Talk of a ‘cure’ for pediatric HIV is still very premature
Many people have probably heard that a second baby was “cured” of HIV this month. Although this is an interesting case to examine, news reports have failed to address a related issue. Namely, why wasn’t the mother treated prior to childbirth?
This most recent case of a California baby follows the announcement of a similar case from Mississippi last March.
In both circumstances, the mothers were HIV-positive, but didn’t receive any treatment while pregnant.
What should have happened is that these women should have received regular prenatal care, including a test for HIV. If they had been found to be HIV-positive, they should have been started on anti-retroviral therapy throughout the pregnancy.
Cesarean delivery should have been considered if the mother had not achieved adequate viral suppression. And after the baby was born, the infant should have been given six weeks of HIV prophylaxis treatment, and bottle-feeding should have been preferred over breastfeeding. All this would have reduced the rate of HIV transmission from mother to fetus from around 30 per cent down to one to two per cent.
But that didn’t happen. In both cases, the babies were born without the benefit of getting HIV medications while they were still in the womb.
In the first case, the mother seems to have completely fallen through the cracks of the health-care system and didn’t receive any prenatal care whatsoever. The other mother was apparently known for HIV, but wasn’t taking her medication. We can’t be sure why these women didn’t get proper care while pregnant without knowing all the facts. The high cost of health care in the U.S., the general lack of insurability for many Americans, and the wide disparities that exist in the health-care system may all have played a role, but it is impossible to say for certain.
What is certain is that in- fant HIV infection is largely preventable with appropriate pre-natal care. Thankfully, issues like cost and insurability are not issues that we have to deal with here in Canada.
That being said, these two cases are indeed interesting, although neither is exactly a “cure.” In the first case, the mother and baby were lost to follow-up and treatment was interrupted. When the child was seen again at age 2, HIV tests were negative. However, some low levels of non-functional virus were still detectable in the blood. So the child wasn’t “completely” cured — but seems to be “functionally” cured, meaning that the remaining virus doesn’t seem capable of causing clinical infection.
The second child is in a similar situation but is still on HIV therapy, so the label of a “cure” can’t be applied unless the therapy is stopped and the tests remain negative. That, of course, would be a profoundly bad idea, and while it might be interesting from a scientific point of view, it would not be in the best interests of the patient.
What is fundamentally different about these cases is that physicians here used a triple therapy of HIV medications rather than the usual protocol, which is six weeks of prophylactic single therapy followed by triple therapy only if infection is confirmed after the six weeks.
Why not start the triple therapy immediately?
The side effects of the medications are the main limitation.
Also, it’s not clear that ear- ly triple therapy will actually work. Two isolated cases is hardly definitive proof. A Canadian study is investigating this treatment strategy to see if it is effective. The results, when they are published, will be interesting. But until then, talk of a cure is very premature.
Also, while these cases may change how we treat infant HIV, it won’t have any impact on adult HIV for which early triple therapy is already the norm.
Also, it’s all well and good to talk about cures, but the point would be moot if we really got serious about prevention. And pediatric HIV can be prevented.