Cure of HIV: No More A Dream
HIV is one of the most common causes of infectious disease mortality despite advancements in its management in the previous decades. Despite the central role of highly active anti-retroviral therapy, the disease was traditionally considered “incurable” and hence the management relied on life long administration of drugs, typically combination of nucleoside reverse transcriptase inhibitors in combination with protease inhibitors. The life long administration besides being financially cumbersome, poses compliance issues and the high prevalence of adverse effects increases morbidity of patients.
The recent past has witnessed several cases of successful eradication of the virus from several patients, atleast to the level of “functional cure”, defined as non-detection of viremia in the absence of anti-retroviral treatment. As students of medicine, we were taught that the CCR5 mutation confers resistance to HIV infection, courtesy of difficulty of the virus in entering the human cell. At that time I had no clue that this mutation will be utilized in the clinical management of disease.
In february 2009, New England Journal of Medicine published a case report of an HIV positive adult with leukemia, who received stem cell transplantation from a donor with deletion in the CCR5. Surprisingly, the patient was cured for both leukemia and HIV and showed undetectable viremia even at 20 months of follow up. At that time, it was hypothesized that immune reconstitution might lead to resurgence of the infection which might be latent. However, a relapse has not been seen to date and the patient is popularly termed as “Berlin” patient (Berlin specifies the city of Germany to which the patient belongs).
Much more recently, in earlier March 2013, the successful care of an infant with HIV gained widespread media coverage. This infant who was HIV positive due to vertical transmission was treated with a full 3 drug regimen (Zidovudine, lamivudine and Nevirapine) in contrast with the one drug regimen (Zidovudine) used for such patient population. Unfortunately, the mother was lost to follow up. However, after 18 months, the child was relocated and to much surprise was found to be having undetectable viremia which in the absence of treatment suggests functional care.
These cases have risen hopes of the hundreds of thousands of HIV patients across the globe and it is a distinct possibility that a widespread cure might be available in the future.
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