March 9th, 2013

There’s now a second case of a probable true HIV cure:

Dr. Persaud [of Johns Hopkins] detailed the case of a two-year-old child in Mississippi diagnosed with HIV at birth and immediately put on antiretroviral therapy. At 18 months, the child ceased taking antiretrovirals and was lost to follow-up. When brought back into care at 23 months, despite being off treatment for five months, the child was found to have an undetectable viral load. A battery of subsequent highly sensitive tests confirmed the absence of HIV.

The physician responsible for the care was in fact Dr Hannah Gay, a paediatric HIV specialist at the University of Mississippi Medical Center. She wisely brought in the rated researchers to do the write-up, unselfishly trading a share of fame for effectiveness.

I wrote in 2009 about the first cure in Berlin: an American man, since named as Timothy Brown, with both HIV and leukaemia, was cured of both by a bone marrow transplant from a donor with genetic resistance to HIV.

Medical experts are making the usual precautionary noises about a single case needing confirmation, but it looks like a breakthrough. Maybe the baby just had an unusually strong immune system and would have cured itself anyway, but that’s not the Bayesian way to bet. Would it be ethical now to have a blind trial on HIV-positive newborns?

The good news for one child comes with two bonuses for the rest of us.

First, it’s a reminder of Lewis Thomas’ insight from 1967 (citation in the 2009 post) that treatments are expensive but cures are cheap. The marginal cost of the Berlin HIV cure was effectively €0 as they would have done the bone marrow transplant anyway. The Mississippi baby was more expensive: 15 months of the triple-drug cocktail costs around $15,000 for an adult – I guess a quarter for a baby. You have to set that against a much longer lifetime regimen, and drug prices are much less outside the USA. We also don’t know if the full 15 months was actually necessary for the knockout.

Billions have been spent on medical research since the sixties in pursuit of cures, and mostly what we have to show for it is treatments. Bruised by failure, it’s tempting for us to settle for second best, and cheaper if possible. The two HIV cures may be isolated, but they tell us not to give up hope. Victories over cancer, malaria, Alzheimer’s and HIV, not just tactical gains, are still the goal.

Second, the two cases gratifyingly show that ordinary front-line clinicians, treating single patients with discernment informed by science and carefully observing the results, can still make important discoveries. Doctors Gero Hütter and Hannah Gay are hands-on innovators in the great line of Edward Jenner, Louis Pasteur, Sigmund Freud, Isaac Luria and Oliver Sacks.

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