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Vol. LXVI, No. 10
May 9, 2014
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Despite Progress, Challenges Remain in Fight Against HIV/AIDS

On the front page...

The steps that led to AIDS being a treatable disease rather than an automatic death sentence and attempts to identify the best treatments for AIDS were topics at a recent Great Teachers Grand Rounds lecture in Lipsett Amphitheater.

Dr. Henry Masur, chief of the Clinical Centerís critical care medicine department, said scientists have made great progress in the fight against AIDS. Dr. Cliff Lane, NIAID clinical director, cautioned that there is still much to learn about AIDS.

Since the disease was first recognized, scientists have made great advances in AIDS research. In 1984, NCIís Dr. Robert Gallo developed an AIDS blood test. In 1987, the Food and Drug Administration approved the first AIDS treatment, zidovudine, a drug initially tested in AIDS patients at the CC by Drs. Sam Broder and Robert Yarchoan of NCI. In 1988, scientists concluded that prophylactic antibiotics could prevent Pneumocystis pneumonia.

Continued...

Clinical Center director Dr. John Gallin (l) enjoys a chat with Grand Rounds presenters Dr. Cliff Lane (c) and Dr. Henry Masur prior to their talks.

Clinical Center director Dr. John Gallin (l) enjoys a chat with Grand Rounds presenters Dr. Cliff Lane (c) and Dr. Henry Masur prior to their talks.

Masur said he’s discouraged that, in the United States, the number of new HIV infections hasn’t decreased since the 1980s. Scientists understand the life cycle of the virus, have developed more than two dozen antiretrovirals and have fashioned prevention strategies.

“The fact that we still have 50,000 new HIV infections a year suggests that we’re not doing a very good job changing the public’s behavior,” Masur said. “We have to find better strategies.”

Masur also said that many patients with AIDS are not receiving proper treatment. In Washington, D.C., for example, only 39 percent of patients known to be HIV-positive stay in treatment. Many of these patients still develop treatable opportunistic infections.

Masur said he’s discouraged by the stubborn persistence of new HIV infections.

Masur (above) said he’s discouraged by the stubborn persistence of new HIV infections. Lane (below) said that while AIDS patients treated with antivirals are living longer, better treatments are still needed.

Photos: Bill Branson

Lane said that while AIDS patients treated with antivirals are living longer, better treatments are still needed.

Lane said researchers still have a lot to learn about the disease and how best to treat it. As patients with AIDS survive longer due to the success of antiretroviral therapy, Lane said that fewer are dying from AIDS-related infections. Antiretroviral drugs can suppress the virus that causes AIDS. Some of the drugs have significant side effects, however, including: glucose intolerance, hyperlipidemia, fat redistribution, osteoporosis and kidney and liver disease. Patients may also develop chronic inflammatory states that appear to accelerate the aging process, leading to cardiovascular, cerebrovascular, kidney and liver diseases.

Lane also touched on current guidelines for antiretroviral therapy. Today, there are 25 anti-retrovirals on the market. Many of these are combination drugs. They contain two or more drugs that inhibit the AIDS virus at different stages of the life cycle.

Current HHS treatment guidelines recommend that all patients with HIV infections take antiretrovirals. Lane said the strength of the recommendation depends on CD4 cell count. CD4 cells are a type of white blood cell that coordinates the immune system’s response to pathogens. A normal CD4 count is greater than 500 cells per cubic milliliter of blood. Typically, patients with AIDS contract opportunistic infections when their CD4 count falls below 200.

Lane noted that observational cohort studies have given conflicting results on whether or not there is clinical benefit to starting anti-retrovirals in patients with CD4 counts greater than 500. He noted that a randomized control trial known as the START study is addressing this question.

Lane said scientists are still intrigued by how one well-described patient was cured of AIDS. The patient received a bone marrow transplant to cure a leukemia that was unrelated to his AIDS infection. The donor was immune to an HIV infection because of a genetic mutation in one of the co-receptors of the virus. Since the extensive conditioning regimen and the transplant, the patient has been off all antiretroviral drugs and the virus has not reappeared. So far, however, no other AIDS patient has been cured.

“We’ve learned quite a bit about AIDS,” Lane said. “But we still have more to discover.”


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