Synergies, tensions and challenges in HIV prevention, treatment and cure research: exploratory conversations with HIV experts in South Africa

'It is scary to pause treatment': perspectives on HIV cure-related research and analytical treatment interruptions from women diagnosed during acute HIV in Durban, South Africa

BACKGROUND

HIV remains a major challenge in KwaZulu-Natal, South Africa, particularly for young women who face disproportionate risks and barriers to prevention and treatment. Most HIV cure trials, however, occur in high-income countries.

OBJECTIVE

To examine the perspectives of young women diagnosed with acute HIV in a longitudinal study, focusing on their perceptions on ATI-inclusive HIV cure trials and the barriers and facilitators to participation.

MATERIALS AND METHODS

Between October 2022 and February 2024, we conducted closed-ended surveys and in-depth interviews with 20 women aged 19-33 living with HIV, who were willing but ineligible or unable to participate in an HIV cure trial.

RESULTS

Many participants reported mental health challenges, including major depression (40%), moderate to severe anxiety (35%), and low self-esteem (35%). While women diagnosed during acute HIV supported pausing antiretroviral treatment (ART) during analytical treatment interruption (ATI) to advance HIV cure research, concerns about health risks and HIV-related stigma were significant barriers to enrollment. Trust in the research team and close monitoring were seen as positive factors, while fears around sharing of HIV/ATI status and transmission to sex partners complicated decision-making. Participants expressed a need for psychological counseling and access to community resources to manage ATI-related stressors.

CONCLUSIONS

Understanding women's perspectives on HIV cure research, especially ATI trials, is vital. Building trust and addressing psychosocial challenges through a healing-centered approach can facilitate trial participation. Socio-behavioral research before and during HIV cure trials will be essential to inform participant-centered protocol design.

The Importance of Social Engagement in the Development of an HIV Cure: A Systematic Review of Stakeholder Perspectives

As research into the development of an HIV cure gains prominence, assessing the perspectives of stakeholders becomes imperative. It empowers stakeholders to determine priorities and influence research processes. We conducted a systematic review of the empirical literature on stakeholder perspectives. PubMed, Embase, Web of Science, and Scopus were searched for empirical, peer-reviewed articles, published before September 2022. Our analysis of 78 papers showed that stakeholders could be divided into three categories: people with HIV, key populations, and professionals. Following thematic synthesis, two main themes were distinguished: stakeholders' perspectives on HIV cure research and stakeholders' perspectives on HIV cure. Research on perspectives on HIV cure research showed that stakeholders' hypothetical willingness to participate (WTP) in HIV cure research was relatively high, while actual WTP was found to be lower. Studies also identified associated (individual) characteristics of hypothetical WTP, as well as facilitators and barriers to hypothetical participation. Additionally, we reported research on experiences of actual HIV cure research participation. Our analysis of stakeholder perceptions of HIV cure showed that most stakeholders preferred a cure that could eliminate HIV and outlined positive associated impacts. Furthermore, we observed that most included studies were conducted among PWHIV, and in the Global North. To empower stakeholders, we recommend that future research include an even greater diversity of stakeholders and incorporate theories of behavior to further explore how stakeholders decide to meaningfully engage in every stage of HIV cure research.

'With this study, we have hope that something is coming': community members' perceptions of HIV cure-related research in Durban, South Africa - a qualitative focus group study

BACKGROUND

Developing a cure for HIV remains a global scientific priority. In 2022, the Females Rising through Education, Support and Health (FRESH) cohort launched an HIV cure-related trial involving an analytical treatment interruption (ATI) in Durban, South Africa.

OBJECTIVES

To explore community perspectives about HIV cure-related research.

METHODS

Between July-August 2022, we conducted three focus groups with community members. We transcribed audio recordings verbatim and used content analysis to analyze the data.

RESULTS

Twenty community members (13 women and 7 men) participated in three focus groups (HIV status not included). Participants viewed HIV cure-related research as a way to address the issue of defaulting on (not taking) HIV treatment. Participants expressed hesitancy around ATIs, since these contradict longstanding treatment adherence messages. Participants shared concerns around the risk of side effects from experimental interventions balanced against potential efficacy. They advocated for trial participants to have the right to decide whether to inform their sex partners about their HIV status and ATI participation, rather than research teams making disclosure mandatory. Focus group participants also emphasized the importance of using simple language to explain HIV cure-related research.

CONCLUSIONS

With HIV cure trials set to launch across Africa in the future, there is a critical need to better understand and respond to local community needs and preferences and to adopt this as standard practice prior to regional trial implementation.

HIV cure: an acceptability scientific agenda

PURPOSE OF REVIEW

Recent years have seen major investments into HIV cure research, seeking a permanent cure or remission. The purpose of this review is to consider how this important research agenda could be broadened to include issues of acceptability and appropriateness for different populations.

RECENT FINDINGS

We discuss how the definitions of cure such as functional cure (remission) or complete cure (viral elimination) could be interpreted differently by various populations. We also discuss the different methods of cure and the importance of including Africa in cure research to ensure that emerging remedies could be trialled and utilized on the continent that bears the brunt of the AIDS pandemic.

SUMMARY

We propose that the social science research of HIV cure acceptability should be done concurrently with the basic and clinical sciences, to ensure that cure methods consider stakeholder preferences.

Community HIV clinicians' perceptions about HIV cure-related research in the Northwestern United States

Background: Research on stakeholder perspectives of HIV cure research has involved people with HIV (PWH), who generally cite the importance of HIV clinician advice in making decisions about trial participation. However, there has been little exploration of non-researcher community HIV clinician perspectives, which are clearly critical to the success of HIV cure-related research.Objective: We aimed to learn how community HIV clinicians perceive HIV cure research and identify factors that would lead them to support or discourage HIV cure trial participation by their patients.Methods: We recruited a purposive sample of 12 community HIV clinicians in metro-Seattle, WA to participate in structured interviews. We completed 11 interviews via teleconference and received one written response. We used conventional content analysis to analyze the data.Results: Overall, community HIV clinicians were supportive of patient participation in HIV cure trials. Factors affecting support included knowledge of local trials, ease of referral, patient immune function and health stability, study risks and benefits, burden of study requirements, patient characteristics, patient life stability, potential impact on engagement in care, study communication plans, and beliefs that patients should have the autonomy to decide to participate. Participants had concerns about trials requiring treatment delays or interruptions and HIV transmission risk. While their knowledge of the field was limited, they were interested in learning more about open HIV cure trials.Conclusions: It would benefit the HIV cure research community if those leading HIV cure trials make stronger efforts to engage community clinicians who care for PWH, but are not active researchers, early in the trial design process. Such engagement prior to launching HIV cure trials will improve trial designs, leading to better enrollment and retention within these important studies.

Subjective Well-Being and Schools in South Africa: A Post-COVID-19 Analysis

From the analysis of the Wave 5 National Income Dynamics Study - Coronavirus Rapid Mobile Survey 2021 dataset, the study conducted in South Africa, we developed a model of analysis based on three dimensions, namely, subjective well-being, material living conditions, and importance attributed to education during the COVID-19 pandemic. A cross-sectional analysis of the data for Gauteng area indicates that the dimension of subjective well-being of families in South Africa-even in relation to the factors such as conditions of deprivation (e.g., hunger)-does not necessarily influence the importance the respondents attach to their children's education, this as reflected in whether or not they send them to school when COVID-19 restrictions allowed for schools to come back to face-to-face teaching. Subjective well-being of parents and guardians is, however, a predictor of concern about their children's education and future. Our working hypothesis is that, although there is little evidence that subjective well-being has a significant association with the respondents' willingness for their children to continue their schooling, there is a significant indirect effect of subjective well-being-which is especially determined by the gender as well as of the living material conditions-and the greater or lesser importance that the respondents attribute to their children's education. Likewise, and in more general terms, subjective well-being is clearly related to gender, with women having the lowest levels of subjective well-being.

Ethics of HIV cure research: an unfinished agenda

BACKGROUND

The pursuit of a cure for HIV is a high priority for researchers, funding agencies, governments and people living with HIV (PLWH). To date, over 250 biomedical studies worldwide are or have been related to discovering a safe, effective, and scalable HIV cure, most of which are early translational research and experimental medicine. As HIV cure research increases, it is critical to identify and address the ethical challenges posed by this research.

METHODS

We conducted a scoping review of the growing HIV cure research ethics literature, focusing on articles published in English peer-reviewed journals from 2013 to 2021. We extracted and summarized key developments in the ethics of HIV cure research. Twelve community advocates actively engaged in HIV cure research provided input on this summary and suggested areas warranting further ethical inquiry and foresight via email exchange and video conferencing.

DISCUSSION

Despite substantial scholarship related to the ethics of HIV cure research, additional attention should focus on emerging issues in six categories of ethical issues: (1) social value (ongoing and emerging biomedical research and scalability considerations); (2) scientific validity (study design issues, such as the use of analytical treatment interruptions and placebos); (3) fair selection of participants (equity and justice considerations); (4) favorable benefit/risk balance (early phase research, benefit-risk balance, risk perception, psychological risks, and pediatric research); (5) informed consent (attention to language, decision-making, informed consent processes and scientific uncertainty); and (6) respect for enrolled participants and community (perspectives of people living with HIV and affected communities and representation).

CONCLUSION

HIV cure research ethics has an unfinished agenda. Scientific research and bioethics should work in tandem to advance ethical HIV cure research. Because the science of HIV cure research will continue to rapidly advance, ethical considerations of the major themes we identified will need to be revisited and refined over time.

Exploring the anti-HIV-1 reverse transcriptase, anti-inflammatory, anti-cancer activities and cytotoxicity of two fermented commercial herbal concoctions sold in Limpopo Province of South Africa

BACKGROUND AND OBJECTIVES

The use of herbal concoctions is very popular in South Africa, including Limpopo Province. The herbal concoctions are claimed to be capable of treating numerous illnesses such as ulcers, cancer, HIV/AIDS, diabetes, certain STDs, blood cleansing to mention but a few. The focus of this study was to evaluate the anti-HIV 1 reverse transcriptase, anti-inflammatory and anti-cancerous activities as well as cytotoxic effects of 2 fermented herbal concoctions used for the treatment of the related ailments in Limpopo province of South Africa.

METHOD

Two fermented herbal concoctions obtained from a herbalist in Polokwane were extracted with 80% acetone. The anti-HIV activity of the herbal concoctions was determined using the anti-HIV reverse transcriptase assay. The anti-cancer and cytotoxic effects of the herbal concoctions were evaluated using cancerous Human Colon (HT-29) cells and the normal human Hepatoma cells (C3A) respectively.

RESULTS

Notable anti-HIV reverse transcriptase activity was observed from the 80% acetone fraction of herbal concoction 1 (IC₅₀ 38.031 μg/mL) which exhibited better activity than the positive control Lamivudine (IC₅₀ 40.90 μg/mL). There was variation in the anti-inflammation activity as determined by the sPL2, 15-LOX and COX enzyme assays. The only concerning matter was the high COX-1 activity in some of the extracts, which is not desirable due to the mucosal protection action of COX-1 enzyme. The herbal concoctions did not exhibit cytotoxic effects on normal human cells, however, toxicity against cancerous cells was observed.

CONCLUSION

The herbal concoctions displayed some considerable pharmacological effects against various ailments as claimed by the herbalist. More work to ascertain the toxicity of both concoctions against cancerous cells need to be followed as this could lead to the discovery of anticancer drugs.

Re-examining the HIV 'functional cure' oxymoron: Time for precise terminology?

For over a decade, the binary concepts of 'sterilizing' versus 'functional' cure have provided an organizing framework for the field of HIV cure-related research. In this article, we examine how the expression 'functional cure' is employed within the field, published literature, and community understanding of HIV cure research. In our synthesis of the different meanings attributed to 'functional cure' within contemporary biomedical discourse, we argue that employing the 'functional cure' terminology poses a series of problems. The expression itself is contradictory and inconsistently used across a wide array of HIV cure research initiatives. Further, the meaning and acceptability of 'functional cure' within communities of people living with and affected by HIV is highly variable. After drawing lessons from other fields, such as cancer and infectious hepatitis cure research, we summarize our considerations and propose alternative language that may more aptly describe the scientific objectives in question. We call for closer attention to language used to describe HIV cure-related research, and for continued, significant, and strategic engagement to ensure acceptable and more precise terminology.

Acceptability of Cell and Gene Therapy for Curing HIV Infection Among People Living with HIV in the Northwestern United States: A Qualitative Study

Multiple strategies to cure HIV infection are under investigation, including cell and gene therapy (C>) approaches. Research, and ultimately treatment, with these novel strategies will require patients' willingness to participate. To elicit the perspectives of people living with HIV specific to these novel approaches, we conducted 4 focus group discussions with a diverse group of 19 English-speaking men and women living with HIV in care at a large academic HIV clinic in the northwestern United States. Thematic analysis indicated participants expressed initial fear about C> research. They articulated specific concerns about risks, including analytical treatment interruptions, and thought only a person in desperate straits would participate. They voiced significant mistrust of research in general and believed there was already a cure from HIV that was being withheld from the poor. Overall, they were satisfied with their health and quality of life on antiretroviral therapy. These findings suggest the importance of community engagement and educational efforts about C> for HIV cure to ensure optimal collaborative partnerships.

The psychology of "cure" - unique challenges to consent processes in HIV cure research in South Africa

BACKGROUND

Consent processes for clinical trials involving HIV prevention research have generated considerable debate globally over the past three decades. HIV cure/eradication research is scientifically more complex and consequently, consent processes for clinical trials in this field are likely to pose a significant challenge. Given that research efforts are now moving toward HIV eradication, stakeholder engagement to inform appropriate ethics oversight of such research is timely. This study sought to establish the perspectives of a wide range of stakeholders in HIV treatment and research to inform consent processes for cure research.

METHODS

In total, 68 South African stakeholders participated in two qualitative research modalities. In-depth interviews (IDIs) were conducted with a purposive sample of 42 individuals - audiotaped with consent. Twenty-six stakeholders participated in three focus group discussions (FGDs). Thematic analysis of transcribed IDIs and FGDs was conducted.

RESULTS

The majority of respondents indicated that there could be unique challenges in HIV cure research requiring special attention. In particular, given the complexity of cure science, translation of concepts into lay language would be critical for potential participants to adequately appreciate risks and benefits in early phase research with experimental interventions. Furthermore, to aid understanding of risks and benefits against a background of desperation for a cure, specially trained facilitators would be required to assist with a psychological assessment prior to consent to avoid curative misconceptions. Long-term participant engagement to assess durability of a cure would mean that the consent process would be prolonged, necessitating annual re-consent. Building trust to maintain such long-term relationships would be critical to retain study participants.

CONCLUSION

Unique consent requirements for cure research in South Africa would include significant efforts to maximise understanding of trial procedures, risks and the need for long-term follow-up. However, the psychological dimension of cure must not be underestimated. Beyond an understanding of cure science, the emotional impact of HIV cure advances the discourse from cure to healing. Consequently, the consent process for cure research would need to be enhanced to include psychological support and counselling. This has several important implications for research ethics review requirements for consent in HIV cure research.

Ethical challenges in developing an educational video to empower potential participants during consent processes in HIV cure research in South Africa

Obtaining consent for HIV research is complex, particularly in low- and middle-income countries. Low levels of education, complexity of science and research processes, confusion about basic elements of research, and socio-economic conditions that make access to medical care difficult have collectively led to concerns about the adequacy of the consent process. Given the exponential growth of HIV prevention and treatment research in South Africa, HIV researchers are increasingly facing challenges obtaining authentic informed consent from potential participants. It is anticipated that HIV cure research, despite being in its infancy in South Africa, will introduce a new discourse into a population that is often struggling to understand the differences between 'cure', 'preventive and therapeutic vaccines' and other elements of the research process. Coupled with this, South Africa has a complex history of 'illegitimate' or 'false cures' for HIV. It is therefore logical to anticipate that HIV cure research may face significant challenges during consent processes. HIV prevention research in South Africa has demonstrated the importance of early community engagement in educating potential research participants and promoting community acceptance of research. Consequently, in an attempt to extrapolate from this experience of engaging with communities early regarding cure research, a 15-minute educational video entitled 'I have a dream: a world without HIV' was developed to educate and ultimately empower potential research participants to make informed choices during consent processes in future HIV cure clinical trials. To aid others in the development of educational interventions, this paper discusses the challenges faced in developing this educational video.

What Would an HIV Cure Mean to You? Qualitative Analysis from a Crowdsourcing Contest in Guangzhou, China

Much HIV cure social science research has focused on high-income countries. Local key population perspectives, especially from people living with HIV (PLHIV), are needed in low- and middle-income countries. We organized an open contest soliciting responses from key populations, including PLHIV, about what a cure would mean in their lives. Tailored in-person events and social media were used to engage PLHIV, men who have sex with men (MSM), people who inject drugs, and local residents. We received 471 contributions over 4 months. Our thematic analysis showed that many people perceived that a cure would sterilize HIV and bring about new life for PLHIV. Many individuals believed a cure would decrease PLHIV discrimination and many MSM perceived a cure would decrease MSM discrimination. Some participants noted that a cure could help improve interpersonal relations, particularly with families and partners. Many individuals envisioned HIV cure as a panacea to bring about social stability. Some participants also anticipated changes in attitudes toward sex that may result in increased condomless sex. Our findings suggest a continued need for careful management of patient expectations and community engagement.

Research on HIV cure: Mapping the ethics landscape

In an essay, Karine Dubé and coauthors discuss the ethics of preclinical and clinical studies relevant to achieving an HIV cure.