HIV is still very much around
CLINICAL MATTERS
Prior to the Covid-19 pandemic, the Philippines had the fastest growing HIV epidemic in the Asia-Pacific. The global HIV pandemic was declared back in 1981. It is still ongoing. HIV has already killed over 36 million people with another 38 million people currently living with the disease. Fortunately, effective antiretroviral treatment has saved the lives of many more millions of people living with HIV (PLHIV). Millions of PLHIV, however, continue to not have access to proper care, especially those who live in countries with limited availability of lifesaving antiretrovirals (ART).
In the 1980s, a diagnosis of AIDS was seen as a death sentence. It was also one of the most stigmatized diseases in history. While more women are currently living with HIV than men, HIV in the 1980s was widely seen in mainstream media and in society as a gay disease. When the causative agent of AIDS was finally isolated in 1983, it became apparent that it was a sexually transmitted infection that could be transmitted to anyone, regardless of sex or gender.
A subset of PLHIV at that time were patients who were treated with blood products. Hemophiliacs were at particularly high risk for infection due to their dependence on concentrated blood products from multiple donors before routine HIV blood screening was instituted.
A 10-year-old hemophiliac named Ryan White who was infected with HIV faced terrible discrimination in his community and was asked to leave his school. Ryan White died of AIDS-related complications a few years later but he left behind an enduring legacy of anti-discrimination legislation. His staunch advocacy significantly boosted funding for AIDS research and awareness.
Even now, HIV continues to be misunderstood by our society. Like Ryan White, however, some high-profile people who are “out” with their HIV status have contributed to improved attitudes toward the disease. While celebrities like Freddy Mercury, Rock Hudson, Isaac Asimov, Gia Carangi, and Arthur Ashe died from AIDS prior to the discovery of effective treatment, others like Magic Johnson are still very much alive and living near-normal lives, thanks to antiretroviral drugs. As more potent antiretrovirals become available and become easier to take, PLHIV are living longer, recovering most if not all of their life expectancy.
PLHIV still need to take lifelong ART as there is still no practical cure. The current formulations of first line treatment, however, are in the form of once-a-day pills. Three drugs—dolutegravir, tenofovir, and lamivudine—are mixed into the single pill and are very well tolerated with minimal side effects. This is a far cry from the original highly toxic antiretroviral regimens where several pills had to be taken up to every four hours round the clock and resistance developed very quickly. Long-acting injectable antiretrovirals, which need only be given, monthly have also been developed and are being rolled out.
Several people with HIV have been cured. Timothy Ray Brown, also known as the “Berlin patient,” achieved a sterilizing cure where there was no more detectable HIV in his entire body. He was able to stop taking ART safely. His cure occurred when he was being treated with a bone marrow transplant for leukemia. The bone marrow donor had a special mutation in his genetic material known as delta-32, which made the donor cells resistant to HIV infection. When Brown had a rejection episode, which killed all his HIV-infected cells, the new bone marrow cells were not infected. Unfortunately, bone marrow transplantation is quite dangerous and expensive and so it is not a practical cure, only attempted when the PLHIV already has some form of cancer that needs to be treated with a bone marrow transplant. Several people have been cured in a similar fashion, but there have been many more instances when the protocol failed. Timothy Ray Brown died last year from a second cancer and not from HIV. Research for a practical HIV cure continues at a fast pace and we are hopeful we will find one in the next few years.
The author with Timothy Ray Brown, a.k.a. the Berlin patient, the first person ever cured of HIV.
Historically, up until 2005, the HIV epidemic in the Philippines was characterized as low and slow. Around half of new HIV cases were imported and brought in by OFWs. It was only in 2006 when local transmission rose and rapidly accelerated. Research done by our laboratory at the Philippine National Institutes of Health revealed that a major factor for this increase was the change in the dominant HIV subtype in the Philippines. From subtype B, which is more commonly seen in the US and Europe, our HIV subtype shifted to a recombinant virus more commonly seen in Thailand called CRF01_AE. Subsequent studies at our institute showed that this newer subtype was more likely to have high viral loads at baseline and a faster progression to AIDS. It also was more likely to become drug resistant against multiple antiretroviral agents, including tenofovir, which is one of the most important HIV drugs. Recent work by our laboratory also shows that there is a significant amount of transmitted drug resistance in the Philippines. This means there are people who acquire HIV, which is already resistant to some of the drugs even before they begin treatment.
As a result of highly effective ART, many PLHIV achieve undetectable levels of HIV in their blood. Several studies have found that PLHIV with less than 200 copies per milliliter of blood do not transmit the virus to other people. In other words, undetectable (viral load) equals untransmissible, U=U in activist shorthand. This finding paved the way for PLHIV to have more normal lives, including conceiving children the natural way. It transformed ART from a purely life-saving intervention to a major public health tool for preventing infection. It also allowed doctors and other healthcare workers who were living with HIV to perform major surgery without risk to their patients, provided their viral loads were checked every six months. Another recent development is PrEP, or pre-exposure prophylaxis, which is taking a combination of two antiretroviral drugs to prevent infection with HIV. This is indicated only for high-risk, HIV- negative persons. PrEP has been endorsed by the WHO as an effective method of HIV prevention.
Over the years, HIV has changed from an invariable fatal disease to a manageable and largely preventable one. While there still exists stigma in our society, the situation is much improved compared to 30 years ago. Despite the HIV pandemic still not having been declared officially over, we have learned to live with it after all these years. This experience gives us a lot of hope that as the Covid-19 pandemic comes under control, there too will come a time when we can resume our lives as normally as possible.