Monday, April 21, 2014
Published in the Baltimore Sun - April 20, 2014
April 23rd is the 30-year anniversary of the day my colleagues and I reported that a new retrovirus, now known as HIV, was the agent causing AIDS. We also announced the development of an effective HIV blood test and the capacity to continuously produce the virus so that drugs could be tested. Since then, basic science has driven a better understanding of how HIV infects humans, resulting in the development of effective antiretroviral therapy (ART). Last summer the National AIDS Treatment Advocacy Project reported that "a 20-year-old HIV-positive individual on ART in the U.S. or Canada is expected to live into their early 70s, a life expectancy approaching that in the general population."
There are still areas where much progress needs to be made, however, particularly in our nation's inner cities, where a large share of the HIV/AIDS burden falls heavily on people of color. According to a 2010 Centers for Disease Control (CDC) report, African Americans comprised 86 percent of newly diagnosed infections in Baltimore City and 78 percent in Washington D.C. Nationally 20 percent of people living with HIV infection are undiagnosed, and 75 percent are either not receiving treatment, are wrongly treated or are not taking their medications, according to the CDC.
Over these last three decades I've frequently been asked if I believe we can eradicate HIV and stop the epidemic. I believe the answer is yes — if the public and private sectors begin to invest more resources in research, treatment and in reaching people at risk.
We are ethically obliged to diagnose and treat HIV/AIDS, but there is also an economic advantage to doing so. Currently the cost of treating a person with HIV over a lifetime is approximately $370,000. One cannot begin to fathom the cost of not treating patients — including numerous visits to the emergency room and long hospital stays.
I believe a "functional" cure for HIV/AIDS is doable. What is a "functional" cure? It is an HIV positive individual who can suppress the virus through drug therapy so completely that HIV becomes nearly unidentifiable for a sustained period of time — hopefully a full lifetime. An HIV-infected person with a "functional" cure will not transmit the virus, nor develop disease and ultimately may not need treatment after a period. With sufficient resources a "functional" cure may be doable within the next five to 10 years.
Our colleague and the U.S. leader in HIV/AIDS, Dr. Anthony Fauci, Director of the National Institutes of Allergies and Infectious Diseases (NIAID), have been a big supporter in funding these research efforts.
Currently, less than a quarter of those with HIV infection nationwide achieve viral suppression. Congressman Elijah Cummings, a Maryland Democrat, has become a significant advocate for a program that achieves virus suppression close to a "functional" cure as 1 out of every 29 African Americans in his district over the age of 13 has AIDS. Effectively and aggressively treating those infected can drastically reduce transmission to others.
I also believe our field can crack the vaccine challenge. We previously overcame what was once thought impossible when we developed effective viral drug therapy for the first time as a result of the AIDS crisis. However, the challenge of the HIV/AIDS preventive vaccine is more complex, but we think solvable. At our Institute of Human Virology in Baltimore, we have a vaccine candidate funded largely by the Bill & Melinda Gates Foundation and, in part, by the National Institutes of Allergies and Infectious Diseases. Similar to the success of the U.S. Army Thai trials in 2009, we are able to produce antibodies for protection in monkeys. But in too brief a time period the requisite antibodies are no longer produced. We need to make these antibodies last longer for protection because we know vaccine boosting every three months or so is not feasible or practical. Thus, we need more science advances as we progress with additional trials.
Past medical history suggests that eradication of HIV/AIDS is possible. After all, we have achieved enormous successes against such viral scourges as polio through public-private partnerships both at the national and international levels. In the middle of the last century, the March of Dimes, for example, forged an effective public-private partnership that led to the Salk vaccine in 1955. And a worldwide campaign led to the complete eradication of smallpox from the planet in 1980. These successes, at the national and international level, provide hopeful precedents for our ongoing work against HIV/AIDS. Admittedly, HIV is a different "beast" and presents far greater challenges in achieving an effective vaccine.
So, as we work toward a "functional" HIV cure and effective vaccine, what should be done in the meantime? Test, test, test and treat, treat, treat. The CDC estimates that more than 1.1 million people in the U.S. are living with HIV infection, and almost 1 in 6 is unaware of their infection. A 2012 Johns Hopkins study reported that the number of new cases of HIV infection among black women in Baltimore, D.C. and other urban "hot spots" is five times higher than previously thought. Over the years I have advocated for the establishment of a domestic program similar to the highly successful President's Emergency Plan for AIDS Relief (PEPFAR) overseas program.
I urge the president and the Congress to fund a PEPFAR-like pilot program in Baltimore and Washington, D.C. — perhaps also including other "hot spots" such as San Francisco and Miami with the goal of ending the epidemic in those cities — and, if successful, to use the lessons for a nationwide effort.
Dr. Robert Gallo, a professor at the University of Maryland School of Medicine, directs the Institute of Human Virology in Baltimore. He is also the scientific director of the Global Virus Network. He led the discovery of HIV, a retrovirus as the cause of AIDS and the development of the HIV blood test as well as the discovery of the first and second known human retroviruses (HTLV-1 and HTLV-2). He can be reached at firstname.lastname@example.org.