From Berlin to Boston, researchers see both hope and quandary on the horizon

Hopeful news broke last week as the International AIDS Society Conference in Kuala Lumpur came to a close – the two bone marrow transplant “Boston patients” show no sign of the HIV virus, even after stopping their medication. While physicians and experts are explicit that the Boston patients should not be considered “cured,” thus far it is the first successful replication of the bone marrow transplant (BMT) treatment used on the one and only man who has officially been declared cured of HIV –“Berlin patient” Timothy Brown.

The BMT procedure transplants multipotent stem cells to patients with blood cancers after they have undergone chemotherapy. Initially the BMT treatment was used in tandem with antiretroviral drug treatments; the big news at the IAS Conference was that even after stopping those drugs, the patients still showed no signs of the virus.

“The Boston patients’ success provides further evidence of the possibility and means by which a clinically feasible cure for HIV might be developed.  It also raises several important issues of medical ethics and social justice,” says Theodore Bailey, MD, JD, MA, a fellow at the Johns Hopkins Berman Institute of Bioethics whose research focuses on the ethics of HIV/AIDS treatment and prevention.

First, Bailey says, is the question of testing BMT treatment more widely: Would it be ethical to design a clinical trial comparing the clinical and public health benefits of bone-marrow transplant as a potential means of cure, with its high risk of treatment-related morbidity and mortality, to the current standard of HIV treatment with life-long anti-retroviral medications known to be highly efficacious, and of generally low toxicity?

In BMT, the patient’s bone marrow, the source of blood cells for the body, is destroyed by chemotherapy before the donor bone marrow is transplanted. This alone carries up to a 20 percent risk of death due to a severely weakened immune system, as estimated by Timothy Henrich, MD, an infectious disease specialist treating the Boston patients.

“What is the ethical significance of the difference between curing and controlling an individual’s HIV infection?” Bailey posits.  It is an ethics question of benefit-risk assessment – determining if the value of a cure, as opposed to management, is high enough to justify the high risk of BMT.

There are significant social justice issues to be considered as well, Bailey notes, that are much broader than BMT.  “Is there a special moral significance or imperative to curing HIV? Or is a cure for HIV better viewed as one means among many aimed at eliminating HIV-associated morbidity and mortality and related social impacts?” Bailey asks.

If any HIV cure does become well established?  Thorny issues remain, Bailey says.  Given that we have, as yet, collectively failed to ensure equitable global access to anti-retroviral treatments for all HIV infected individuals and effective HIV prevention measures for all individuals at risk of infection, the question of how to ensure fair, equitable access to an eventual cure is a huge one, Bailey says.

Any progress on the HIV front is encouraging.  While the results announced at IAS should be viewed as preliminary and not yet as conclusive as the Berlin patient case, Bailey says the corresponding ethical issues raised cannot be put off until the day a cure is confirmed.

“These ethical questions should be posed and addressed now rather than later, so that they can inform our actions and policies going forward,” Bailey says.

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Leah Ramsay
Saad Anjum
Ted Bailey

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