remission different from viral suppression and being “undetectable”?
HIV remission refers to the situation when people living with HIV interrupt antiretroviral therapy and have no evidence of HIV replicating in their bodies for some period of time. HIV remission is different from viral suppression. People living with HIV are said to be “virally suppressed” or “undetectable” when taking HIV medications that prevent HIV from replicating (or making copies of itself).