Community key against HIV – study

● Second case of remission after bone marrow transplant sparks hope of likely cure

A community-wide HIV-prevention strategy can reduce new infections‚ a new study has found.

Researchers have presented results from the HPTN 071 (PopART) study at the annual Conference on Retroviruses and Opportunistic Infections in Seattle in the US.

The study examined the impact of a package of HIV-prevention interventions on community-level HIV incidence in urban and peri-urban communities in SA and Zambia.

Findings show that delivery of an HIV-prevention strategy which includes offering inhome HIV testing to everyone‚ with immediate referral to HIV care‚ and treatment for people living with HIV based on prevailing in-country guidelines‚ can substantially reduce new HIV infections.

“We saw a significant 30% decrease in new HIV infections with a prevention strategy where HIV treatment was started according to in-country guidelines‚” HPTN 071 protocol chair and London School of Hygiene and Tropical Medicine professor Richard Hayes said.

“We did not see a similar reduction in new HIV infections with another strategy where universal HIV treatment was offered from the start of the study.

“Additional analyses are under way to explore the reasons for this finding.”

The HPTN 071 (PopART) study involved more than a million people living in 21 communities in Zambia and SA‚ making it the largest HIVprevention trial to date.

The study measured the effects of two HIV-combination prevention strategies offering HIV testing to people in their homes annually‚ with linkage to HIV care and treatment at their local health facility for those living with HIV.

“Overall‚ both strategies improved knowledge of HIV status and uptake of treatment‚” HPTN co-principal investigator and Columbia University, New York, epidemiology and medicine professor Wafaa ElSadr said.

“These findings show that a combination prevention strategy similar to PopART may be an effective tool to slow the global HIV epidemic.”

HPTN 071 (PopART) researchers are examining the effects of the interventions on other study outcomes, including herpes simplex virus-2 incidence‚ tuberculosis and HIVrelated stigma.

Work is also in progress to estimate the cost-effectiveness of the interventions.

The research team in SA was led by Nulda Beyers and Peter Bock‚ research clinicians at the Desmond Tutu TB Centre in the department of paediatrics and child health at Stellenbosch University.

In both SA and Zambia‚ hundreds of community HIV care providers went house to house in 14 intervention communities over four years‚ with repeated offers of HIV counselling and testing.

The centre also worked closely with the Western Cape department of health and the City of Cape Town health department in linking HIV-positive study participants to antiretroviral treatment at clinics.

“Results from the study strongly support the ongoing expansion of the communitybased platforms for health service delivery,” Bock said.

The City of Cape Town welcomed the results.

Matoral committee member Zahid Badroodien said: “Not only did we learn what capacity there exists within health facilities to increase the number of HIV tests conducted‚ but it [the study] also shed light on the difficulties clients face between diagnosis and accessing care.

“Most important were the lessons learnt around regular door-to-door HIV testing . . . and how it could be in ensuring that more people know their status.”

A second person was in sustained remission from HIV-1, the virus that caused Aids, after ceasing treatment and was likely cured, researchers said on Tuesday in what was hailed as proof that the condition could one day be cured.

Ten years after the first confirmed case of an HIV-infected person being rid of the deadly disease, a man known only as the “London patient” had shown no sign of the virus for almost 19 months, doctors reported in the journal Nature.

Both had received bone marrow transplants to treat blood cancers, receiving stem cells from donors with a genetic mutation present in less than 1% of Europeans that prevents HIV from taking hold.

“It is a landmark. After 10 years of not being able to replicate [the first case], people were wondering if this was a fluke,” lead author and University of Cambridge professor Ravindra Gupta said.

“I think it is important to reaffirm that this is real and it can be done.”

Millions of people infected with HIV around the globe keep the disease in check with antiretroviral therapy, but the treatment does not rid patients of the virus.

Almost one million people die every year from HIV-related causes.

A new drug-resistant form of HIV is a growing concern.

Gupta and his team emphasised that bone marrow transplant was not a viable option for HIV treatment.

But a second instance of remission and likely cure following such a transplant will help scientists narrow the range of treatment strategies.

“The second case strengthens the idea that a cure is feasible,” Peter Doherty Institute for Infection and Immunity director Sharon Lewin said.

“We can try to tease out which part of the transplant might have made a difference here and allowed this man to stop his anti-viral drugs.”

The International Aids Society said in a statement on Tuesday that results from the second patient “reaffirm our belief that there exists a proof of concept that HIV is curable”.

Towards an HIV Cure initiative co-chair Mark Dybul said the London case was “as important as it is exciting”.

Both patients received stem cell transplants from donors carrying a genetic mutation that prevents expression of an HIV receptor, known as CCR5.

The study describes an anonymous male patient in Britain who was diagnosed with HIV infection in 2003 and had been on antiretroviral therapy since 2012.

Later that year, he was diagnosed with advanced Hodgkin’s lymphoma.

He underwent a so-called haematopoietic stem cell transplant in 2016 from a donor with two copies of a CCR5 gene variant, which is resistant to most HIV-1 virus strains.

“CCR5 is something essential for the virus to complete its life cycle and we can’t knock out many other things without causing harm to the patient,” Gupta said.

“We know CCR5 can be knocked out without any serious consequences because people are walking around without that gene.”

CCR5 was the target in the genome of the controversial gene-edited twins born in 2018 in China, whose father is HIVpositive.

After the bone marrow transplant, the London patient remained on antiretroviral therapy for 16 months.

Regular testing has confirmed the patient’s viral load remained undetectable.

The first sustained remission survivor known as the “Berlin patient”, Timothy Brown, was given two transplants and underwent total body irradiation to treat leukaemia, while the British patient received just one transplant and less intensive chemotherapy.

“I did not want to be the only person in the world cured of HIV,” Brown wrote in a medical journal in 2015, explaining why he decided to reveal his identity.

Gupta said he hoped to expand research on the stem cell transplant technique to focus on communities in Africa, where the HIV-beating mutation does not naturally occur.

“Expanding remission to populations that are affected disproportionately is quite important,” he said.