A message of hope, Global AIDS day 2021
Dr Pat Vigil
Reflecting on World AIDS day in 2021 it is easy to be pessimistic. We are still in the grips of a world wide pandemic the likes of which we have not seen in 100 years,. Our nemesis is a virus that seems to mutate and outpace even the best that modern science and modern medicine has to offer
Viruses are interesting that way, they are relentless and never rest. And with this world wide day of reflection and remembrance of all the difficulties we have seen with the HIV virus, there is real reason for hope. Countless individuals have worked tireless since the start of the HIV pandemic and made enormous progress. First understanding the virus, its unique mode of replication and effect on the immune system, was a triumph. It is not too much of an exaggeration to state that the entire field of immunology was rewritten with the early studies of HIV. I would like to spend a few moments of your time reviewing what I see as the main messages of hope and those measures that can be acted on. We need not be passive but can take an active role in combating and ultimately triumphing against HIV. Reflecting for a moment on these successes might also provide a welcome respite in our current, pandemic dominated lives.
1. Get tested and know your status
First it is interesting to note that the idea of testing, surveillance, and epidemiology has greatly changed since the HIV virus was first identified. The transition from an entirely fear based scare-mongering tactic about ‘the gay virus’ has not been an easy one, and too much stigma remains, but progress has occurred and one thing is clear. The more testing that is done, the less transmission occurs and the better we are able to control the spread.
Stigma and lack of testing has been particularly pronounced and detrimental in Africa and the global south, and unfortunately the current COVID-19 situation has only made this worse. The last two years have, if anything, been an important reminder of just how important ongoing consistent effort is needed to slow the spread of the virus.
For those fortunate enough to have access, HIV testing is easy, fast, and discreet. The US Preventative Services Task Force, one of the organizations that sets our nations primary care and preventative care guidelines, recommends all adolescents and adults be screened at least once in their lifetime for HIV. We now recognize the universal risk of infection and truly universal screening is the first step towards stopping the further spread of HIV. That is progress.
2. Effective prevention measures are available
Second, it is wonderful that prevention measures are better, more available, and better overall compared to our original situation. For example, it used to be that condoms and abstinence were touted as the only prevention strategies for sexually transmitted HIV. This has fortunately changed, and pre-exposure prophylaxis (PrEP) now has shown to be effective in preventing infection in a wide range of circumstances.
3. Undetectable = untransmissible
We now know that effective treatment, leading to full suppression of viral replication and an undetectable viral load, is not only achievable but also results in effectively zero chance of transmitting the virus through sexual contact. This is an incredible achievement and it is worth pointing out the contrast with other viral infections. For example, genital herpes is most often caused by the HSV-2 virus, which is extremely common among the general population. Furthermore the virus continues to be active, replicate, and can spread without overt disease or between outbreaks. We do have medication that can treat the virus, and even in people that take the medication continuously to prevent further outbreaks can transmit the virus to their partners and continue to spread the infection.
Contrast that with the situation with HIV. Effective treatment of HIV reduces the rate of viral replication to levels that are lower than what our best detection methods can measure. This effectively reduces the risk of passing the virus to another person to as close as zero as we can measure. In fact, studies have shown no transmission to sexual partners over the course of many years if the HIV+ person has maintained viral suppression. This has even been replicated in follow up studies, leading to a new approach to preventing new infections, known as treatment as prevention. There are very few chronic viral diseases that we can prevent this way.
4. Treatment options are better than ever
Finally, our options for treating HIV continue to improve and the advances seen have had tangible benefit for those living with HIV. Early treatments used to include a large cocktail of medications, many of which had to be taken several times a day. Combination pills and medications that only need to be taken once a day were a great advance. But we now have more exciting developments with several medications that have now been approved or in development that can be injected once a month or less!
Medications have continued to improve, with fewer side effects and better quality of life. Importantly, this has translated to reduced morbidity and mortality. In the US, the rate of HIV related deaths declined from 2010 to 2017 by 48%! It is now more common to die of an unrelated cause than HIV. In a few decades we went from a disease first recognized only in those individuals in the most advanced states and with HIV as a cause of death, to a chronic disease that can be managed and suppressed.
Final thoughts
This year also marks an almost unbelievable milestone, the documentation of a second individual who’s immune system for all intents and purposes beat HIV. Although the media only briefly picked up the story of a woman who was identified as an ‘elite controller,’ who was found free of infection, it is worth repeating. She was identified originally as one of those rare individuals whose immune system is capable of controlling HIV to the point of suppression without medication. She was subsequently chosen for further study to identify if the virus persisted in her cells, and despite an extremely thorough effort was found to have no detectable viral DNA sequence in her immune system cells. She was dubbed the “Esperanza patient,” and the name hope certainly applies not just to her situation, but to the situation as a whole.
In medical school I was taught that a cure was impossible, that the best we could wish for was controlling infection and minimizing symptoms. That progression was inevitable, and that eventually all patients with HIV would progress to AIDS and die from the infection. I am delighted beyond belief to say this is all a lie. One patient who’s own immune system cleared HIV is a scientific curiosity, two is impossible to ignore. We now have evidence that a true cure, without a potentially dangerous stem cell transplant, is possible. Efforts to study new vaccine strategies, including using the mRNA technology we are all currently obsessed with, are now underway. This year may come and go as one of immense suffering and sorrow at the hands of a virus. But it may also mark an important milestone in the fight against HIV and mark a time of true hope for the future.
