No Longer Cured: HIV Relapse in "Mississippi Child" Raises New Questions
Undoubtedly, the biggest HIV story last year was the functional cure of an infant from Mississippi, after antiretroviral treatment was started within hours after her birth. The baby girl was on treatment for 18 months until being lost to follow-up, at which point the mother took her off treatment. Surprisingly, when the baby was returned to care five months later, she showed no traces of HIV despite no longer being on treatment. This continued for more than two years, with the child remaining off medications.
Unfortunately, earlier this month during a routine checkup, the child -- now almost 4 years old -- was suddenly found to have a detectable viral load of 16,750 copies/mL. Another test 72 hours later showed a viral load of 10,564 copies/mL, confirming that the child's HIV had rebounded, according to a news release from the U.S. National Institute of Allergy and Infectious Diseases (NIAID) issued on July 10.
Moreover, the child's CD4 count had decreased, and she had developed HIV antibodies, signaling active HIV replication. Based on these findings, the child was started on antiretroviral treatment again. She is currently tolerating the medications well with no side effects, and is showing a decreased viral load, according to the news release.
Genetic sequencing confirmed that the child's virus was indeed the same strain acquired from the mother. Hannah Gay, M.D., a pediatric HIV specialist at the University of Mississippi Medical Center in Jackson, who has been the child's doctor since birth, will continue to monitor and provide care to the child, the release states.
While this is unfortunate news, the focus now shifts to better understanding how the Mississippi child was able to maintain undetectable levels of HIV for more than two years without treatment, and also to explore what might be the keys to prolonging HIV remission in the absence of treatment.
At this year's CROI, we got news of a second child who was seemingly cured after a similar approach of commencing HIV treatment shortly after birth. The question now is whether this second child will also rebound. Certainly, after this update on the Mississippi child, doctors will continue to closely monitor the second child.
Additionally, this isn't the first case of relapse in patients who were seemingly cured. Two Boston patients initially showed no signs of HIV after receiving bone marrow transplants, but months after stopping treatment, the virus reemerged. We don't yet know why, nor do we know whether the mechanism behind the rebound is similar to that behind the Mississippi child's, but these are questions worth examining in future studies.
"Scientifically, this development reminds us that we still have much more to learn about the intricacies of HIV infection and where the virus hides in the body. The NIH [U.S. National Institutes of Health] remains committed to moving forward with research on a cure for HIV infection," said Anthony S. Fauci, M.D., NIAID director, in the NIAID statement.
"The case of the Mississippi child indicates that early antiretroviral treatment in this HIV-infected infant did not completely eliminate the reservoir of HIV-infected cells that was established upon infection but may have considerably limited its development and averted the need for antiretroviral medication over a considerable period. Now we must direct our attention to understanding why that is and determining whether the period of sustained remission in the absence of therapy can be prolonged even further," Fauci concluded.