Baby with HIV “cured” – what does this mean for Africa?

Are we a step closer to finding a cure? In 2008, the first person Timothy Ray Brown known as “The Berlin Patient” was the first person reportedly “cured” of HIV. Six years on since having a series of complex medical procedures which included chemotherapy and a bone marrow transplant, he has no detectable levels of HIV.  Last week  the media was in a frenzy over a second possibly cured patient – this time a two year old child, dubbed the Mississippi baby.  The infant, now two and half years old needs no antiretroviral drugs.

The baby tested positive for the virus at birth. She became infected because the mother was not tested in early pregnancy and was not given antiretroviral treatment to prevent mother to child transmission (PMTCT).

By the time the doctors realised that the mother had HIV, it was too late for the normal PMTCT protocol so instead as soon as the baby was born, 30 hours after birth, she was given the full three antiretroviral drug combination as opposed to the single dose ARV drug normally given to babies. The baby continued treatment for 18 months then the baby and mother disappeared – which is referred as “lost to follow up”. However when the infant returned six months later, even though she had not been on treatment for six months,  when tested the infant was found to have an undetectable viral load.

Scientists refer to this as a “functional cure”- when people test negative for the virus but some of the virus has remained but is inactive. Normally babies treated with this drug complement stay on treatment but this mother never came back for more treatment so this unexpected event of the baby not continuing treatment is how the scientists derived their “functional cure”.

According to UNAIDS, there were 330 000 children newly infected with HIV in 2011.Every child born free of HIV a UNAIDS initiative reports only a third of infants in need of antiretroviral prophylaxis receive it.

Is this the big one? Do scientists have the cure? Unfortunately it is not as simple as that. What this “functional cure” does provide is exciting new areas for research. This one HIV-free baby may also be an exception to the rule. It is possible that this baby, for reasons unknown, may be different to other babies. More rigorous research is required before scientists can determine whether newborn babies can be treated in this way.  Furthermore this potential treatment may not work when HIV is discovered later, such as with adults.

What does this mean for Africa? Unfortunately with most new and improved treatments, developing countries are always the last ones to benefit. Odd, when they are places most in need. But do we really need a cure for babies with HIV if they are already effective methods of preventing transmission from mothers to children?

Dr. Mary Guinan writes in CNN

But there was another great advance against the HIV virus that did not make big headlines. A simple treatment with anti-retroviral drugs can prevent babies from being infected by their HIV positive mothers in the first place. Of course, a patient cure is much more visible than an infection prevented. Maybe that is why we celebrate cure in a way that we do not celebrate prevention”

But she also ends well by saying

…..let us celebrate each success. Each one gives hope that we will eventually conquer one of the most formidable of viruses.

 

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The most popular question about HIV

One of my other passions is writing an HIV and AIDS column in the Malawi Nation Newspaper. Readers are welcome to, in fact they are strongly encouraged to, email me their weird and wonderful questions and encouraging or scathing comments.

I  dug into my email archives to find out what is the most popular question people asked….If you guessed “Can vitamin supplements help fight HIV?” – guess again. If you guessed “How long can I live with HIV?” not that one either…the question I got asked most often…would you believe is…drum roll please….is about cuts and open sores. Here are some of the questions that readers have asked:

“If don’t have any cuts on my penis – I checked very carefully but I slept with a girl who might have HIV, am I safe?”

“ So if a chick alibe ma (does not have) sores and I don’t have any, is there any way for HIV to infect me?”

“If I masturbate someone else can I get HIV? Should I be wearing gloves?”

Note the question usually comes from guys.

And here ladies and gentlemen is the response:

People are often misled by the notion that during sexual intercourse the only way to become infected is through the open cuts and sores. This is only partly true.

HIV is spread during vaginal sex when HIV-infected semen, vaginal fluid, or menstrual blood comes into contact with the mucous membranes of the vagina or penis.

The Department of Health New York, US sums it best

In general, since there is more mucous membrane area in the vagina, and a greater possibility of small cuts in the vagina, women are more likely than men to get infected with HIV through unprotected vaginal sex. Teenagers and women entering menopause are at especially high risk for getting HIV (and other sexually transmitted diseases) because the tissue lining of the vagina is more fragile at these ages. Cuts or sores on the penis or vagina raise the risk of HIV infection during vaginal sex for both men and women. The presence of sexually transmitted infections also increase the risk of HIV transmission.

Cuts present on or in genitals can be invisible to the naked eye. HIV can NOT cross healthy unbroken skin but it can enter through an open cut or sore, or through contact with the mucous membranes. Transmission risk is very high when HIV comes in contact with the more porous mucous membranes in the genitals (vagina and penis), the anus (the bum), and the rectum which are inefficient barriers to HIV. Transmission is also possible through oral sex because body fluids can enter the bloodstream through cuts in the mouth. Likewise transmission is possible during masturbation or “fingering” if cuts are present.

Nobody has magnifying glasses for eyes so you wouldn’t be able to see the smallest of cuts, you are much much much better off using a condom to reduce the risk of getting HIV during vaginal sex.

Alcohol increases desire for unprotected sex

Adapted from Lifting the Lid on AIDS, published in The Nation Newspaper, Malawi, 31st December 2011.

An analysis of a number of scientific studies have proved that alcohol increases the desire to have sex without a condom.  The review was published in the journal Addiction, the investigators in the study conclude that “The higher the blood alcohol content, the more pronounced the intention to engage in unsafe sex.”

It is well known that consuming alcohol reduces inhibitions, which leads to risk-taking behaviour, affects cognitive capacity, and has an impact on immune function but what has remained unclear is the link between alcohol and the transmission of HIV.

The investigators in this study examined the relationship between blood alcohol levels and self-reported intention to use a condom or engage in unprotected sex. They were able to analyse results from 12 studies conducted in the US that fit their research criteria.  They found that an increase in blood alcohol content of 0.1mg/ml was associated with a 3% increase in the likelihood of having unsafe sex.

Blood alcohol content depends on the strength of the drinks e.g. whisky is stronger than beer, your weight, whether you ate any food, how fast you drank, and how fast your body can metabolise alcohol….that means unfortunately I cant give you a fixed equation but on average if you weigh about 80kg, drinking 3 beers in an hour could increase your blood alcohol content to 0.1mg/ml.

There are several limitations to this study but one major concern is that it is only looking at people’s intentions to engage in unprotected sex and not actual condom use. It should also be considered that people who drink more alcohol and have unsafe sex may have higher risk personality traits than others. This means that they may have personality characteristics that put them at higher risk of both activities, rather than that the alcohol caused them to have risky unprotected sex when they normally wouldn’t do so.

JustMilk, the nipple shield for preventing mother to child transmission of HIV

(adapted from  article in the Weekend Nation, Malawi – Lifting the Lid on HIV and AIDS 2nd April 2011)

Modifying technology might be the solution to curbing the spread of HIV and AIDS.  JustMilk nipple shield is a low cost, modified nipple shield that releases antiviral compounds to reduce HIV transmission from mother to baby during breastfeeding.

The JustMilk nipple shield is the work of scientists at the University of Cambridge with collaborators from the United States. A nipple shield is a nipple shaped flexible plastic covering worn over the nipple during breastfeeding. Nipple shields are used in various situations: to help young babies who have problems latching onto the breast, for women with irregular nipples that point inside the breast, for mothers with cracked nipples or for babies who are used to the plastic bottle teat.

Research shows that approximately 200,0000 babies contract HIV from breastfeeding each year in sub-Saharan Africa. HIV positive mothers often have no alternative than to breast feed as formula feeding can be very risky. Formula feeding in low resource settings is either not provided adequately or regularly resulting in malnutrition in the baby and is often made with unsafe drinking water which causes diarrhoea.

Image courtesy of JustMilk (http://justmilk.org/)

The nipple shield is meant to be a low cost option for HIV-positive mothers. Think of the nipple shield as a breast milk filter. Inside the filter are antiviral agents that reduce the likelihood of HIV transmission by either reducing the amount of virus in the milk or providing partial protection within the infant against infection. The study is also investigating the delivery of medications and nutritional supplements through the modified nipple shield.

Their approach involves modifying an existing commercial nipple shield by adding replaceable inserts (e.g. cotton-wool) that contain antiviral agents that inactivate the HIV without harming the baby. This allows the mother to directly feed the baby rather than having to collect and heat the milk (currently the only established method of treating HIV infected breast milk), which can result in social stigma. Anti-HIV agents have been identified that do not have a detrimental impact on the nutritional content of milk, and initial research and laboratory tests performed by the team indicate this idea may be feasible.