World AIDS Day: There’s hope for cure - where we stand now

With the help of new scientific and technological developments, the HIV/AIDS research community is increasingly turning to an ambitious goal: finding a cure for HIV/AIDS.

If the world is to get close to meeting the UN Sustainable Development Goal of reducing HIV infections and AIDS-related deaths by 90% between 2010 and 2030, a cure for HIV/Aids would be a game changer.

Much progress has been made during the 30 years in the fight against HIV/Aids. An HIV diagnosis is no longer the death sentence it was in the 1990s.

Antiretroviral treatment – which targets and suppresses the replication of the virus within the body – means people living with HIV can live long, fulfilling lives, without the risk of spreading the HIV to others.

However, even with antiretroviral treatments, living with HIV increases the risk of other serious health issues. All of this puts an economic burden on states, through increased healthcare spending and losses in workplace productivity.

South Africa is a good example of a country that would benefit from discovering a cure. South Africa has been providing free antiretrovirals through the public healthcare system since 2004. It is the largest factor behind the 50% drop in the number of new HIV infections in South Africa from 2010 to 2021.

But the programme is expensive. In 2023, South Africa’s total budget for HIV response was R30 billion (around US$1.5 billion). This amount includes funding from international sources, such as the US President’s Emergency Plan for AIDS Relief, better known as Pepfar. Consider that the country’s total national healthcare budget for 2022/23 was approximately R64.5 billion (around US$ 3.5 billion).

Also, we never know when the external funding, or part of it, might dry up. Funding for HIV/Aids response is heavily dependent on political will and leadership. Recent political developments in high-income countries, such as the US presidential election, would suggest a reluctance and even opposition towards pumping funds into healthcare beyond their own borders, especially in Africa.

I work in HIV prevention and cure research. My work focuses specifically on understanding interactions between HIV and the immune system and how these may be harnessed and translated for HIV prevention or cure.

As the world marks World AIDS Day on Sunday, there is hope and optimism that HIV can be cured, with various strategies beginning to show some promise, with partial successes reported.

Finding a cure

Cure research is in its infancy, but there are exciting hints that gene therapy and immunotherapies might lead us to a cure.

So far, there have been seven people, worldwide, cured of HIV. They were persons living with HIV who developed cancer and were treated for cancer through bone marrow transplantation, a form of gene therapy, and this also led to the elimination of HIV because the bone marrow transplants were from donors lacking HIV coreceptors – proteins on cell surfaces that viruses use to bind and enter cells.

A logo is pictured outside a building of the United Nations AIDS agency (UNAIDS) in Geneva, Switzerland, April 6, 2021. Picture taken April 6, 2021. (Photo: REUTERS/Denis Balibouse)

But a bone marrow transplant is a radical, expensive and often dangerous procedure. There is no way we can view it as an avenue for developing a cure when there is reliable ART on hand. In contrast, some strategies involving a combination of early treatment and immunotherapy are also showing some promise and these could be developed further for long-term control of HIV without antiretroviral therapy.

While curing a viral infection is difficult, medical science is already able to eradicate some viral infections, such as hepatitis C. Others, such as the common cold and Covid-19, are effectively eliminated by a well-functioning immune system.

The challenge with HIV is that it locks into an individual’s DNA, making it particularly difficult to get rid of. It also mutates a lot, which is why it is so difficult to develop a vaccine against it.

That has led us to explore why some people appear able to neutralise HIV when not taking antiretroviral therapy but on once-off or temporary therapy that boosts their immune system. This seems to happen in some people who are diagnosed with HIV early on in their infection and immediately go on ART, and then interrupt the treatment but simultaneously take the special immune-boosting treatments with antiviral properties.

So far, the HIV research community is unable to predict who will react in this way, but the Africa Health Research Institute and the HIV Pathogenesis Programme, within the University of KwaZulu-Natal, are conducting research among a group of young women from a community in KwaZulu-Natal, South Africa, with a high HIV infection rate.

These young women are invited to participate in a socio-economic empowerment programme that has them attend a clinic twice weekly for training in basic computer skills, HIV prevention and other life skills.

At each attendance, each woman is tested for HIV. If one is found to have acquired HIV, she is immediately given a standard course of ART. After a while, immune-boosting therapies that include broadly neutralising antibodies are added, and then the woman is asked to stop ART treatment under strict monitoring to establish whether she can control the virus on her own. If not, she is immediately returned to ART. Of more than 2,500 attendees since the study began a decade ago, 108 have become HIV-positive. Of these 108 living with HIV, 20 are participating in the cure clinical trial.

The study is ongoing, and we hope that this strategy will lead to long-term control of the virus in the absence of ART in some of the women. This can then help us to better understand the immune mechanisms that may control the virus without antiretroviral therapy, and this could lead to a cure.

Much work still needs to be done but finding a cure is important, especially for the 40 million people across the world living with HIV.

The world is not on track to meet the UN goal of ending the HIV/Aids pandemic by 2030. While the rate of HIV infection has dropped remarkably, it is still much higher than the targets the global healthcare community has set for itself. For example, in 2023 there were 1.3 million new HIV infections worldwide against a target of 500 000 to achieve the aim of nearly eradicating HIV by 2030.

HIV/Aids research must continue in Africa because, while the incidence of HIV infection is reducing markedly, this status quo could change at any time and we could be back fighting a pandemic. It would be good to do so with better tools.

Also, we must find a cure or vaccine that is tailored to Africa, where HIV is a young woman’s disease, while also seeking the same for the regions where HIV infection is rising – Asia, Latin America and Eastern Europe.

We’re playing a long game, but there is definitely hope, and that is something to celebrate.

By Thumbi Ndung’u, Director for basic and translational science, Africa Health Research Institute (AHRI)