By Kailey Nolan, i-sense
Professor Deenan Pillay is Director of the Wellcome Trust funded Africa Centre for Health and Population Studies in South Africa and Deputy Director for Clinical Research at i-sense. Here, Deenan talks to i-sense's Kailey Nolan about his significant contributions to the field of HIV research, the ongoing challenges for HIV treatment and his role at the heart of this devastating disease.
Your research has focused on drug resistance in HIV. Can you explain the implications of this?
Put simply, developing drug resistance means that treatment for HIV stops working or becomes less effective. People affected will progress in their disease.
This is a worldwide problem, but the consequences are more severe in resource poor countries. Resource wealthy countries like Europe and North America have several drugs and therapies available, as well as the technologies to test for resistance. However, in the developing world, in particular sub-Saharan Africa where the epidemic is at its worst, there are cost limitations so the amount of drugs available are limited. Therefore, resistance has a greater impact.
Your work mapping resistant strains of the HIV virus has led to a change in national guidelines for monitoring HIV. What impact has this had?
We were the first to identify that drug resistant viruses emerging in one person can be transmitted to another. More specifically, 10% of all new infections are resistant strains of the virus.
This research has prompted a policy change in the UK - every individual now diagnosed with HIV is tested for drug resistance. We do this by sequencing the genome of the virus. This was the very first example of gene testing being routinely used to guide clinical assessment. We now test every HIV patient for resistance before a course of treatment, ensuring the patient receives the most appropriate treatment immediately
What are the main challenges for HIV diagnosis and treatment?
Resistance testing is very expensive. The test to diagnose drug resistance in HIV is around £200, making it one of the most expensive diagnostic tests on a blood sample in existence. However, this cost is insignificant when compared to that of a course of antiretroviral drugs, which costs about £10,000 per year. The drugs often turn out to be ineffective because drug resistance has not been sufficiently assessed.
While these tests are national protocol in the UK and many parts of Europe, resistance testing is unique to the developed world. In South Africa, where I’m based and which has the highest incidence of HIV in the world, there is no state-funded resistance testing as this is considered too expensive. So, part of my teaching at the Centre will be to teach clinicians about what they can expect in terms of resistance patterns, in the absence of funding for adequate testing.
Also, crucial for preventing transmission, is early detection of the disease. Ongoing transmission of HIV is one of the most prominent healthcare issues globally; in the UK the instances of infection per year are continuously increasing. Early detection is vital to limiting the spread of the epidemic.
Finally, one of the big worries in tackling HIV is drop out from the ‘Care Cascade’, whereby if you look at the number of people that are diagnosed against those that get into care and those who receive treatment, the numbers reduce sharply along the way. This is not so prominent in the UK as we have a free healthcare system, however it is a real problem in resource poor, rural areas. This is the particular attraction of working with HIV in the Africa Centre and I would like it to be the test-bed for new devices to address this problem.
How can the Africa Centre work with i-sense to address these challenges?
i-sense’s early warning systems would both facilitate early diagnosis of HIV and, for those already diagnosed and receiving treatment, help identify if there are better ways to monitor treatment.
I’m also really enthused by the concept of wireless connectivity in point-of-care diagnostics. Testing in remote rural areas such as South Africa is problematic; obtaining and transporting blood samples in this environment is very difficult. Wireless devices would enable test results to be logged there and then and treatment can be implemented immediately.
i-sense’s vision for mobile phone-connected tests would help ensure that people are not lost in the system. Geographically linked, real-time information means we can keep people in follow-up care. This is crucial to reducing patient drop-off rates and the impact of the Care Cascade.
What other preventative methods have proven effective?
The area that has probably shown the most promise is ‘treatment as prevention’. Treating patients reduces the amount of virus in their body, making them less infectious. It is also important to diagnose and treat HIV early to reduce the transmission rate.
The Africa Centre has conducted a large population survey, the data of which was published in Science this year, that showed that as more and more of the population were treated, the number of new infections came down. This was the first evidence to support the ‘treatment as prevention’ theory. Early detection is crucial to implementing this approach.
The problem with this approach is the sustainability of using widespread treatment in large numbers of the population. This is not only a cost issue, but a motivation issue - it is difficult to motivate people to continue with treatment for life. People often adhere to a course of therapy less well over time, with that comes drug resistance and then drug resistance spreads. A large focus of HIV research is therefore to develop a therapeutic approach for the health service that is sustainable.
You helped establish the Bloomsbury Research Institute (BRI), which brings two great institutions together- the LSHTM and UCL. How can i-sense benefit from this relationship?
There are three scientific programmes being developed for the BRI, one of which is centred around diagnostics and i-sense’s research. This means that i-sense will be the real innovative core of a large-scale diagnostics programme and the sky’s the limit.
Bringing together the two universities through the BRI is beneficial as it brings critical mass and great synergy, without overlap: UCL are strong in virology, while LSHTM’s strength lies in what we call neglected diseases (parasites for example), particularly in the developing world. LSHTM has a global reach, and UCL has very strong basic science, so bringing the two together makes sense.
i-sense sits precisely between these two ends of the spectrum, which is an ideal environment to really push HIV early-warning systems forward.
What would you like to achieve in the next 5 years at the Africa Centre?
Within two years, I would like to see some prototypes of wireless tests in South Africa. This was one of the main attractions of this role for me. There is very little research done in this type of setting for wireless devices, so we would be setting up a new way of tackling HIV in resource-poor communities.
There is great strength at the Africa Centre in geographical mapping of infections. We use tri-annual demographic surveys to map the population; where people live, who lives in each household and then link this with infection rates. I think there is great opportunity here to add an additional data resource or layer of tracking to this large amount of information - from mobile phone data to self-reported symptoms on Google and Twitter.
I want to be talking in detail about what we could do to better use our resources to create a comprehensive, geographical method of tracking transmissions. The Africa Centre provides data and global impact, while i-sense provides data-linkage so I can envision collaboration between the two to explore this area further.
There are lots of diagnostic kits around for HIV, but these are often costly and slow. If we can detect infection early, we can get people into care quickly and increase the likelihood that people will seek initial and continuous care. We don’t want to lose people along the way.
Professor Deenan Pillay is a leading Clinical Virologist, Director of the Wellcome Trust Africa Centre for Health & Population Studies in Mtubatuba and Durban, South Africa and Deputy Director of Clinical Research at i-sense. He maintains his position as Professor in Virology and Co-Director of the Division of Infection and Immunity at University College London (UCL). He helped establish the Bloomsbury Research Institute, a partnership between infectious disease research groups from UCL and the London School of Hygiene and Tropical Medicine and was previously Director at the UCLH/UCL National Institute of Health Research (NIHR) Biomedical Research Centre (BRC).