As the antiretroviral drug pipeline has slowed to a trickle, the HIV field is increasingly focused on refining therapy, increasing access on a global level, and ultimately finding a cure, and these were all key themes at the seventh International AIDS Society Conference on HIV Pathogenesis, Treatment, and Prevention held recently in Kuala Lumpur, Malaysia.
The IAS meeting is a smaller, more science-centered gathering that alternates every other year with the large International AIDS Conference, last held in Washington, D.C.
"We need to address key populations still left behind, to ensure access for all to prevention and care," said Francoise Barre-Sinoussi, IAS president and conference co-chair. "We all know stigma and discrimination are among the key barriers, and respect for human rights is fundamental to ending the HIV epidemic."
Hints of a cure
The stand-out news was a report by Timothy Henrich from Brigham and Women's Hospital revealing that two Boston men who received bone marrow stem cell transplants to treat lymphoma remain free of HIV at seven and 15 weeks after stopping antiretroviral therapy. Viral rebound usually happens within two to four weeks, according to lead investigator Daniel Kuritzkes.
Unlike Timothy Brown, known as the "Berlin Patient," the Boston patients did not receive stem cells from a donor with genetically resistant immune cells. They did, however, undergo a milder pre-transplant conditioning regimen that allowed them to stay on antiretroviral treatment.
Only after they remained HIV free for six months did the researchers try the treatment interruption to see what would happen. To date, HIV genetic material has not been detected in either man's blood or gut tissue using the most sensitive tests. Henrich hypothesized that the new donor cells may have cleared out residual HIV-infected host cells in a "graft-versus-host" reaction.
But it is far too soon to say these cases represent a cure.
"The virus could come back next week, after a few months, or even after a year," Henrich told reporters.
In another long-awaited report, Deborah Persaud from Johns Hopkins followed up on the case of the Mississippi baby she presented with much fanfare at the retrovirus conference in March.
The child was born to an HIV-positive woman who did not receive prenatal care and did not take antiretroviral drugs to prevent mother-to-child transmission. The infant started a course of combination therapy 31 hours after birth, but was later taken off treatment. After 15 months of follow-up, the child has no detectable trace of HIV.
These findings do not mean a cure is at hand, but they do suggest that some individuals, under special circumstances, may be able to achieve a "functional cure" that allows them to remain off antiretroviral treatment without disease progression for a prolonged period.
While cure-related research garners headlines, speaker after speaker emphasized that the current priority is making antiretroviral therapy available to all who need it worldwide – and that number has just increased by approximately 9 million.
On June 30 the World Health Organization issued updated HIV treatment guidelines recommending that everyone should start antiretroviral therapy when their CD4 T-cell count falls below 500. This is an increase over the current global threshold of 350, and matches current U.S. guidelines.
The change was motivated by a growing body of evidence showing that earlier treatment has benefits both for the health of individuals with HIV and for public health by lowering the risk of transmission.
According to WHO, raising the CD4 threshold "could avert an additional 3 million deaths and prevent 3.5 million more new HIV infections between now and 2025."
The new guidelines were not universally commended, as some advocates expressed concern that expanding coverage will add short-term costs that overstretched budgets cannot accommodate, and earlier treatment could potentially do more harm than good in countries that still use older, more toxic drugs.
Drug policy fuels HIV
This year's IAS meeting was the first to be held in Asia, where the HIV epidemic is largely driven by injection drug use. Malaysia was selected in part because of its successful implementation of harm reduction programs that have dramatically reduced HIV incidence among people who use drugs, said local conference co-chair Adeeba Kamarulzaman.
Prohibition-based drug policy has fueled the spread of HIV, hepatitis B and C, and tuberculosis, and must shift to a public health focus, international experts from a range of disciplines agreed at two conference sessions.
Worldwide, it is estimated that one in five people who inject drugs is infected with HIV, and in some regions up to 90 percent have hepatitis C virus. According to UNAIDS, in 49 countries the prevalence of HIV among people who inject drugs is 20 to 50 percent higher than that of the general population.
"It's pretty clear that the war on drugs is unwinnable, the war on drug users is terrible and also unwinnable, but the war on HIV, HCV, and TB can be won with evidence-based policy," said IAS President-elect Chris Beyrer, who identified himself as the first openly gay man to hold the position in the organization's 25 years.
HIV and aging
Steven Deeks from UCSF gave the conference's keynote address, focusing on HIV and aging. In particular, he discussed how persistent inflammation – even in people on ART with undetectable viral load – raises the risk of age-related conditions such as heart disease.
These other diseases are becoming far more important than AIDS for people with HIV who have consistent access and good response to treatment, and managing age-related conditions will become an increasingly important aspect of HIV medicine worldwide in the coming years.
"It looks like [HIV] adds a decade in terms of age-associated conditions," Deeks said. "I spend my time in the clinic talking about exercise, management of lipids, a Mediterranean diet, and so forth ... That is the future of HIV care." [See related story for more on HIV and seniors.]
Concluding the meeting, Julio Montaner from the British Columbia Centre for Excellence in HIV/AIDS, co-chair of the next IAS conference in 2015, expressed the aspirations of many:
"We want all those in need – wherever they live, whoever they love, whatever their drug use history, however they earn a living – we believe they all must have access to the best HIV treatment and care and the most effective prevention strategies."