Obstacle in the battle against pediatric HIV

For over 20 years, Harvard infectious disease expert Roger Shapiro has battled HIV on the ground in Botswana, where infection rates surpassed 30 percent in certain regions during the 1990s.

Advancements have been consistent. As per the World Bank, Botswana continues to maintain one of the highest infection rates globally — over 20 percent of the adult populace — but significantly fewer HIV fatalities. The crucial lifesaver has been antiretroviral therapy (ART).

Shapiro initiated his work in Botswana in 1999 under the guidance of groundbreaking AIDS researcher Max Essex, who was instrumental in establishing the Botswana Harvard Health Partnership (BHP) as a collaboration between the nation’s Ministry of Health and what was previously known as the Harvard School of Public Health. Since then, Shapiro has conducted numerous studies on HIV/AIDS in Botswana and has emerged as an authority on the impact of HIV on maternal and child health.

Among Shapiro’s ongoing studies is a trial with the potential to assist certain children in managing HIV without requiring treatment. Although attempts to develop a vaccine have not succeeded, there are promising new progressions involving products referred to as broadly neutralizing antibodies, or bNAbs, according to Shapiro.

This trial aims to discover a new treatment method by investigating the implications of a blend of three broadly neutralizing HIV antibodies. The research builds on earlier findings suggesting that bNAbs may enhance the immune response to eliminate the virus more effectively than conventional ART, presenting a hopeful route towards achieving post-treatment viral control, he adds.

“This is the only pediatric study exploring three antibodies as a combined treatment for HIV and ultimately as a pathway to a potential HIV cure,” stated Shapiro, a professor of immunology and infectious diseases at the Chan School. “It’s genuinely thrilling science, as we are evaluating if some children can cease all treatment and regulate HIV independently.”

“Botswana may possess the best program to inhibit HIV transmission to children on the continent.”

Roger Shapiro

In May, the five-year grant supporting the study was significantly reduced amid the Trump administration’s widespread cancellation of Harvard research funding. Four additional grants for Botswana-based initiatives led by Shapiro were also terminated. These cuts have not only inflicted a significant setback on the participants in the trial and their families, stated Shapiro, but have jeopardized advancements toward a pediatric HIV cure.

“This was one of the most comprehensively funded studies to begin making progress in this domain,” he remarked. “Now all this research is uncertain. It has the capability to delay the pediatric cure initiative for years, if not indefinitely.”

Backed by the National Institutes of Health and the National Institute of Allergy and Infectious Diseases, the trial is monitoring 12 children, aged 2-9 years, who are living with HIV. The study is in its second year, with researchers preparing for the children to pause standard ART and transition to using antibodies solely as treatment.

The team had aimed to scale up to 41 children, but due to the cuts, they are now targeting 30. They secured donations to continue the project until March, but it remains uncertain what will happen afterward.

According to the Centers for Disease Control, Botswana is a frontrunner in global HIV initiatives, having surpassed the UNAIDS 95-95-95 objectives: “95 percent of individuals living with HIV in Botswana know their status, 98 percent of those who know their status receive treatment, and 98 percent of individuals receiving treatment are virally suppressed.”

“Botswana likely has the most effective program for preventing HIV transmission to children on the continent,” stated Shapiro. “Now, less than half a percent of children become infected because most women have access to free medication during pregnancy, effectively halting transmission. It’s a minuscule percentage, but it still results in more pediatric HIV cases than we observe in the United States.”

Administering treatment to children infected with HIV daily for the rest of their lives is a daunting expectation for many families, stated Shapiro. Families were enthusiastic about the chance of their children being freed from consistent infusions of antibodies.

The grant’s cessation has introduced additional uncertainty to Botswana’s struggle against HIV/AIDS. In February, support through USAID, the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), and the Centers for Disease Control and Prevention to the African nation was also reduced. Botswana’s government finances medication, but it depended on those funds to offer services related to HIV, notes Shapiro.

“HIV/AIDS is essentially a chronic issue in Botswana, and a chronic issue demands ongoing treatment,” he commented. “If treatment fails … We are concerned about HIV transmission rising again, not only in Botswana but throughout all of Africa.”