This piece is part of “The Cure for Everything:” A series of stories that looks at the breakthroughs, setbacks, and overall status of vaccines and cures for hard-to-treat diseases and viruses, from HIV and herpes to the flu and hangovers.
WHEN NBA LEGEND Magic Johnson revealed he was HIV-positive in 1991, he famously said: “Life is going to go on for me, and I’m going to be a happy man.” At the time, his plans seemed bold. HIV and AIDS infections were rising. Few treatments existed. At its peak in 1995, AIDS killed 50,628 people in the U.S.—that's more than 10 times the latest yearly death toll.
Today, Johnson and many other Americans are doing well decades after contracting HIV. Modern HIV medications can suppress the virus to undetectable levels so it doesn’t advance to AIDS or spread to others. Does that mean the fight against HIV is over? Not quite.
“We still don't have HIV cures,” says Jirair Ratevosian, DrPH, M.P.H., Associate Research Scientist at Yale School of Nursing. “We still don't have an HIV vaccine because the science is really difficult on this, but the modern-day treatment and prevention options really give us the tools that we need to control it.” Here’s what you need to know about HIV now as the search for a cure continues.
Stopping the Virus From Replicating
Scientists first identified HIV in 1983, but the virus has been with us longer. Research suggests HIV probably infected its first human about a century ago. We know it spread stealthily between people as early as the 1960s.
In men, most new infections come from sex or injection drug use. What makes HIV so tricky is that once it finds its way into your body, it takes hold. HIV is a retrovirus, which means it can integrate its genetic material into your cells’ DNA. As cells reproduce, the HIV DNA inside replicates fast and makes mistakes, creating mutations that can make treatment harder. Antiretroviral therapy, which interrupts the virus’ copy-and-paste routine, is the stalwart of HIV treatment.
“We have medications that stop it at certain points from replicating, but if you don't, it could replicate on a daily basis billions of times per day,” says Melissa Badowski, Pharm.D., M.P.H., a clinical professor and clinical pharmacist at the University of Illinois at Chicago College of Pharmacy. “So then that's in your body, and it's making more virus in your body.”
The first HIV drug, which came out in 1987, blocked nucleoside reverse transcriptase, an enzyme HIV uses to replicate. A few similar medications followed over the next few years, but the fast-mutating virus found ways around them. Early treatments also required multiple daily pills and often caused harsh side effects. Things started to change in 1995 with combination therapy, which used two nucleoside reverse transcriptase inhibitors to hamstring the virus.
The next year brought the breakthrough that still defines HIV treatment today: highly active antiretroviral therapy (HAART). HAART uses three or more drugs that work in at least two different ways. There are now more than 30 antiretrovirals, with pills that combine multiple meds in one tablet for easy use.
Another option is long-acting antiretroviral therapy, an injection administered every month or two. “It helps give men options tailored to their lifestyles, especially for those who find a daily pill challenging,” says Dr. Ratevosian. For people with drug-resistant infections, a monoclonal antibody came out in 2018 for use along with other HIV medications.
If you start treatment early and stay consistent, you can manage HIV like diabetes, high blood pressure, or other chronic conditions, says Badowski. “Our first discussion with patients is: Despite what you might have heard, this is not a death sentence,” she says. “You can live a long, happy, healthy life.”
As effective as they are, though, today’s HIV treatments are not cures. A reservoir of the virus remains in the body. Scientists have only found one way to drain it: a risky, experimental stem cell transplant. Of the 88.4 million people in history infected with HIV, just seven have been cured this way since 2007. In this procedure, stem cells carrying an anti-HIV genetic variant are infused into an infected person’s blood.
These transplants are unavailable outside research settings. “They're highly risky, they're very expensive, and it's inconceivable to think that these can be brought to scale,” says Dr. Ratevosian. “It's important, though, because the science itself helps inform more science on how to get to a functional cure eventually.”
Treatment is one thing. The best way to stop HIV, of course, is to avoid it. The CDC says 31,800 Americans were infected in 2022. HIV infections still happen despite a paradigm shift in prevention over the past decade: the advent of pre-exposure prophylaxis, or PrEP.
In 2012, the FDA approved the first PrEP medication for people at risk of HIV. Taken daily, this antiretroviral drug builds up in your system to reduce the odds you will contract HIV if exposed. Oral PrEP is up to 99 percent effective at blocking HIV from sex and at least 74 percent effective at preventing HIV from injection drug use. A second PrEP pill was approved in 2019, followed by a long-acting injectable antiretroviral option in 2021. (Post-exposure prophylaxis is also available to take within three days of a known HIV exposure.)
Experts recommend pre-exposure prophylaxis for anyone who has a sexual partner with HIV, doesn’t consistently use condoms, or has had a sexually transmitted disease other than HIV in the last six months. They also recommend it if you inject drugs and have an injection partner with HIV or share equipment.
Lots of guys fall into at least one of these categories, but just 41 percent of men (and 15 percent of women) who could benefit from PrEP get it, according to CDC estimates. Usage rates are lowest among Black Americans, Hispanic Americans, and people in the South—the part of the U.S. where new HIV cases are rising most.
“Sometimes people go and ask their healthcare provider about PrEP options, and healthcare providers have no idea what the person's talking about, so that is still an issue,” says Dr. Ratevosian. “There's still stigma and discrimination as well, especially with certain men and men who have sex with men in certain communities.”
Despite progress over the last four decades, there’s more to do.
“We're at a crossroads because on one hand, you have these exciting scientific developments and these new prevention and treatment modalities coupled with these new delivery mechanisms,” says Dr. Ratevosian. “But on the other hand, HIV has fallen off the radar.”
HIV doesn’t dominate the headlines anymore, but scientists are still searching for the Holy Grail in HIV–vaccines and cures for everyone.
The Quest for the Next Breakthrough
Soon after the discovery of HIV, scientists started working on vaccines. Four decades later, it’s still a work in progress, and many efforts have failed. HIV’s quick and messy replication, mutation, and recombination–where genetic variants swap segments–make it unpredictable. Genetic diversity among HIV subtypes makes the virus difficult to target.
Today, more than 20 clinical trials are underway to test potential HIV vaccines. For example, the International AIDS Vaccine Initiative is studying a combination of two mRNA vaccines (like Covid-19 shots) that could help people develop antibodies against HIV. The U.S. Army Medical Research and Development Command is studying antibodies in people who receive booster shots after vaccination in an earlier study.
One of the most promising recent breakthroughs is not a vaccine. It’s an existing HIV treatment with potential as PrEP or pre-exposure prophylaxis. This summer, at the International AIDS Conference, which is like the Olympics for people who study HIV and AIDS, researchers from Gilead Sciences shared data about their antiretroviral lenacapavir that wowed the crowd. Lenacapavir, usually used to treat multidrug-resistant HIV, was 100 percent effective at preventing HIV infections in women and girls in Sub-Saharan Africa who received it twice per year.
“This is kind of unprecedented in the sense that we've never seen this kind of scientific data ever presented,” says Dr. Ratevosian. Results in other groups, including men, are expected by early 2025. “I think that injection, which is every six months, is a very exciting opportunity, especially for men who have highly active lifestyles, who are traveling, who don't want to take daily pills, who are on the go,” he says.
Researchers are developing novel treatments for people who are already infected, too. For example, researchers at the University of Pittsburgh and Ohio State University are studying a potential vaccine for people with HIV made from infection-fighting white blood cells.
What to Do About HIV Today
Get tested.
Yes, you. “People think that HIV only affects certain groups of people, and that's not true,” says Dr. Ratevosian. While some groups are exposed more often, the virus can infect anyone. Of the 1.2 million Americans with HIV, about 158,249 don’t know it yet, the CDC estimates.
Everyone needs at least one test between ages 13 and 64, according to the CDC. Test yearly if you have had sex with another man, had sex with someone who has HIV, had more than one sex partner since your last HIV test, shared drug injection equipment, exchanged sex for drugs or money, been diagnosed with or treated for another sexually transmitted infection, hepatitis, or tuberculosis (TB); or had had sex with someone who has done any of these things (or if you don't know their sexual history).
Grab an at-home test kit at a drugstore or ask your doctor for a test. If you test positive at home, you will need to see a healthcare provider to confirm the results and discuss treatment options.
If you test negative, consider prepping.
Ask your doctor about PrEP if you have sex with anyone with HIV, don’t consistently use condoms, or have had any sexually transmitted infections other than HIV in the last six months. Same if you inject drugs and share equipment, especially with someone with HIV. If you’re embarrassed to ask—or if your doctor brushes you off—find a provider who prescribes PrEP through this CDC directory. Most insurance plans cover it as preventive care.
If you test positive, don’t panic.
With prompt treatment, you can live a normal lifespan and protect others, too. “If you're someone who's HIV positive, and you're on HIV medication, and your viral load is suppressed to undetectable levels, this means that the virus can't be transmitted to your sexual partner,” says Dr. Ratevosian.
Most people do well on today’s HIV drugs. “There are very, very few side effects from these medications, and they're very well tolerated,” says Badowski. “It's not the battle days of HIV. There's just a lot of better tolerability, better efficacy, with what we do have.”
While the worst of HIV seems to be behind us, we can’t forget it. “I think people who hadn't seen the battle days of HIV, they don't understand that people were dying with opportunistic infections or cancers, and that could easily happen to them if they don't have it treated,” says Badowski.
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