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HIV Management In Depth

Interview

The Future of HIV Prevention, Treatment and Care

An Interview With Mark Harrington

June 23, 2014

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Do you think we're going to see a vaccine in our lifetime?

I don't know. I hope so. I think they have a better understanding of what kind of antibodies they would like to elicit. I don't think they know how to elicit them.

What about a cure?

Well, apparently, two people have been cured: one baby and one adult.

We may have a third.

I know. That's what people said last year about the Massachusetts patients. We shouldn't count that third person until the second baby goes off therapy. All we know about is two cures right now: one baby, and one adult. Neither one has been confirmed with another case. At this point, they are exalted and exciting medical anecdotes. We don't know how to repeat them. We haven't been able to reproduce what happens in them yet. So there's nothing that's scalable about it. We can't even do it in a second bone marrow transplant patient yet. We might have a second baby, or we might not. But we won't even know for a long time, because I think they're going to wait until that baby's been on therapy at least two years, or something. And I can't remember how old the baby is.

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I think the baby is 9 months, from California.

We might as well not talk about it being cured until we find out when it goes off therapy. We have no idea. We don't know how to measure the reservoir. And the only way to find out is by taking the poor kid off therapy. It's not worth the risk until they're probably at least 2 years old.

What was the one thing at CROI 2014 that you were excited about?

The use of molecular phylogeny to interrupt ongoing chains of active HIV transmission among MSM [men who have sex with men] in San Diego, as presented by Susan Little from UCSD [University of California - San Diego], using the pol gene sequences and showing how they were assessing people's risk. Really, their risk had more to do with how many people they were connected to in their network than safety per act. And the people who are more connected in networks are more in a situation to be part of a transmission chain.

What she said, in answer to a question, was that they have data that treating people early, like within 12 weeks of infection, within those clusters could break ongoing chains of transmission. Now, she said it, but she didn't show data to show it. We assume it's an ongoing project that is either in submission or that they're waiting for more data.

What she did show was very beautiful molecular epidemiology using those data. It solicited some interesting discussions about community participation in prevention science. Because those individuals in the study have to consent. Now the state has our pol gene, for anyone that's been diagnosed. But Susan is getting their pol gene; and she's got data, I guess, before the state has it, or is outside of the state surveillance. Because she said their identifiers are being protected by a 13-key algorithm -- which means that nobody, "not even the NSA [National Security Agency]" can crack their ID. Now, of course, once it goes up to the state, anyone with the password to the state database can get it.

So they're concerned about the issues of community consent. They're addressing them in a prospective way. I think there's an obvious concern about if you document the relatedness of various strains of HIV, that if there's a criminalization law in your jurisdiction, those data could be used in a very, very harmful way.

But so far as we know, that hasn't been the case with these datasets up to now. And we need to make sure they're protected. But we do have the molecular tools to start interrupted ongoing chains of transmission if we can get community buy-in and willingness.

Really, it's almost like thinking about partner notification and contact tracing before you get infected, instead of after. Like, what if we did the New York Chemoprophylaxis Registry, where everyone who got PEP or PrEP was in a registry? And then, by definition, they're in an intervention cohort where you could start getting data on their networks, and then could potentially reach out to people in their network and say, "Hey, do you want to join this cohort? It's a chemoprophylaxis cohort. It's designed to help people stay negative."

And we could build on that -- just the way we have transmission networks -- to have non-transmission networks. Wouldn't that be cool? To me, that was the most exciting paper of the meeting.

What advice do you have for a young activist who's just starting out?

People ask me that kind of thing all the time. People have to find their own mission in life, their own issue, their own target, their own strategy and their own way of doing it. The one thing that older activists can do and more experienced activists can do is we can help; we can answer questions. We can help people learn. We can talk about our experiences. We can mentor people.

But you can't really mentor somebody if they don't want to be mentored. And so I think, really, it's a matter of, where are they coming from, and what do they want to do? What are the issues that really are most meaningful to them?

It's really not for me to say what a person should do with their life. This epidemic touches on almost everything that's unjust about our world. And yet, at the same time, in this one space, humanity has made more progress and shown more solidarity with some of our most excluded and despised brothers and sisters than we have in many other cases. And so, out of great suffering, some great human work has been done.

And we're far from finished, so there's plenty of work for everyone. I think we should all try to figure out how to end the epidemic as quickly as possible. But there's not one way to do it.

This transcript has been lightly edited for clarity. Due to poor audio quality, this episode of HIV Management in Depth is transcript only.


Copyright © 2014 Remedy Health Media, LLC. All rights reserved.
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Reader Comments:

Comment by: joseph wanjala (bungoma kenya) Thu., Oct. 9, 2014 at 6:59 am UTC
my comment is how can i start this in my community here
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Comment by: Enrique (Buenos aires Argentina) Thu., Sep. 11, 2014 at 8:38 am UTC
Hello All!
I am hiv pos and I ve foubd out 10 days ago
My CD4 are in 649 range and viral charge 1750 aprox
My dr told me no treatment need it as of yet and in 3 months if i get the same results still no treatment due to the fact that my CD4 are above 500
I hope to remain like this for a long time sonI can delay the drugs .
I am not scared anynore nor depressed or angry at myself but i do wonder if a vaccine to cure or prevent the growtj of this virus in our body wil ever happen?
I am healthy and my boyfriend got tested negative thk God!
Who knows when i ve got it maybe 3 yrs ago? Dont care
Tks
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Comment by: Leonard Cheloti (Kenya) Wed., Aug. 27, 2014 at 8:41 am UTC
Are HIV positive people on ARV more prone treatment failure when thy approach 60 years? Or is aging a risk factor of ARV treatment failure?
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Comment by: Beth Hastie (Boston, MA) Tue., Jul. 1, 2014 at 3:32 am UTC
Exciting to hear about generic pricing relieving PrEP price tag in future. As an HIV+ woman (24 years HIV+) in a 19 year marriage with an HIV- woman, the findings about minimal risk to my HIV- partner due to my undetectable viral load is really a relief. Even if oral-vaginal HIV risk is low it's a relief and it does effect our sex life positively (and I remember the old days when we had NO data on that and it was very frustrating being in a lesbian serodiscordant relationship). PrEP is so exciting- seriously, I don't understand why more people are not over the moon about PrEP. 90% risk reduction when taken consistently; and perhaps 99% when used with condom (for sex with men). This is a sea change and the slut-shaming has got to go. The women's health movement, gay liberation, the AIDS empowerment movement all share tenets of personal and sexual liberation. PrEP is the first real HIV prevention method women can actually control. And as a woman who was exposed to HIV through a date rape in 1990 and wished we'd had a morning-after HIV pill then, now we have PEP. Glad there is some momentum with ACT UP and AIDS United and New York state and other advocates around the country pushing the CDC and others on resources for PrEP education. A national women and PrEP webinar today, entitled "2 Years Laterů and still counting women inů " reported that few messages were going to women and they were upset at not knowing about PrEP. And recent studies have shown that both men and women are underestimating their risks for HIV - and therefore underestimating the benefits of/ need for PrEP.
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Comment by: We're not dead yet Sun., Jun. 29, 2014 at 11:54 pm UTC
"But you can't really mentor somebody if they don't want to be mentored".

Of course no one wants to be mentored by you! Where is the fight for anything that would actually improve life for people who are already HIV+? Where is talk of a viable cure? Where is the "treatment" in "Treatment Action Group"?Please do not suggest our disaffection is laziness.
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Comment by: ogutuken (kenya) Fri., Jun. 27, 2014 at 10:58 am UTC
this is a good article
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Comment by: Michael J. Kerr (NY, NY) Fri., Jun. 27, 2014 at 2:44 am UTC
Insightful responses to very good inquiries which definitely have me thinking. First, in my own current treatment (so Thank You Terri and Mark). Secondly, in the use of molecular phylogeny to interrupt ongoing chains of active HIV transmission among MSM. I need to read more about using the pol gene sequences and risk assessment. Not sure I really understand that part of the interview.
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