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In his State of the Union address earlier this month, President Trump made an ambitious pledge: to eliminate the HIV epidemic in the U.S. within 10 years. “Scientific breakthroughs have brought a once-distant dream within reach,” he said. The policy promise is no less bold than President George W. Bush’s global initiative PEPFAR (President’s Emergency Plan for AIDS Relief), which has been credited with saving more than 17 million lives since its inception in 2003. Whereas Bush’s initiative tempered the destructive force of AIDS, could Trump’s end it altogether?
The stakes are high in this choose-you-own-adventure, particularly for America’s marginalized communities. HIV/AIDS in the U.S. disproportionately affects gay and bisexual men, the transgender community, African Americans, the prison population, injection drug users, our inner cities, and other underserved communities. Half of black and a quarter of Latino gay and bisexual men are expected to acquire the disease in their lifetime. Four out of five women with HIV/AIDS in the U.S are black or Hispanic/Latina. And infection rates among injection drug have soared during the opioid epidemic.
According to a blueprint released by the Department of Health and Human Services, President Trump’s plan to end HIV will be focused on expanding efforts to diagnose, treat, and prevent cases of HIV/AIDS. Although the president’s initiative has potential to meet his stated goal, an overreliance on preventative and antiretroviral drugs could prove to be an unintended Trojan Horse. To permanently eliminate the scourge of HIV/AIDS, what we need isn’t just a motley mix of preventative half measures. What we need is a cure.
A pillar of the president’s plan is pre-exposure prophylaxis, or PrEP — medications that dramatically reduce the risk of contracting HIV. Among the best known of those medications is Truvada, a once-daily pill manufactured by the pharmaceutical company Gilead Sciences.
Although few people outside the gay community have heard of PrEP, it has caught on like wildfire among gay men. New York City’s Department of Health plastered subways and gay neighborhoods with alluring “Play Sure” ad campaigns, implicitly endorsing the new drug regimen as a first-line defense in situations of casual sex. A flurry of apparently underground, but highly polished, X-rated social media campaigns and internet memes— with taglines like “Truvada Whores” and “PrEP Squad” — sprouted up all over gay sites. The take home message for gay men: A pill a day will take HIV away.
Indeed, PrEP has been credited for a decline in HIV-infection rates in some communities. For HIV-discordant monogamous couples — those with one HIV positive and one HIV negative partner — PrEP may ultimately be the intervention of choice. In those cases, it’s possible to determine which viral strain is carried by the HIV positive partner and tailor a PrEP regimen that will guard against it.
The problem is that no single PrEP medication is effective against all strains. In a recent case study, for instance, the strains of HIV in some 6 percent of people living with HIV/AIDS had “high-level resistance” to Truvada. Can we reliably count on anti-retroviral drug therapy to virally suppress all of these people, all of the time? Over time, as condom use among men who have sex with men continues to drop, the emergence of new and existing drug-resistant strains of HIV/AIDS will surely accelerate. Left unchecked, this situation could lead us into a vicious cycle: Patients will require increasingly strong daily cocktails of increasingly ineffectual drugs just to stay healthy. And when that PrEP bubble bursts, the impact on high-risk communities could be catastrophic.
Only a cure, a vaccine, or both can end AIDS for good. As recently as a decade ago, such a cure was scientifically unthinkable. But then came a development that gave us reason for optimism: In 2007, Timothy Ray Brown, an American who had been living with HIV for more than a decade, became the first person to be cured of AIDS. Brown was cured using stem cells transplanted from a donor who was among the small fraction of the population that exhibits natural HIV resistance. Whether the same method can be applied to develop a widespread cure is uncertain: Patients would need to be paired with immune-matched, HIV-resistant donors, who can be exceedingly difficult to find. However, several research labs, including my own, are pursuing approaches that may allow them to use a patient’s own stem cells as the starting material to create curative stem cells.
I hold out hope that the final agenda for Trump’s initiative to end HIV/AIDS will include substantial support for a vaccine or cure — or, at the very least, that the spotlight he’s shining on the disease will spur others to take up the pursuit. It is no longer the science or the challenge of cellular engineering that stands in the way. Rather, it is primarily a question of leadership and our capacity for imagination. On at least this one point, Trump was undoubtedly spot-on: The once-distant dream is now within reach.
Kambiz Shekdar is president and founder of the Research Foundation to Cure AIDS (RFTCA). Prior to establishing the RFTCA, Kambiz served as Chief Scientific Officer of Chromocell Corporation, a biotechnology company he co-founded.