Obstacles to achieving durable HIV remission in lower- and middle-income countries affects these nations’ ability to carry out needed research.
Although powerful antiretroviral drugs have had a profound effect on HIV-positive individuals’ overall health and longevity, there remain obstacles to research on remission and eradication, particularly in low- and middle-income countries (LMIC). In order for this research to be conducted, a significant population that has been able to achieve durable viral suppression needs to exist. As a result, most of this research has been carried out in higher-income nations where greater numbers of people with HIV receive treatment.
A new article in the Journal of the International AIDS Society, penned by infectious-disease specialists from the National Institute of Allergy and Infectious Diseases (NIAID), the Institute for Global Health and Infectious Diseases at the University of North Carolina at Chapel Hill, and other institutions around the world, reveals the results of their recent review on remission and eradication research. The team searched several databases to find literature that discussed differences between LMIC and wealthier countries that might explain variations in the size of each country’s latent HIV reservoir, or the total number of immune cells infected with HIV that are currently dormant but can replicate and that have the potential to become activated. This latent HIV reservoir is considered to be the biggest barrier to remission and, ultimately, a cure for the disease.
Worldwide, at least 36 million people live with HIV; most of those are in LMIC. Across nations, however, the profiles of typical HIV patients can look very different—and this may translate into differences in treatment regimens and how patients respond to them. In wealthier countries such as the United States, the HIV epidemic is fueled by men who have sex with men. In developing nations, women and children are disproportionately infected. In fact, women account for more than half of all people with HIV worldwide, with 1.8 million children also infected.
Besides age and gender, the viral subtype of HIV may make a difference in whether infected people can achieve sustained remission, as may chronic co-infections (bacterial, viral, and parasitic), sexually transmitted diseases, and nutrition. Individuals who have existing co-infections are likely to have higher levels of immune-system activation and inflammation, which may hinder the ability of antiretroviral drugs to work their magic. And in many communities in LMIC, the virus is continually replicating and the viral load is high because a substantial portion of people who have HIV are unaware of this fact and never go for treatment, or go for testing and treatment at a late stage in the disease.
This last point is worth emphasizing. “Getting on [antiretroviral] therapy and staying on therapy is the single best thing any person living with HIV can do to protect their health,” Carl Dieffenbach, PhD, the director of the Division of AIDS at NIAID, told Contagion®. “We have these wonderful drugs. They are truly life changing. But drugs don’t take themselves.”
Although higher-income countries such as ours do have a substantial portion of HIV-infected people already in treatment, Dr. Dieffenbach would like to see those numbers rise. Even in the United States, there exist pockets in which HIV runs rampant, such as in communities of color and particularly among gay and bisexual black men. Dr. Dieffenbach attributes this largely to the stigma many men in these marginalized groups feel, which results in them not getting tested and, if positive, not remaining on antiretroviral drugs. In fact, emerging literature reveals that in Uganda, the latent HIV reservoir is about one-third the size of the one in Baltimore—evidence that barriers to research on remission and eradication exist in more places than just LMIC. “I think they’re global barriers,” he said, referring to the potential obstacles any community anywhere in the world may face when it comes to conquering HIV.
Laurie Saloman, MS, is a health writer with more than 20 years of experience working for both consumer and physician-focused publications. She is a graduate of Brandeis University and the Medill School of Journalism at Northwestern University. She lives in New Jersey with her family.