July 26, 2017

9 years later, child's HIV infection still in remission

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A South African child's HIV has been in remission for nearly nine years since the child's last treatment, suggesting that early treatment of HIV in children could be an effective way to put a child in long-term remission, according to a case study presented at the 9th International AIDS Society Conference on HIV Science in Paris.

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Currently, according to the Associated Press, treatment for HIV can keep the disease under control but must be taken throughout the patient's life. Only one individual, a man called the "Berlin patient," is believed to have been cured of the disease, but his case is distinct because it involved a bone marrow transplant from a donor who had a "natural resistance to HIV," AP reports. Such transplants, however, are "risky and impractical to try to cure the millions already infected" with HIV, the AP reports, so researchers have primarily focused on the "next best thing": long-term remission.

Background

The child, who is 9-years-old, was involved in a clinical trial funded by NIH that took place from 2005 to 2011 in hospitals at Johannesburg and Cape Town, South Africa, involving nearly 400 babies who were HIV-positive.

The goal of the study, according to Mark Cotton, a pediatric AIDS expert and a lead author of the recent case study, was to ascertain whether treating HIV-positive infants immediately after diagnosis was a more effective approach than the standard approach, where treatment isn't initiated until the HIV-positive individual begins showing symptoms of illness or a weakened immune system. Specifically, the researchers wanted to examine whether such an approach to treatment would enable long-term remission, at least in some cases, the AP reports.   

For the study, researchers separated the infants into three groups:

  • One group received antiretroviral treatment (ART) at the standard time, after infants in the group began showing symptoms;
  • One group received ART immediately post-diagnosis and continued treatment for 40 weeks; and
  • A third group received ART immediately post-diagnosis and continued treatment for 96 weeks.

According to preliminary data, the average remission period was 30 weeks for those who received immediate treatment that lasted 40 weeks and 70 weeks for those who received immediate treatment that lasted 96 weeks. 

A special case

There was one special case, however, the researchers said.

The child, born to an HIV-positive mother, was enrolled in the study at about 8 weeks of age and was placed in the group of infants who received immediate treatment for 40 weeks. According to the researchers, the child's viral load at the start of treatment was relatively low—and by the time the child finished treatment, at nearly 1-year old, the viral load was undetectable. Tests on the now 9-year-old child show that while there are signs of the virus in a small number of immune cells, none of them are capable of reproducing—effectively placing the disease in remission.

According to Anthony Fauci, head of the National Institute of Allergy and Infectious Diseases, the child does not have a gene mutation that would give a natural resistance to an HIV infection, meaning that the remission appears to be entirely due to treatment. However, Fauci cautioned that HIV tends to conceal itself in "funny places" and that it's not "entirely inconceivable" that a small amount of the virus could be hidden in the child's body and potentially begin replicating again.

Doctors said she was 'cured' of HIV. They were wrong.

Other similar cases

There have been three other cases of HIV-positive children reaching a long-term remission, according to the AP. An infant in 2010, known as the "Mississippi Baby," was born HIV-positive and 30 hours after birth, the infant received the usual dose of three antiretroviral drugs. The infant stopped receiving treatment at 18 months, and 23 months later, the disease seemed to be in remission—however, the disease reappeared shortly after researchers highlighted the tentative success, and the child was placed back on ART.

Another case came to light in 2015, when scientists reported on a French child who had been born with HIV in 1996, who received treatment at 3 months old, and stopped the treatment at age 6. Since then, the individual—who is now about 20 years old—has been able to control the virus without the use of drugs.

In addition, according to the AP, several adults have had their HIV in remission for several years after stopping their treatments.

Comments

Avy Violari—one of the study authors and head of pediatric research at the Perinatal HIV Research Unit—in a statement said of the South African child, "To our knowledge, this is the first reported case of sustained control of HIV in a child enrolled in a randomized trial of ART interruption following treatment early in infancy."

However, the study authors said they think other factors could be playing a role in the child's continued remission, such as a stronger immune system. Cotton said, "I think the [South African child] is blessed with a good immune system that we need to learn more about. But I also think there was probably a combination of being on treatment early, protecting [the child's] immune system and allowing it to get used to the virus and adapt and cope."

Meanwhile, according to the Washington Post, stakeholders are responding to the case with cautious optimism. For instance, Fauci said while "it is encouraging to see a child going for such a long period of time without rebounding, ... we don't have the full answers to what this means yet."

Separately, Deborah Persaud, a virologist at Johns Hopkins Children's Center, said, "This is really the first step toward HIV remission and a cure," but "I do want to caution that many kids around the world have been treated, and, having gone through this with the Mississippi child, I think it's important to know this is a very rare outcome, a notable outcome, but not a common one."

And while the results are encouraging, the researchers aren't suggesting any changes in the standard of care just yet, TIME reports. "Although the [ART] medications have risks, the benefits far outweigh the risks," Violari said. "At this stage, we don't recommend any child stops treatment" (Cha, Washington Post, 7/24; Marchione, Sacramento Bee, 7/24; Sifferlin, TIME, 7/24).

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