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Mississippi Doctors See Child-Size Breakthrough in the Global Fight Against AIDS

March 4, 2013 at 12:00 AM EDT
Researchers announced that for the first time, a child born with HIV has been cured. To learn whether this offers hope to thousands of HIV positive babies worldwide, Ray Suarez talks to Dr. Anthony Fauci of the National Institute of Allergy and Infectious Diseases and Rowena Johnston of amfAR, the Foundation for AIDS Research.
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RAY SUAREZ: Researchers confirmed a two-year-old girl born with HIV has been functionally cured and remains virus-free even after treatment months ago.

It marks the first time HIV has been essentially eradicated in a child, making her just the second person ever said to be cured of HIV. Doctors at a Mississippi hospital say they gave the girl an especially intensive three-drug regimen within 30 hours of birth, before tests confirmed she was infected and wasn’t merely at higher risk from her mother.

The findings were announced at a major AIDS conference in Atlanta and are stirring much discussion about what it could mean for more than 300,000 babies born with HIV each year, mostly in Africa.

We talk to two experts now watching this closely, Dr. Anthony Fauci of the National Institutes of Health, and Rowena Johnston, vice president and director of research at the American Foundation for AIDS Research, amfAR.

Dr. Fauci, few babies are now born HIV-infected in the United States because their mothers are usually already on antiretroviral medicine. But when it does happen, what’s the normal protocol? What usually happens?

DR. ANTHONY FAUCI, National Institute of Allergy and Infectious Diseases: What happens, that if you get good prenatal care, the mother if she’s infected during the pregnancy would be treated just like you would treat any other infected person, both for her own health as well as for the fact that it would dramatically diminish the likelihood that that mother would transmit the virus to their baby during the period of perinatal or during the birth period.

To be extra-specially sure that that doesn’t happen, what you do is you then prophylax, not fully robustly treat, but prophylax the baby with one or usually two drugs, which is not enough for a full treatment, but enough for prevention. And you do that for six weeks. If the baby turns out to not be infected, then you stop that prophylaxis.

If the baby turns out to be infected, then you add the extra drug or two, which will give a triple combination. And that in fact would be the regular treatment for an infected baby. One of the problems is, is that if the baby is infected and you waited six weeks or so — or a few weeks at least to determine definitively if the baby is infected, then the virus could have the opportunity to form what we call reservoirs, and take a full hold into the baby.

And that makes it more difficult to eradicate. What the pediatricians did in this case was something — what was a gutsy call, but the right call. They felt that the baby was at such risk because the mother wasn’t treated that they started right off from the get-go with the triple combination within 30 hours of the baby being infected, i.e., born.

And that seemed to have, what we’re seeing now, essentially cured the baby.

RAY SUAREZ: Rowena Johnston, why was that decision made and how was the effect monitored? When they started this drug regimen right away, what were the special circumstances?

ROWENA JOHNSTON, American Foundation for AIDS Research: Well, this was a mother who came into medical care — well, she presented during labor. And she had not been in medical care.

And a rapid HIV test was administered during labor. And she was determined to be HIV-positive. And the pediatricians recognized that, under those circumstances, because the mother had not been taking prophylaxis, there was really a fairly high risk that she might transmit HIV to her baby. And, as Dr. Fauci mentioned, they decided to take that gutsy decision to administer a full treatment dose of antiretroviral therapy at 30 hours after birth.

I mean, a baby might not normally get a full treatment dosage of antiretroviral therapy until even as several weeks, six weeks after birth. And so what was different in this case is that this regimen was started actually at about 30 or 31 hours after birth. And as Dr. Fauci had also mentioned, what might be critical here is that because that therapy was administered so early, they may have beat the virus to the punch.

And that is, they may have administered the therapy early enough that these viral reservoirs were not able to establish themselves. And what we do know when — those of us who are interested in finding a cure for HIV infection, we know that the major impediment to curing HIV infection is the establishment and the maintenance of those reservoirs.

The fact that we have those reservoirs and the antiretroviral therapy cannot eradicate those reservoirs, that’s really the barrier that stands between us and an HIV cure. And so what these researchers did here, what the hypothesis is, is that perhaps they actually disrupted this process early enough that those reservoirs never had a chance to establish themselves.

RAY SUAREZ: And, Rowena Johnston, to follow up, how was it realized that the baby was essentially HIV-free? And did it take a while before that was understood?

ROWENA JOHNSTON: Well, there were several things that happened in this case.

This child was in regular medical care until roughly 18 months of age and had been taking antiretroviral therapy, as recommended, but at about that 18 months of age point, both the mother and the child disappeared and didn’t visit their doctor. And when they came back into medical care, the mother did confess at that time that the child had not been taking antiretroviral therapy for at least five months.

And so one of the first thing that the pediatrician in charge of the case did was to administer a viral load test, because she of course wanted to determine how much virus outgrowth there had been and how one should most appropriately treat the baby at that point. And she was astonished to find that there was no virus. And so she thought that actually this must be a mistake. And so she readministered that viral load test. Lo and behold, yet again, there was no virus to be detected.

RAY SUAREZ: Dr. Fauci, what can you learn from a case like this that could be applied in those countries where many people are born HIV-infected?

DR. ANTHONY FAUCI: Well, in the countries that you’re talking about, the problem is enormous. Globally, even though we only have about 100 to 200, which is 100 to 200 too many, infections in infants from their mothers in the United States per year, there are about 1,000 infections per day mostly in the developing world, particularly in sub-Saharan Africa, so it’s a huge problem.

What we can learn from this case, Ray, is that the first and most important thing is to try to prevent infection, mainly, get mothers in treatment during pregnancy and then do the same sort of prophylaxis on the infant to prevent infection in the first place. However, that doesn’t always happen at all in the developing world.

And, not infrequently, a mother will present in exactly the same way as this mother presented in Mississippi here in the United States, namely walking into a clinic or an emergency room with no prior therapy. Having this index case now of showing at least the possibility of, with aggressive early therapy, curing an individual, then you might want to ask the question, when you’re in that situation, is the risk-benefit ratio much more favoring towards the benefit of being very aggressive from the very beginning and not waiting that period of time until you have proven that the person, the baby in this case, is infected?

And those are things that are now being discussed. For clinical trials, it could be done under the appropriate conditions and with the appropriate ethical considerations that you might be able to, if you fail to prevent the infection in a situation such as a mother who has not been treated, can you then actually cure the baby if you start the treatment aggressively and early enough?

So, that’s the critical question that now looms that will really be answered by saying, is this more broadly applicable than just an individual case in an unusual situation like we saw here in the United States and Mississippi? We hope the latter is true.

RAY SUAREZ: Anthony Fauci of the NIH, Rowena Johnston of amfAR, thank you both.

DR. ANTHONY FAUCI: Thank you.

ROWENA JOHNSTON: Thank you very much.

GWEN IFILL: On our website, you can find an interview with one of the doctors who conducted the research.