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Comment by cmdkeen | Hacker News Reader

Could someone in the know explain, given the costs and difficulty of a bone marrow transplant, the likelihood of this becoming a treatment if it does indeed pan out? My initial impression is that it would be very much a "rich Western countries only" solution by a very wide margin.

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Yes, definitely this is not a simple treatment. Among other things it requires lifetime immunosuppressive medications.

So at least for now this will never be used in places without a strong medical establishment.

However it's a lot easier to find donations for a cure than for a treatment. So money will probably not be a factor - instead they will have to try to build a complete medical community in each area.

This may end up being a positive thing since good doctors are useful for more than just transplants :)

Places like India will probably have no trouble, but Africa will.

I'm curious - why does the bone marrow transplant require a lifetme mmunorepresants? Is it because otherwise the new immuno-system would attack the host organism?

Also - isn't an organism on immunorepresants essentially n a smilar position as an organism with inactive immun system due to HIV?

Yes, http://en.wikipedia.org/wiki/Graft-versus-host_disease

The drugs do not suppress the entire immune system, just parts of it. (Otherwise the person would die from random infections.)

Thanks :)

It's not just the cost that's the problem, it's the huge risk of a bone marrow transplantation. I've worked in a transplantation ward, and the mortality rates are huge. In our case, about a third of patients was cured following the procedure, a third died within the first few months, and another third developed serious graft versus host disease, a complication where the donor cells attack the host body (5-year-survival-rate 53 % in our patients.)

In patients with leukemia, you usually try at least one round of chemotherapy first, and reserve transplantation for desperate cases where the drugs don't work. Even if this turns out to be viable as a cure for AIDS, I expect it'll work the same way. It's just too deadly as a regular treatment.

This isn't just an issue of wealth. To do a bone marrow transplant you have to find compatible bone marrow, fry your own (very nasty) and then live in isolation (as in an isolated room) till the new marrow kicks in. And that's the best case.

would be very much a "rich Western countries only" solution by a very wide margin.

Assuming this method pans out as a cure for AIDS... what starts out today as a solution for those with money causes interest in making it more widely available. Interest leads to new techniques for reducing the cost and complication of bone marrow transplants. Reducing the complication and cost of bone marrow transplants spills over to benefit many other ill people.

Best of all, curing AIDS with any method whatsoever will likely lead to discoveries about the very nature of the disease that could obviate the need for a full marrow transplant.

Arguably more importantly, this gives researchers a very strong new lead on developing therapies that have similar effect to bone marrow transplant.

The thing that makes bone marrow transplantation so expensive (about € 100.000 a pop in Germany, probably more expensive in the US) is that in the time between killing off the patient's own immunosystem and the donor immunosystem taking hold, the patient effectively has no immunosystem at all. This takes about 100 days right now, during which the patient has to be isolated in an environment almost entirely free of pathogens.

So if you want affordable bone marrow transplantation, you either need to find a way to cheaply isolate someone while giving them a very high level of medical care, find a way to grow a complete immunosystem in a few days, or find a new drug that'll effectively fight off every possible infection in a body with no protections of its own. Oh, and then of course you have to affordably stop the donor cells from attacking the host's body, too. Finding a cost-effective drug to cure AIDS looks a lot more likely to me than any of that happening in my lifetime.

1yr survival rate article: http://www.mskcc.org/blog/msk-s-one-year-survival-rate-after...

Life expectancy alteration: http://jco.ascopubs.org/content/28/6/1011.full (figure 3) (keep in mind the cohort in the study excluded all those dying within 5 years)

once the affordable health-care act goes completely into effect, it may be out of the reach of 99.995% of people in the US too.

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