[Contagious Conversations] Approaching HIV elimination

This is the second episode of in the series, [Contagious Conversations] from the Australasian Society for Infectious Diseases. Expert guests in this series will come from right across the interface of research, clinical care and public health.

In today’s episode we look at the immense progress that has been made over three decades in the management of HIV. Once a fatal diagnosis, the disease can now be completely controlled by anti-retroviral therapy. Access to prophylactic treatment has also made a huge impact on rates of transmission in the community although barriers still remain to equitable access.

Guests
Professor Sharon Lewin OA FRACP PhD (Peter Doherty Institute for Infection and Immunity, Director; University of Melbourne; Cumming Global Centre for Pandemic Therapeutics, Director)
Professor Dato’ Dr Adeeba Kamarulzaman FRACP FASc (Monash University Malaysia, President & Pro Vice-Chancellor; Centre of Excellence for Research in AIDS).
Richard Keane (Living Positive Victoria, CEO)

Host
Associate Professor Sanjaya Senanayake FRACP (Canberra Hospital; Australian National University)

Production
Production supported by Mic Cavazzini DPhil, and the Viral Hepatitis and HIV Special Interest Group particularly Dr Emma Paige and Dr Sushena Krishnaswamy. Thanks also to Inge Meggitt, events coordinator at ASID. Music licenced from Epidemic Sound includes ‘Exploring the Lake’ by View Points and ‘Emerlyn’ by Valante. Image copyright ASID (2026).

Visit the Pomegranate Health web page for a transcript and supporting references. Add educational activity to MyCPD. Subscribe through any podcasting app or our email alerts list.
 

Transcript

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SPEAKER_02 0:09

Welcome to the second episode of Contagious Conversations from the Pomegranate Studios. This series has been developed by members of the Australasian Society for Infectious Diseases to explore evolving evidence, practical knowledge, and real-world challenges in this field. I'm Mick Kavazzini, but I'm going to hand you over to Associate Professor Sanjaya Senanyake, who directs the Department of Infectious Diseases at Canberra Hospital and lectures at the Australian National University. Dr. Senanyake and his guests discussed the immense progress that has been made over three decades in the management of HIV. Once a fatal diagnosis, the disease can now be completely controlled by anti-retroviral therapy. Access to prophylactic treatment has also made a huge impact on rates of transmission in the community, although barriers remain to equitable access. And despite the remarkable control we can have over viral load, HIV is still a tricky pathogen, and the prospect of a cure or even a vaccine remain elusive.

SPEAKER_04 1:10

Welcome everyone for our second podcast. Last time we talked about vaccination. Today we're talking about HIV, and we've got three wonderful guests who are joining us today. First of all, let me introduce Professor Sharon Lewin A.O. who is a virologist and infectious diseases physician with a hugely impactful research output. And Sharon, you're the inaugural director of a couple of very important Australian institutions. Can you tell us more?

SPEAKER_01 1:42

Thanks so much, Sanjay, and great to be here. Yes, I'm director of the Doherty Institute. The Doherty Institute's now 12 years old, a joint venture of the University of Melbourne and Royal Melbourne Hospital. But a recent, more recent appointment is I also am the director of the coming Global Centre for Pandemic Therapeutics, which launched in response to the pandemic.

SPEAKER_04 2:03

Thank you, Sharon. Professor Adiba Kamarul Zaman is president and pro-vice-chancellor of Monash University Malaysia and also established Malaysia's Centre of Excellence for Research in AIDS. Adiba, what else should we know about your background?

SPEAKER_03 2:23

Well, I'm an HIV physician and like Sharon, we both graduated from Monash University and trained at the beloved Fairfield Infectious Diseases Hospital.

SPEAKER_04 2:36

Know it well, yeah. It uh lives in the memories of many infectious diseases physicians. So many, many of my colleagues who I've worked with in Canberra were there as well.

SPEAKER_03 2:45

And and we're both past presidents of the International AIDS Society.

SPEAKER_04 2:49

Wonderful, wonderful. And Richard Keene is the CEO of Living Positive Victoria, a not-for-profit, which advocates for the rights and well-being of people with HIV. And Richard, how long have you been in that role for?

SPEAKER_00 3:05

So I've currently been in the CEO role for eight years. I was diagnosed with HIV when I was 19 years of age, way back in 1989. So I've kind of seen the progress, the advancements, and a whole range of other impacts across the HIV response.

SPEAKER_04 3:22

Thanks, thanks, Richard. And before we get into the nitty-gritty, I thought maybe a bit of reflection on where we were in the past and to where we are now. And I remember as a registrar, one of the microbiologists I was working with attended in the 1980s one of the American conferences, I think it was IDSA or the American Society for Microbiology, where they presented this case series of a few young men who got a very unusual pneumonia, pneumocystis pneumonia, and some of them died. And at that time it was a real puzzle, and of course, though that was the first inkling of the HIV epidemic that began. And then you fast forward to now where we've got over 30 antiretrovirals, and most HIV cases in Australia are treated in outpatients, uh just like a GP visit. So for me it's astounding where we've come from. Sharon, what what are your reflections?

SPEAKER_01 4:54

Actually, it's interesting, Sanjay, almost identical to you. I started, um I graduated from medicine in 1986, and um and HIV wasn't really on my radar then, but I did spend a year working in Kenya in 1989, and that's when I became much more aware of what was happening in HIV globally. And at that time, and in the subsequent decade after that, until antiretrovirals came along in the mid-90s for us and the early 2000s in Africa, you know, there were the the impact on society was just enormous in Africa with you know funerals every day, enormous stigma associated with the infection. Um, and um, and similarly, uh by the time I started doing my infectious disease training in the early 90s, the first part of my training were were young men dying on the wards, and then the second part of my training was everyone was on antivirals. I spent, I moved to New York in the mid-90s at the very beginning of antiviral therapy when people actually thought antiviral therapy might even cure HIV. Um, of course, it can't. Um, but the and I and we're talking about treatment advances. The other really incredible advances is around prevention, and that's a whole nother new story.

SPEAKER_04 6:16

Thank you. Thanks, Sharon. Adiva, what comes to mind for you?

SPEAKER_03 6:21

Yeah, um similar to yours and Sharon's until I returned to Malaysia, um, where the treatment access um was a little bit behind. Um and one of the one of the starkest memories is I guess um when at the time it was called hard, right? When produce inhibitors came um online, and and uh it was literally a matter of life and death for people who could afford treatment in Malaysia at 2,800 ring a month versus those who didn't so part of our early advocacy was in in trying to bring affordable um anti-retroviral therapy to the country and you know, worked with the Ministry of Health and others to improve compulsory licensing to allow generics. Um and then the other side of it, of course, I I trained in Australia um and didn't see anyone at the field or any of the other hospitals I worked at, um who required HIV as a result of injecting drug use, whereas every single patient I saw in the world simulation required um uh HIV through sharing of needles and other paraphernalia. And that was what got me kind of interested to do something about that and and my involvement in in harm reduction and public health in general, while still doing the clinical work. Yeah.

SPEAKER_04 8:01

Yeah. And I I think what you also highlight with that story is that while we have to think globally about HIV, there are variations in terms of uh case numbers, availability of uh and access to treatment in different parts of the world. Yeah. And Richard, what about your your thoughts?

SPEAKER_00 8:21

I think I come from um a community impact kind of point of view. And when I was diagnosed in 1989, I came out into an environment where there was an overwhelming sense of grief and loss that was both community-wide but also intensely personal. But the other things that I found there was a community that I connected to, and um everyone rolled their sleeves up. I joined care teams, went into home care and support for people. Um, I lost a partner when I was 23 myself who I absolutely adored, and those personal initial impacts were quite staggering, but I also had this kind of endeavor to put my body on the line and go into early treatment trials wherever they're accessible here in the country. I was relatively young and relatively healthy compared to some of my peers, so I took every opportunity I could to explore options to advance treatment and connection to um HIV treatments and services.

SPEAKER_04 9:20

Yeah. And Richard, I I think that example just shows with any global infection, no matter how clever we are as healthcare workers, no matter what medications are available, without that advocacy at the grassroot levels from consumers such as yourself, we cannot succeed. So, yeah, well done to you and those around you. That's fantastic. Having said, it's uh we're at a relatively wonderful stage of the HIV epidemic compared to where we were. The reality is there's still a lot of HIV around. So since the pandemic started, the figures I've seen are approximately 84 million people have been infected with HIV, some 40 million plus have died. In 2021, around 40 million people were thought to be living with HIV. That was about 7 per thousand of the global adult population age between 15 and 49. So it's certainly still out there, and there are figures of around 14,000 new cases every day, unfortunately, most of which are in the world's poorest country. So it's still an issue. But at the same time, Adiba, we are talking and hear about all the time HIV elimination. Do you want to talk to me about what HIV elimination means? What does it mean practically?

SPEAKER_03 10:51

I think what it means practically is until we find a cure, until we have uh an effective vaccine, it means that it's no longer a major public health threat like it was before we had this um effective treatment. And I guess in practical terms, enough people have been tested and know their um status, HIV status, who then go on to go on to treatment and and have effective treatment and undetectable viral levels. And you hear about this you know the 95-95 goals um that the global HIV uh community talk about. Um so I think that that is what we're aiming for when when we talk about uh elimination um as a as a public health trait.

SPEAKER_04 11:48

Yeah, and when when you say 95, 95, 95, that's a percentage of people who know their status, who have access to treatment and get get viral suppression.

SPEAKER_03 11:57

We have undetectable viral levels, yeah.

SPEAKER_01 11:59

Yeah, that's yeah, and and another definition um that's sometimes used of HIV elimination, what Adiva says is um completely true about um all the strategies we use. But one other definition, which I think is really relevant for Australia, um, is a 90% reduction in new HIV infections and AIDS-related deaths since 2010. And I think why that's so interesting and relevant for Australia is because we're actually almost there in Australia. And several years ago, at least in Inner Sydney, um, numbers of new HIV infections has really declined by that amount since 2010. Very few other places in the world are coming close to that. Um, but I think it's one thing that we should be proud of in Australia. HIV is an over, but really we've done well on reducing new HIV infections. I'm sure Richard can tell us lots more about that because it's so much related to the hard work of the um gay community largely who've done such a great job on education.

SPEAKER_04 13:01

Yeah and Richard, yeah, I'd in fact uh that's that's a great segue to you because I did want to ask at the the grassroot levels, what do you see that success and what barriers are left to getting there completely?

SPEAKER_00 13:17

Uh that's that's a really big question. Um, there's a range of barriers that I think we still need to challenge, um, and they're structural barriers around discrimination, criminalization of HIV, things that might create barriers for people wanting to test and find out their HIV status. We do have um continued late diagnosis, particularly amongst our heterosexual population living with HIV, um, which presents a whole range of different challenges. When our community first heard about the goal of virtual elimination, there was almost a visceral negative response from some members of my community who felt that virtual elimination meant elimination of service delivery to positive people, of us being potentially eliminated as a focus study. So there was some work to do to walk our community through what virtual elimination means for us, and that was easy for me to do. We've always been on board with the lofty goals that we set for ourselves, and um the virtual elimination of HIV uh would be a huge achievement for us, but for us, the holy grail still sits with Cure in the work that Sharon's doing to move towards Cure because we'll all still be living with HIV tomorrow, even if we reach virtual elimination. So it was a nuanced conversation that we need to have, but these lofty goals have always driven innovation, partnership, and success in this country, and and we're behind it 100%.

SPEAKER_04 14:48

I know wonderful. And now, Richard, you touched on on two things or two words criminalisation and discrimination of HIV. Now, living in Australia, a very sort of liberal country, people might be surprised to hear you talk about use those terms in Australia. So are those issues here?

SPEAKER_00 15:08

Those issues still remain as potential barriers for people wanting to test, with um a whole range of laws that still exist on the books that are quite contradictory. In some ways, our and I'll talk jurisdictionally here in Victoria, we have a set of laws that say you don't need to disclose your HIV status if you're undetectable, if you're engaged in uh prevention strategies like condom use and other things like that. Yet at the same time, we've got this contradiction that if somebody asks you about your HIV, that you need to disclose to them. Otherwise, you could be kind of um in a challenging legal space for that person to say, I wouldn't have engaged in sex with you if I had known you were living with HIV. So we've got this kind of contradictory thing. Um, Living Positive Victoria and myself continue to support our state government's health response. So we have a health response for managing risk in Victoria that has a range of interventions that engage with problematic behaviours, lack of adherence, a whole range of other challenges that um somebody living with HIV may face. And we kind of prefer that model. That still leaves the door open for a criminal prosecution if all of those other efforts and standards have not been met. But that sits with the chief health officer rather than a criminal response by police.

SPEAKER_04 16:32

Wow, that's uh they're completely contradictory, aren't they, though, those two laws. So it must be very confusing.

SPEAKER_00 16:39

And particularly for those folks who have migrated here, who English isn't their first language, we spend a lot of time developing plain language resources, assisting people through engagement with our peer navigation program, so there's a genuine understanding about what their rights and responsibilities are once they receive a HIV diagnosis. And it's important to take that responsibility on as a HIV-positive person by engaging in effective treatment and adhering and protecting ourselves, we're also protecting others.

SPEAKER_03 17:13

If I may jump in here, Sanjaya, I think you know, um much as they've they've affected um Australians and and particularly migrants, this this two issues, stigma and criminalization, uh are huge in countries around Australia, including Malaysia, Indonesia, Philippines, every every country in the region, right? And what we're witnessing at the moment are at least two major um HIV surges, if you like, crises in the Philippines and Fiji and a lot and and Papua New Guinea and Indonesia as well, and a lot of what's underpinning that um um criminalization, um stigma, it's all interrelated, right? In the case of in the case of the Philippines, um it's uh around uh cancer and and and possibly some some um um even relating it to the previous war drugs, um, and fe G is um injecting drug use in the absence of injecting meth and vitamin D, exactly, um in the absence of harm reduction. So it's very, very much uh uh a problem here and now. We we're witnessing huge, huge percentages of uh increase in both those countries I've just mentioned, Fiji and um the Philippines.

SPEAKER_01 18:49

And maybe I can just add to that um that it amongst uh several African countries, there is reversal of uh laws around criminalization homosexuality. So that that homosexuality, which was previously non-criminalized, has now been criminalized in countries like Uganda and elsewhere in Africa. So uh we can't take for granted that progressive views on behaviours will stay with us with a shift to whether it's political or religious driven, um, but some worrying legal changes that are taking us back to another era for both people who inject drugs but also um gay men and sex work as well, all whom are key populations at risk of HIV.

SPEAKER_04 19:41

Yeah, no, thank you, Sharon. I think as of September last year, about 65 countries had negative laws against homosexuality. But I should also add in the context of this conversation that most cases, new cases of HIV in the world today are through heterosexual transmission. And Richard did touch on the fact that there are some populations who are difficult to reach and uh heterosexual populations are one of them, maybe because of that stigma, uh because of the earlier associations with uh homosexuality. And of course, there are other groups that uh Richard talked about culturally and linguistically diverse groups, and not just linguistically, the cultural beliefs, etc., might guide their behaviours in terms of seeking health help, etc. And probably I believe also in our indigenous populations here in Australia that can also be a challenge dealing with a positive diagnosis. Richard, do you want to comment?

SPEAKER_00 20:44

Uh, it certainly is, as with other um conditions, there's a disproportionate impact on First Nations folks in Australia and um location and the being able to access an S100 provider in a regular way that we kind of take for granted being in a large city like Melbourne here in Victoria, it's extremely difficult. If you're in Alice Springs, that S100 provider travels down from Darwin once a month. If you're in a remote community or you're living kind of um in town camps outside of Alice Springs and you miss that appointment, um, there's a whole range of challenges with accessing your treatment as well as some safety issues around carrying that treatment around with you and being identified as having HIV treatment and being asked what that's for, a whole range of other things. So there's a whole range of potential cultural impacts that can impact the ability to adhere as well as receive the messages around prevention that we kind of take for granted in our larger cities.

SPEAKER_04 21:48

Yeah, no, that thank you, Richard. Uh, in terms of preventing HIV, I think uh e even in the old days when a healthcare worker got exposed. To someone with HIV, they go into single agent antiretroviral therapy. So the concept of pre-exposure prophylaxis was there. But now we've taken it to a whole nother level with PrEP. And I might direct this question to Sharon with uh both Adiba and Richard. Uh feel free to contribute as well. So, what do you think of the PrEP? Has it been successful? How does it look in the long term? Do we have to make changes to it using longer-acting drugs, etc.?

SPEAKER_01 22:34

Yeah, well, PrEP is undoubtedly one of the great success stories of the HIV response, along with treatment and people no longer filling up wards and living normal, long, healthy lives. PrEP has totally transformed the risk to acquiring HIV. The risk to acquiring HIV is a result of two things, actually. The first is treating people who have HIV because once their viral load reaches undetectable levels, they can no longer transmit the virus. Something that we call undetectable equals untransmissible, or U equals U. Absolutely revolutionary impact on people's lives and also risks of transmission. And as Richard said, people who have an undetectable viral load can safely have sex with whoever they want, they're not going to transmit the virus. At the same time, taking an antiviral to prevent HIV is also very effective. In Australia, it's been particularly effective using what we call oral prep, which is a single tablet a day taken either daily or before or after sex. And its efficacy is really high as long as you take it. Been super high here with people that are educated and have great public health support and great public health campaigns. But in some low and middle-income countries, oral prep has not been that successful because, as an example, young women who want to keep this secret from their sexual partners just don't take it at the same frequency. And the real recent advances has been injectable PrEP initially every two months, but in the last two years have become aware of a incredible advance, which is giving PrEP or drug called Lenacapavir every six months with close to 100% efficacy in settings where previously oral PrEP was 25% effective. So now we have almost like a menu of prevention options for people, a lot of choice, as we have, say with contraception, and it's very, very exciting where we haven't yet advanced to a product. But there have been scientific advances in developing an effective HIV vaccine. Much harder. But there's still some exciting advances there. But PrEP and U equals U are the two things that have driven infections down in a country like Australia, but also in um in some countries in sub-Saharan Africa. This is not just seen in high-income countries.

SPEAKER_04 25:10

Yeah, and I love U equals U. I won't forget that one.

SPEAKER_00 25:13

Oh well, I need to jump in then because I just think that that's been a revolutionary change in the way that positive people see themselves. Knowing that you can't transmit your HIV onto a sexual partner means that for the first time in my experience, we started to see folks kind of accessing the healthy sexual and reproductive relationships that we thought were not possible for us. And particularly across heterosexual communities, heterosexual men and women living with HIV, they would turn up and engage with our peer navigation program after a diagnosis and think that was the end for them, that's the end of their life. Three or four years later, you're going along to a social event and you'll see them there with their new husband or wife, baby on their arm, grin across their face. It has been such a huge change. And I also want to acknowledge the bipartisan approach of government in this country has also been central to the success in the rollout of not only um the U equals U messaging and a whole range of other things, but shortly the removal of barriers for Medicare ineligible folks to access ARV treatment, now the same with PrEP, means that this is a key factor in us moving towards what I think is a realistic goal of virtual elimination in this country, and I'd love to see Australia get there first.

SPEAKER_04 26:41

Wonderful. Thank you, Richard. Now we talked about the wonderful success of PrEP here in Australia. Adiba, if we go to Malaysia, what's the state of PrEP there?

SPEAKER_03 26:55

Um after a slow start, I think we're starting to um to scale, although not to the extent that um we'd like. But what we have, um I think we given the conservative um environment that we live in here. Um we do have government support is um based on domestic funding. Um good partnerships with um CEOs and and um private also with private GP providers. So we're getting there, but not as fast as we can. And I think um one of the way we can stigma has less than someone, but it's still not enough. It still is uh preventing people from coming forward, etc. So finding ways in which um digital technology can not just raise awareness but um allow people to um sort of access um information and even even when we have a program where um potential patients can order the test kids to do self-testing and then be linked to either press or treatment. I think these are the programs that we put in place post-pandemic that we're starting to see um uh expand. So I'm I'm hopeful that um but um you know there's still a lot of work that needs to be done to to get it to scale to really bring down the numbers. It's been sitting planted in about 3,000 new cases a year and and largely um within key populations that are no longer uh injecting drug users from decades ago.

SPEAKER_04 29:02

Yeah. And Richard mentioned the bipartisan political support we had here. Is the political landscape similar there, even though the resourcing may not be the same?

SPEAKER_03 29:13

It's a little bit more tricky because uh, like I said, the the conservative nature and um government often um current ruling government and and previous government that's a little bit more progressive often have to defend themselves in parliament. Like, why are you giving free press why are you giving free free treatment to this to this group of people? Um and that's where I think the success of working with um civil society um is is really important because civil society can kind of uh cushion some of that um negativity. So we work very closely with government. We here, meaning I'm I'm putting my civil society hat on.

SPEAKER_04 29:56

Um thank you, Andrew.

SPEAKER_01 29:58

I think it's also worth commenting that um you know the global landscape for access to both treatment and PrEP has dramatically changed in the last two years. Um it has not affected countries like Australia and perhaps not so much um Malaysia, but the dismant you know, the change in US administration, the dismantling of USAID, the changes in the a program called PEPFA, which is America's biggest investment in access to antiretroviral therapy, a $6 billion a year program, the President's Emergency Relief Fund for AIDS. Um, that has meant that many countries that had really successful programs of both treatment and prevention, but particularly prevention, no longer have access. So um we um we we should really acknowledge that globally uh things are not as rosy as they really we thought they were heading towards even just two years ago with with with you know injectable prep, uh you know, global uptake U equals U, we've gone back significantly in many countries.

SPEAKER_03 31:09

Yeah. I I think add global fund to the mix because it's it's it's not just the US government, it's government, you know, wealthy governments around the world that are not putting their money into the global fund. I think they're they're short by several billion from the uh recent replenishment, so huge setback.

SPEAKER_00 31:32

I also have a couple of concerns about the populist politic of the day and the permission structure that's being provided to walk away from these commitments that have been engaged over a very long period of time. So um we are very lucky to have the Friends of HIV Network, a multipartisan body at the federal government level, and uh we'll continue to work with them regardless of whether there's a change of government in the future. But all of us are a little concerned about the permission structures that are being enabled to kind of walk away from previous commitments.

unknown 32:07

Yeah.

SPEAKER_04 32:08

And look, I I think the only infection we've ever eradicated from the world was smallpox, and the next one we came close to was polio, but then when we were sort of almost there, we've had hiccups in terms of vaccination programs, etc. So I think maybe we're not talking about eradication of HIV here, but elimination and controlling it. It's on a global scale, it's always going to be tricky, it won't necessarily be smooth running, but I guess that's my segue talking about two vaccine-preventable diseases. About Sharon, do you what's the HIV vaccine landscape like at the moment? And what are the barriers?

SPEAKER_01 32:50

Yeah, um, developing a vaccine for HIV is tremendously difficult because no one naturally clears the virus. So when we design vaccines like the COVID, we just need to imitate a healthy immune response with our vaccine. That's been really tricky with HIV. We've got a few clues of what helps, um, but we don't have a natural model of clearance. So there are two major arms of your immune system that we want to boost with vaccines. One is antibodies, everyone knows about antibodies because of COVID, and the other is T cells, two arms of the immune system that are actually important for HIV clearance. And with an HIV vaccine, we've sort of bounced around about what's more important, T cells or antibodies. I think the big advance in the, and and I should also say, huge investment in vaccine science from largely the US government. And that's taught us so much about immunology, and actually, it taught us a lot about developing vaccines that were highly relevant for COVID, but we're not there yet. The exciting bit, and I'll talk very briefly about vaccines now, is a discovery that some people make really good antibodies naturally, and that we call them broadly neutralizing antibodies, meaning that the antibody recognise lots of different strains of HIV and can stop those viruses in their tracks. And we know how to make those broadly neutralizing antibodies in test tube models, and we're now learning about how to induce them in people. Um, and in fact, there have been some phase one studies of broadly neutralizing antibody-inducing vaccines, very complicated. You need sort of six to eight vaccines to get there, and you people can make broadly neutralizing antibodies following vaccination. So there's a big shift focused now on trying to induce broadly neutralising antibodies, but we're a way off getting at its scale. To do a vaccine study at scale now, um, you have to compare to best to um prep because you can't just randomize people to a placebo. So efficacy studies are very, very expensive, and so you need big investment here from a government like the US or big pharma to really um you know nail us getting a vaccine. But there is advances on the science, um, but and I still believe we need one because PrEP requires a lot of infrastructure around it. You've got to buy the drugs, they're not cheap, especially not the injectable ones, and you have to have an infrastructure to keep people taking them or keep delivering to them. Um, a vaccine would be far preferable, but we're still not there.

SPEAKER_04 35:39

Yeah. And I think for people who know, there there'll be some people listening to this podcast who know a little bit about HIV, but not too much. And they might think that if you can get rid of levels in the blood, make it undetectable in the blood, why isn't it cured? But there are places that HIV hides, aren't there, Sharon? Do you mind briefly explaining that?

SPEAKER_01 36:02

Yeah, so um, when you put people on treatment, as you say, the virus rapidly disappears from blood, you can no longer transmit the virus, your immune system recovers and you can live a normal, healthy life. But the virus goes into hiding in something called latency. Many viruses have latent forms. COVID doesn't, as an example, while the glandular fever virus does. So, you know, latency is a very nice trick of viruses to persist forever. And so we know that the virus goes into hiding in cells. Very few infected cells, maybe one in a million cells, are infected. But as soon as you stop treatment, if you've been on treatment for 10 years or 20 years, um, your virus pretty much comes straight back up in two to three weeks. And so there's a lot of work now around the world trying to eliminate latent virus or alternatively boost someone's own immune system, like trying to get people to make their own broadly neutralizing antibodies, and that will keep the virus under control once you stop antiviral therapy. And just in the last two to three years, there's been a number of clinical trials, small, you know, phase two studies, you know, ranging from 30 to 100 people, show that you can actually induce quite good immune responses in people already infected with HIV. But we're still way off. Um, a cure that would mean your virus is truly undetectable at undetectable levels. Also, some really exciting advances in gene therapy where you can actually deliver someone a gene for to make those broadly neutralizing antibodies. So we're going to see a lot of new changes, I think, in options for cure as the science gets better around immunotherapy, that lessons we learn from cancer around gene therapy, around mRNA therapeutics. These are all technologies that will really help us solve this problem of eliminating latent virus.

SPEAKER_04 38:04

Yeah, and I think while prevention is better than a cure. A cure, I'd certainly take a cure any day if we could achieve it. And you're right, gene therapy is is so important. We're seeing conditions like sickle cell anemia in the US, they're offering gene therapy, which uh I believe can cure it. So we're thinking about things we we never considered before. So that's that's really wonderful. And uh Deba, maybe do you mind just uh briefly talking about we the cures we have had for HIV in the context in which they occurred? I guess specifically the Berlin and London patients, what what they were could you explain to our audience what they were all about?

SPEAKER_03 38:46

I think that that goes to um Sharon as well. She's the guru there, but very briefly, I think um, you know, what each time when we when we have those those uh patients who um have been cured, and I believe the it's not so simple. You know, especially the first few patients who were cured were cured because they had to undergo transplantation and you know, both and cell transplantation and others. So um the the pathway to get a cure itself is was not easy, but it allowed the scientific community to understand what it takes, and you know, a lot of a lot of further research then goes into it. And I think it gives um a lot of hope to a lot of people, and Richard will be able to speak better to this. So you know, I think um there are many lessons that we learn each time. Um, there is uh an episode of someone who's been cured from HIV is my big picture of it with you know the signs. You need to throw that question back to Sharon because she's she's the see-fu here. You explained it more than that.

SPEAKER_01 40:03

Yeah. I can just mention it briefly. There's um been 10 people cured following stem cell transplantation globally. They've all been in high-income countries, I should say, no reports yet from low and middle-income countries. And most of them, but not all of them, received a bone marrow transplant from a donor who is naturally resistant to HIV. So there's a gene that um called CCR5 that is HIV needs to enter into a cell, and about 1% of people of Caucasians lack that gene and don't express CCR5. It's not the whole story about about um cure, but ADB, and there's there's other components that led to um people being cured, the donor being CCR5 negative, graft versus host disease, the preparation you have for your transplantation. But I think Adiba is absolutely spot on about um the everyone gets very excited about this. There's always lots of news headlines, and we try and damper down people saying this doesn't mean a cure for everyone, but it's incredibly inspiring for a community that it is possible and it does give us clues. So, for example, there is a whole program of work being done to use gene therapy to knock out CCR5 rather than having to have a transplantation. So we learn a lot from this. And we also know that there's a very few people that can naturally control their viruses to undetectable levels. And again, these people are very, very rare. We call them exceptional elite controllers. There's been about five adults described, and um, a few more children described that have been able to do this. And again, many groups around the world are studying their immune system intensively to understand what it was that allowed these people to essentially eliminate the virus on their own.

SPEAKER_00 41:56

And I think from a community perspective, I want to acknowledge all of those ten. They were probably gravely ill to undergo those treatments to begin with. Many of them are no longer with us, but they chose in that moment to trust the science, take the opportunity, put their bodies on the line in an altruistic way that I think we see represented in both small and large ways across our community, and they continue to inspire us to support the work that Sharon does in Cure with treatment interruption trials and a few other things like that, where people are still passionate about doing anything that they can to move us towards that end goal of that holy grail for us, which is cure.

unknown 42:42

Yeah.

SPEAKER_04 42:43

Look, on that final note, I'm gonna close this wonderful discussion where we've looked at HIV over the decades from a consumer epidemiological clinical laboratory point of view and covered so much. And I think there's definitely more cause for optimism than pessimism, particularly with people like Adiba, Richard, and Sharon involved in HIV medicine. So thank you all for your time, and I hope we can catch up again.

SPEAKER_01 43:15

Thanks so much, Sanjay.

SPEAKER_04 43:16

Thank you.

SPEAKER_03 43:16

Thanks everyone. Bye.

SPEAKER_02 43:30

Thank you once again to Richard Keene, Professor Adiba Kamarulzaman, and Professor Sharon Loon for taking the time to share their expertise. And also to Associate Professor Sanjay Sananyake for volunteering to be the able host of Contagious Conversations. Development of today's episode was also assisted by Dr. Emma Page and Dr. Sushuna Krishnaswamy from ACE's Viral Hepatitis and HIV Special Interest Group. Thanks also to Inga Meggett, Tireless All-Round Coordinator at the Australasian Society for Infectious Diseases. If you'd like to get your own specialty society up in lights, please get in touch with me via the email address podcast at rcp.edu.au. I'm happy to discuss what kind of input and commitment is required to get a series like this going in the new year. At our website you'll find 150 previously published episodes of pomegranate health. Just click on Episode Browser to filter this back catalogue by series, clinical specialty, or domain of professional practice. And if you want to learn more about infectious diseases, the College Learning Series has over 30 lectures on STIs, tuberculosis, microbacterial infections in children, and more. Just head over to eLearning.racp.edu.au and check out the CLS or the Medflix Library, which contains some great seminars. These include recordings from RACP's Lyft series, designed to promote learning, innovation, and forward thinking. This podcast was produced on the lands of the Gadigal clan of the Euro Nation. The RACP is committed to equitable healthcare for all Aboriginal, Torres Strait Islander, and Māori people. I'm Mick Kavazzini. Thanks for listening.