HCV and HIV: Great Advances, But Far to Go

Last night marked the opening of the 2015 Conference on Retroviruses and Opportunistic Infections (CROI)-the 23rd such annual event. What started as a meeting of 1000 scientists and clinical researchers in 1993, now has an attendance capped at 4000, of whom about 40% are from outside of the US. This annual meeting is considered the premier scientific event of its kind, and is actually rather hard to get permission to attend (limited primarily to those who are actively doing research in the fields of HIV and HCV).

Not surprisingly, there was tremendous anticipation surrounding the two named, plenary talks.

The first was a very thorough review of HCV by Charles M. Rice of The Rockefeller University, New York, highlighting especially the amazing progress that has been made in the past 2 years. The second was a look back as well as forward in the fight against HIV by Dr David A. Cooper from the Kirby Institute, University of South Wales, Sydney, Australia. 

Two summary points deserve mention:

Nevertheless, each of the two talks highlighted the financial and other logistical hurdles that exist, such that a “cure” for even a simple majority of those infected with either virus seems years away. There are estimated to be 170 million persons infected and living with HCV worldwide and over 35 million infected and living with HIV worldwide. In the case of HCV, only about 50% of infected individuals are aware of their diagnosis; with HIV, at least 20% are unaware of their infection.

In other words, there is a huge pool of infected persons who will not be seeking therapy and who are at risk for either disease progression or serving as, at least for those infected with HIV, sources of spread to others. Even in resource-rich countries, at least until recently, in only 1 of 3 persons known to have HCV infection was therapy prescribed. Currently, the US retail pharmacy cost of these “90% – 95% effective” combination therapies is over $80,000 per course, even though the actual cost to produce the combination of products used are somewhere in the range of $10,000 per 12-week course.

It is obvious to me that even using the US$10,000 figure, these therapies will not be used in countries with gross domestic products (GDPs) less than US$5000 – US$10,000 (compared with the US GDP of $50,000). Even in the US, many insurance companies are balking at covering the cost ($80,000 or more) for a course of therapy to eradicate HCV. In addition, and as was pointed out by Dr Rice, even those who are in the 95% group of “sustained virologic responders” may still have progression of their liver disease and the subsequent development of cirrhosis and/or hepatocellular cancer.

With HIV, eradication of the virus is not possible currently. Nevertheless, there has been a “functional cure,” available for years, as a result of combination antiretroviral therapy (cART). And while there has been an impressive “scale-up” effort worldwide to make antiretroviral therapy available to everyone (or at least to those with CD4+ cell counts <350/µL), currently only about 40% of those with an HIV diagnosis are receiving cART. The WHO would like to get to “90 – 90” by 2030, meaning diagnose and treat at least 90% of those infected with HIV (compared with 50 – 40 currently worldwide). If successful, the WHO estimates that new HIV infections would fall by 70% (ie, treatment as prevention). 

Getting there, however will be daunting. Currently, there are 13.6 million persons receiving cART, compared with the 28.6 million who need the therapy (those with CD4+ cell counts <350/µL). At a time when funding for these efforts is “flat," the situation begs the question, “do we, in resource-rich countries, have the will and the resources to spend locally and/or globally on either HIV or HCV eradication?” Even if we do, we may not substantially slow new infections. In Australia, for instance, currently at “90 – 80,” there actually has been a slight but steady increase in the number of new infections each year for the past decade (ie, failure of treatment as prevention).

In summary, the mood of the audience coming out of the two talks was best described as “somber.” We have the tools (medications), but the goal of eradication of both HIV and HCV seems almost as elusive as ever.