Q&A: Putting the ‘London patient’ in perspective

Saira Butt, MD
Saira Butt

After researchers announced that a man in London became the second person to be potentially cured of HIV via a stem cell transplant, experts cautioned that the treatment is costly, risky and not suitable for most patients.

The “London patient” underwent an allogeneic hematopoietic stem cell transplantation for Hodgkin’s lymphoma. Similar to the “Berlin patient,” he was treated with cells from a patient containing a genetic mutation that resists HIV, in addition to receiving chemotherapy.

To put the case into perspective, Infectious Disease News spoke with Saira Butt, MD, assistant professor of clinical medicine and program director of the infectious diseases fellowship at Indiana University School of Medicine, about the important takeaways from the report, how to speak with patients about it and what a true HIV cure would look like. by Marley Ghizzone

What should clinicians take away from this case report?

The second patient (London patient) cured of HIV is a scientific leap and has future research implications for HIV researchers. The two cured patients had HIV and cancer for which stem cell transplant was indicated. The Berlin patient had acute myelogenous leukemia, and the London patient had Hodgkin’s lymphoma. They were infected with CCR5 tropic virus and received a homologous stem cell transplant (HSCT) from a donor with CCR5 delta-32 mutation. The Berlin patient has undergone HSCT twice and had also received total body radiation. Both patients underwent T-cell depletion regimens. They both had complications including graft vs. host disease. These are risky procedures with serious complications. We do not plan to transplant stem cells in all HIV patients. This case report is not newsworthy for common people living with HIV (PLWH) because there is not going to be a widespread cure for HIV in their lifetime. There are multiple researchers working on HIV latency-reversing agents, but the answer is not near. Clinicians need to be diligent in educating their patients with HIV about excellent HIV medications that are already available. We have made great progress in ART. We have multiple combinations of ART available in pill form. Most patients have to take only one or two pills daily to keep their virus suppressed or undetectable.

Everyone gets excited by word “cure.” How about we get excited about ART and pre-exposure prophylaxis (PrEP), which are already available? However, the sad part is we are not using what we have. Only half of PLWH in the United States are on ART. While we are trying to reach for the stars, we are not smelling the roses within reach. We need to turn our focus to using excellent ART and make it available to all in need, especially minorities and the rural population. Our goal is to teach 100% adherence to those on ART, getting everyone tested for HIV regardless of their risk factors, testing for sexually transmitted infections (STIs), placing people on ART and PrEP and linking people to care and continuum of care. If we put the entire at-risk population on PrEP and all HIV patients on ART, we can end the HIV epidemic pretty quickly.

What will you tell your own patients about it if they ask?

Both of these patients had blood cancers for which a stem cell transplant was indicated. Both of these patients had a prolonged hospital stay and suffered complications. Stem cell transplant is not the indicated treatment for PLWH without certain cancers. A cure for the general population with HIV is not coming anytime soon, but that is OK because we already have excellent ART. Not too long ago in early 1990s, patients were dying of AIDS. We have come a long way, and now we can suppress the HIV virus with one pill. There is no cure for high blood pressure or diabetes, but we do not see media looking for cure for these conditions. HIV has become a chronic condition just like high blood pressure and diabetes. Patients have to take their medications daily to stay healthy. You can live a long and healthy life if you stay on ART. This is a huge accomplishment for patients with HIV. Also, if you are on ART and your HIV viral load is undetectable, you cannot transmit HIV to another person (Undetectable=Untransmissable; U=U). I want physicians to, 1) advocate to their peers about HIV/STI testing; 2) get patients on PreP if they are HIV negative; 3) get patients on ART if they are HIV positive; and 4) ensure patients stay on ARV and stay in care.

What is on the horizon for HIV treatment that you are excited about?

Multiple new antiretrovirals will be available in near future. Long-acting monthly injections of cabotegravir and rilpivirine can keep virus suppressed, similar to daily pills. In these studies, PLWH were already virally suppressed on pills and then switched to long-acting injections. Other novel antiretrovirals in the pipeline are HIV capsid inhibitors, broadly neutralizing antibodies, maturation inhibitors and monoclonal antibodies. Besides oral once-daily pills like Truvada and now Descovy, multiple PrEP formulations are in the pipeline, including the on-demand dapivirine vaginal ring, long-acting injectables and neutralizing antibodies.

What will a true HIV cure look like?

A true HIV cure requires not only controlling the active virus replication but also controlling HIV latency. Many scientists are working on HIV latency-reversing agents. An HIV cure could include a vaccination protocol given earlier in life, which prevents future HIV transmission. It can also include pre- and post-exposure prophylaxis with long-acting injectables given to high-risk populations.

Is there something in the field of HIV care that you wish got as much attention as the London patient case?

We need to highlight that HIV is a chronic disease and that we have excellent medications to keep the virus suppressed. People with HIV can have normal life expectancy with great health. A person with HIV on medications with an undetectable viral load cannot transmit the virus to another person (U=U). We need to make PrEP common knowledge.

Reference:

Gupta RK, et al. Abstract 29LB. Presented at: Conference on Retroviruses and Opportunistic Infections; March 4-7, 2019; Seattle.

Gupta RK, et al. Nature. 2019;doi:10.1038/s41586-019-1027-4.

Disclosure: Butt reports no relevant financial disclosures.

Saira Butt, MD
Saira Butt

After researchers announced that a man in London became the second person to be potentially cured of HIV via a stem cell transplant, experts cautioned that the treatment is costly, risky and not suitable for most patients.

The “London patient” underwent an allogeneic hematopoietic stem cell transplantation for Hodgkin’s lymphoma. Similar to the “Berlin patient,” he was treated with cells from a patient containing a genetic mutation that resists HIV, in addition to receiving chemotherapy.

To put the case into perspective, Infectious Disease News spoke with Saira Butt, MD, assistant professor of clinical medicine and program director of the infectious diseases fellowship at Indiana University School of Medicine, about the important takeaways from the report, how to speak with patients about it and what a true HIV cure would look like. by Marley Ghizzone

What should clinicians take away from this case report?

The second patient (London patient) cured of HIV is a scientific leap and has future research implications for HIV researchers. The two cured patients had HIV and cancer for which stem cell transplant was indicated. The Berlin patient had acute myelogenous leukemia, and the London patient had Hodgkin’s lymphoma. They were infected with CCR5 tropic virus and received a homologous stem cell transplant (HSCT) from a donor with CCR5 delta-32 mutation. The Berlin patient has undergone HSCT twice and had also received total body radiation. Both patients underwent T-cell depletion regimens. They both had complications including graft vs. host disease. These are risky procedures with serious complications. We do not plan to transplant stem cells in all HIV patients. This case report is not newsworthy for common people living with HIV (PLWH) because there is not going to be a widespread cure for HIV in their lifetime. There are multiple researchers working on HIV latency-reversing agents, but the answer is not near. Clinicians need to be diligent in educating their patients with HIV about excellent HIV medications that are already available. We have made great progress in ART. We have multiple combinations of ART available in pill form. Most patients have to take only one or two pills daily to keep their virus suppressed or undetectable.

Everyone gets excited by word “cure.” How about we get excited about ART and pre-exposure prophylaxis (PrEP), which are already available? However, the sad part is we are not using what we have. Only half of PLWH in the United States are on ART. While we are trying to reach for the stars, we are not smelling the roses within reach. We need to turn our focus to using excellent ART and make it available to all in need, especially minorities and the rural population. Our goal is to teach 100% adherence to those on ART, getting everyone tested for HIV regardless of their risk factors, testing for sexually transmitted infections (STIs), placing people on ART and PrEP and linking people to care and continuum of care. If we put the entire at-risk population on PrEP and all HIV patients on ART, we can end the HIV epidemic pretty quickly.

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What will you tell your own patients about it if they ask?

Both of these patients had blood cancers for which a stem cell transplant was indicated. Both of these patients had a prolonged hospital stay and suffered complications. Stem cell transplant is not the indicated treatment for PLWH without certain cancers. A cure for the general population with HIV is not coming anytime soon, but that is OK because we already have excellent ART. Not too long ago in early 1990s, patients were dying of AIDS. We have come a long way, and now we can suppress the HIV virus with one pill. There is no cure for high blood pressure or diabetes, but we do not see media looking for cure for these conditions. HIV has become a chronic condition just like high blood pressure and diabetes. Patients have to take their medications daily to stay healthy. You can live a long and healthy life if you stay on ART. This is a huge accomplishment for patients with HIV. Also, if you are on ART and your HIV viral load is undetectable, you cannot transmit HIV to another person (Undetectable=Untransmissable; U=U). I want physicians to, 1) advocate to their peers about HIV/STI testing; 2) get patients on PreP if they are HIV negative; 3) get patients on ART if they are HIV positive; and 4) ensure patients stay on ARV and stay in care.

What is on the horizon for HIV treatment that you are excited about?

Multiple new antiretrovirals will be available in near future. Long-acting monthly injections of cabotegravir and rilpivirine can keep virus suppressed, similar to daily pills. In these studies, PLWH were already virally suppressed on pills and then switched to long-acting injections. Other novel antiretrovirals in the pipeline are HIV capsid inhibitors, broadly neutralizing antibodies, maturation inhibitors and monoclonal antibodies. Besides oral once-daily pills like Truvada and now Descovy, multiple PrEP formulations are in the pipeline, including the on-demand dapivirine vaginal ring, long-acting injectables and neutralizing antibodies.

What will a true HIV cure look like?

A true HIV cure requires not only controlling the active virus replication but also controlling HIV latency. Many scientists are working on HIV latency-reversing agents. An HIV cure could include a vaccination protocol given earlier in life, which prevents future HIV transmission. It can also include pre- and post-exposure prophylaxis with long-acting injectables given to high-risk populations.

PAGE BREAK

Is there something in the field of HIV care that you wish got as much attention as the London patient case?

We need to highlight that HIV is a chronic disease and that we have excellent medications to keep the virus suppressed. People with HIV can have normal life expectancy with great health. A person with HIV on medications with an undetectable viral load cannot transmit the virus to another person (U=U). We need to make PrEP common knowledge.

Reference:

Gupta RK, et al. Abstract 29LB. Presented at: Conference on Retroviruses and Opportunistic Infections; March 4-7, 2019; Seattle.

Gupta RK, et al. Nature. 2019;doi:10.1038/s41586-019-1027-4.

Disclosure: Butt reports no relevant financial disclosures.