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Tuesday, October 29, 2013

Ongoing remission in a child born with HIV

Two and a half years ago, a child was born with an HIV infection that he got from his mother. While tragic, this part of the story is hardly surprising. Over 250,000 babies are born with HIV each year. However, this particular infant’s story takes a turn toward the amazing. He may be the second person ever to have been cured of AIDS.

At 30 hours old, the baby tested positive for HIV and was put on an aggressive anti-retroviral treatment (ART) regimen. His HIV titers steadily decreased until they were undetectable at 29 days, which is a typical pattern for infected individuals undergoing ART. However, when people discontinue their treatment, their HIV levels rapidly rebound. Not so with this little guy.

Based on pharmacy refill records, clinic visits and the mother’s report, the child had had no ART since the age of 18 month, and possibly none since 15 months. Yet, at least 18 months after the cessation of all treatment, the child still shows no signs of HIV infection. 

The fact that this child’s HIV infection did not return suggests that the ART eliminated the reservoirs of dormant virus that usually persist despite all treatments.

To be clear, doctors prefer to use the word ‘remission’ rather than cure when talking about HIV. Like with cancer, it’s possible that the disease will return at some point. So far, for this child, remission looks as good as a cure.

The authors ruled out laboratory error as an alternate reason for the disappearance of HIV positive status since the child had had five positive tests and responded to ART in a typical fashion.  For similar reasons, they discount the possibility that the HIV in the child’s bloodstream had been due not to an active infection but to maternal blood circulating through the infant. 

The child also does not have any of the markers seen in the tiny subset of patients whose immune systems can naturally control HIV. The one other case of HIV remission, known as the ‘Berlin Patient’, became HIV-negative after receiving a bone marrow transplant from one of these 'super HIV suppressors'.

Lead author Deborah Persaud of Johns Hopkins explains:
Our findings suggest that this child's remission is not a mere fluke but the likely result of aggressive and very early therapy that may have prevented the virus from taking a hold in the child's immune cells.
Early next year, a trial will commence testing this ART protocol in HIV-infected newborns. 

Deborah Persaud, Hannah Gay, Carrie Ziemniak, Ya Hui Chen, Michael Piatak, Tae-Wook Chun, Matthew Strain, Douglas Richman, & Katherine Luzuriaga (2013). Absence of Detectable HIV-1 Viremia after Treatment Cessation in an Infant The New England Journal of Medicine DOI: 10.1056/NEJMoa1302976.

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