So it's official. The "cure" isn't the cure. That most publicly
posed of questions -- Can HIV be eradicated? -- now has an answer:
No. After the disappointing findings of three major studies
published last November, the verdict is in: Whether driven by
cynical manipulation or misguided good intentions, eradication is a
How we wanted and needed to believe! Yet no sooner had Dr. David
Ho, the toast of Vancouver and Time's 1996 Man of the Year,
tantalized the planet than his ever-elusive cure began to fade. With
each passing season's scientific conference, it slipped further from
our grasp. Early last year, Eradication Inc. declared two to three
years' treatment enough to wipe out HIV infection; by spring, it was
six years; last fall, a decade or more.
And then the model imploded. Buried in the footnotes to the
headlines of therapeutic euphoria were two fundamental
preconditions: That the current cocktails shut down viral
replication 100 percent in all parts of the body, and that the cells
already pirated by the virus grow old and die before the patient
does. Neither is true.
Taken together, the three studies -- each by a leading researcher
-- report ongoing, low-level viral replication, the persistent
presence of infectious cells and at least one type of infected CD4
whose numbers never so much as dwindle. Even in someone whose viral
load has been undetectable (less than 200) for 30 months, the virus
lives on; stop therapy, and -- at least in the lab -- it can return,
If the cure doesn't exist, what is to be done? Is it time, once
again, to charge our credit cards to the limit? Or can life go on
without eradication? Experts disagree. Hard-nosed realists argue
that viral eradication was never even a possibility. "Can HIV be
eradicated?" was the wrong question, they say. These determined
empiricists have maintained all along that HIV infection is forever.
A more realistic scenario would be to maintain HIV at levels low
enough to spare the immune system and allow the virus and its host
to peaceably coexist -- with or without treatment. Follow this line
of thought, and the apotheosis of eradication sacrifices the lion's
share of its mystique.
Eradication or not, nothing in the bleak ramifications of these
three experiments in any way undoes the renewed well-being and
Lazarus-like returns of thousands of PWAs over the past two years.
Many who had a mere 10 to 20 CD4 cells in 1995 now have 200 or more.
And with viral loads dramatically reduced, once-ravaged immune
systems can now function at a satisfactory level. But with the
twilight of the eradication ideology, it is doubtful that the
current rush to treat is in the long-term interest of asymptomatics
with a moderate viral load and an intact immune system. For anyone
who has not yet bought a ticket to the triple-cocktail lottery,
waiting even six to 12 months to embark upon this uncharted
pharmaceutical odyssey may make a world of difference: This year we
may finally figure out what harm and good these drugs are actually
doing and have regimens that are easier to start and stick to.
For the hordes who have already succumbed to the pressure to "hit
it early and hard," it's more important than ever to take this
pill-popping business seriously. But the bravest of the lucky ones
-- those with "undetectable" viral loads for 12 to 18 months or more
-- might consider a leap off the edge of the known treatment map
into "subtraction" therapy: Reducing or switching a three- or
four-drug combo to a two- or one-drug regimen. The idea -- highly
speculative -- is that once the virus has been brought to its knees,
a less aggressive assault may keep it down. Toss out the protease
inhibitor (or the 3TC) before resistance develops, and you may be
able to use them in the future.
While right now the drug pipeline is as empty as Mother Hubbard's
cupboard for all but antiretroviral virgins, there are enough new
approaches for a scintilla of optimism. The pleasant surprises of
the eradication era have infused us all with a new energy that we
mustn't lose. If the antiretroviral approaches have taken us as far
as they can, so be it: Now immunological and cellular approaches
must carry us the rest of the way. With vigilance and advocacy,
these therapies could be available in a year or two. All we have to
do is stay well until then.