More than 1,000 new HIV cases were reported in Ohio in 2017, but experts are optimistic that a cure will be discovered.
AIDS has neither disappeared nor been cured. The headline-grabbing health care crisis of the early 1980s that started with hundreds of unexplained deaths resulting from abnormal cancers or pneumonia stumped physicians for months before a diagnosis was found.
Over the last three decades, various treatments have been discovered and put to use. Still, the disease continues to grow. Today, one in seven people who have HIV, the precursor to a diagnosis of AIDS —or acquired immune deficiency syndrome—do not even know they have it.
Or that they may pass it along.
In 2017, Ohio reported 1,019 new cases of HIV infection, with 81 percent of them men and 45 percent of them African-American, according to the Ohio Department of Health. Over half of the new patients were between the ages of 20 and 34 years. Twenty-three percent of the infected people in Ohio lived in Franklin County.
Even though research has progressed to the point that doctors can control the disease with a powerful cocktail of drugs that work together and are administered in a one-pill-per-day regimen, with minimal side effects, physicians still have concerns.
“We consider it to be a chronic illness, much like living with diabetes,” says Dr. Carlos Malvestutto, an infectious disease specialist at the Ohio State University Wexner Medical Center. “We can manage it, but there is no cure.”
Dr. Susan Koletar, who is also an infectious disease specialist at OSU’s Wexner Medical Center and works with Malvestutto, says treatment and research have changed the game in positive ways, but people still must be aware of the danger and take action if they suspect they have been exposed to the virus. Even though the numbers of local cases have remained steady, the demographics of those who are diagnosed have changed.
“In 1986 clinical trials, up to 96 percent were men having sex with other men,” she says. “Now it has shifted primarily to about 85 percent of young men having sex with other young men, 18- to 24-year-olds, clearly with a predominance of racial minorities.”
Anyone who is sexually active—homosexual or otherwise—is at risk because sexual contact is the main mode of transmission, Malvestutto says.
Besides sex, the spread of HIV comes through shared contaminated needles or syringes, infected blood or blood products, and from infected women giving birth or breastfeeding. “An important population is IV drug users, and in some other countries, that is actually the main population,” Malvestutto says.
Confronting complacency, especially among younger people, is a battle doctors must continually wage. “The younger generation has never met anybody who has died of AIDS, but for older generations, many of them lost their loved ones and friends,” Malvestutto says. “Some younger patients think HIV is not a big deal.”
Koletar says, “They say, ‘I can take one pill a day and do quite well.’”
Certainly, medical care has progressed over the last 30 years. “In the mid-1980s when I started researching, your life expectancy was somewhere between six to nine months,” she says. “Now, there is no reason people should die. We have good treatment, but if someone is not diagnosed and they do not get treated, they will die.”
AIDS attacks the immune system, generally destroying the body’s ability to fight infections and certain cancers. And HIV can impact all body parts, even when controlled. Heart, lung and kidney diseases are all more common in people with HIV, Koletar says.
“We have done trials along the way that have tried to address those specific complications,” she says. “Opportunistic infections take advantage of a weakened immune system.”
While the numbers of newly infected have decreased slightly in the U.S. overall, in some parts of the country, particularly in the South, transmission remains high where access to care is limited.
“All of these things go together. Testing happens late, so people are presenting later with more advanced disease,” Malvestutto says.
Getting diagnosed early is key to successful outcomes, Koletar says. “If you can identify people who are infected and treat them and suppress them, then you can decrease transmission,” she says. “It does require concerted effort.”
Both OSU doctors engage with HIV researchers and clinical trial networks across the U.S. and internationally, and all are searching for medical magic—therapeutic and preventative vaccines to cure and preclude the disease.
“We are doing some pretty exciting work, looking at people already infected but otherwise doing well, and how to take advantage of a vaccine to help boost their own natural immune system,” Koletar says. “We have a couple of different studies looking at that.”
One area of research is focused on manipulating the immune system to control the virus. Researchers in the last few years have been able to identify neutralizing antibodies developed by some patients’ systems that control most strains of the virus. Those broadly neutralizing antibodies—known as BNAbs—are now being cloned and manufactured and given to patients. The research is promising, Malvestutto says.
“Now we are looking at possibly using combinations of these and giving them to patients to see if we can keep the virus controlled for several months and possibly years,” he says. “Patients then may only need an infusion of these antibodies once a year, or perhaps more infrequently than that.”
Another benefit from this method compared to standard treatment is that it might limit or terminate the ability of HIV to conceal itself within the body and reactivate later, Malvestutto says.
“One of the reasons we can’t cure the virus is that the virus can hide in certain parts of the body and can integrate its own genetic material into the genetic material of the cell, and by doing that it stays hidden and doesn’t cause problems until it becomes reactivated,” Malvestutto says. “These neutralizing antibodies may be a tool to eliminate that.”
The combination of treatments continues to improve every year. “The idea in the future is we will be able to tailor the treatments, which we do now to some extent,” he says.
Despite successes over the years, one element that has not changed since the early days is the stigma associated with AIDS. Malvestutto calls it a huge barrier.
“It’s the reason why some people do not want to get tested and the reason why even physicians still have a difficult time discussing sexual history with their patients, even though that should be the norm,” he says.
Koletar says the stigma continues to be a big battle for doctors.
“I saw a woman last year that was diagnosed. In my mind your first question should be, ‘What can I do to take care of myself?’” Koletar says. “Her question was, ‘What will people think?’”
It’s a critical question for people with HIV outside of the U.S., too, especially for women in sub-Saharan Africa. If they are exposed as having the disease, and that can happen even if they are seen taking a pill every day, they can be ostracized or even killed, Malvestutto says.
Now researchers have developed injectable forms of drugs that only require a dose every two months. And even more promising, in the research pipeline there are drugs that need to be administered just every six months, he says.
Continued progress is focused on clinical trials because they help determine if a treatment might work. Animals are tested, but results don’t always translate to people, so human trials are essential. Both physicians praised the thousands of volunteers who step up every year as test subjects.
“They don’t need to do it to survive, whereas in the early days it was the only way you could get some of the medications,” Malvestutto says. “They understand how important it is, even if the findings don’t benefit them directly.”
Health care is a team sport, and we need people and providers equally engaged, Koletar says. “We rely heavily on the people who volunteer to participate in these studies, so it is our obligation to do the best job we can do,” she adds. “The research is ramping up actually, but the question is, ‘Will there be enough funding?’”
Both physicians believe an AIDS cure will be eventually discovered. Many treatments are available and new ones are being discovered on a regular basis, says Malvestutto, who has been researching HIV since 2010.
“I believe we are at least 15 years away from a cure,” he adds. “We are getting closer to having a functional cure where we are putting somebody on treatment that they don’t have to take very frequently and where their virus is completely controlled.”
Koletar has worked in the field for 30 years and has seen exponential advances. One man was cured about eight years ago after a complicated bone marrow transplant from someone whose body prevented the virus from attaching.
“The donor had a mutation, and that gave the scientific community hope we could do this,” she says. “We’ve cured Hepatitis C, so that also gives us hope, but HIV is much more complicated. And we still haven’t cured heart disease or diabetes.”
Koletar believes it will be a combination of treatments, not a single therapy, that will eventually lead to a cure.
“It won’t be one thing. The issue with all disease is it really takes time,” she says. “We won’t really know if something works until years later because you have to give it time to ensure there’s no reoccurrence.”
Koletar believes researchers are unlikely to find a cure in her professional lifetime.
“The goal is always to cure things, but it’s not a short-term, realistic goal. Long-term control is the important thing,” she says. “But now I think there is hope, and there should always be hope.”