March 14, 2013
Much has already been discussed and written about the remarkable case of this infant girl born in Mississippi to an HIV-infected, but undiagnosed, woman who also didn't get any prenatal care; but if you haven't yet heard:
The mother was confirmed to have HIV infection by rapid test at delivery, and later shown to have wild-type, subtype-B virus and an HIV viral load of 2,434 copies/mL. Intravenous zidovudine (AZT, Retrovir) during delivery was not administered and the baby was born by spontaneous vaginal delivery. The infant was started immediately (at ~30 hours) on triple-drug therapy (oral nevirapine [Viramune] plus zidovudine and lamivudine [3TC, Epivir]) and HIV infection was confirmed with DNA and RNA tests (plasma viral load 19,812 copies/mL) that were initially conducted at 30 and 31 hours of age, respectively. Three additional HIV RNA tests performed at days 7, 12 and 20 were positive, and demonstrated the typical viral decay kinetics under HAART. The child's HIV RNA became undetectable at day 29 of life.
The mother stopped infant antiretroviral therapy (ART) around month 18 and the child was lost to follow-up until month 23. All subsequent 16 HIV RNA tests were undetectable, despite the absence of ART. HIV ELISA and Western blot tests remained negative. Further analysis using ultrasensitive RNA and DNA analyses and attempts to recover infectious virus from resting CD4+ cells were negative; both the mother and child had wild-type CCR5 genotype.
This remarkable case suggests that the child was HIV infected: Her persistent viremia early in life suggests that infection was effectively established, while multiple analyses off of ART that failed to detect virus suggest cure. It's possible that very early triple-drug treatment offered to infants of HIV-infected mothers might prevent establishment of a latent reservoir. If confirmed, the strategy will transform the care of HIV-exposed infants and possibly achieve cure in many.
While it looks clear that the infant HIV infection has cleared, it is not so clear that HIV infected the infant reservoirs. Actually, newborns lack long-lived memory cells that are responsible for HIV integration, as was explained in a brilliant talk by Robert Siliciano.
Which other studies presented at CROI 2013 will have lasting impact long after memories of the conference itself have faded? Read more of Dr. Llibre and Dr. Young's top picks.
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