February 18, 2005

New York issues health alert on drug-resistant HIV

Crystal meth user is infected with strong virus after unsafe sex with dozens

by Anthony Glassman

New York City--The case of a man infected with a rapidly-progressive, multiply drug-resistant strain of HIV prompted a city health alert on February 11, followed almost immediately by criticism that the warning was premature.

The unidentified gay man, described as being in his 40s, is believed to have been infected in October. He habitually used crystal meth and had unprotected anal sex with over a hundred partners before progressing to full-blown AIDS.

In addition to concern over the three-month progression from infection to AIDS, doctors are also concerned that the strain of HIV the man caught was already resistant to three of four classes of antiretroviral drugs currently used to combat the disease.

HIV can become resistant to the drugs after treatment, but this man had not yet been treated. This indicates he may have been infected by someone who had been taking antiretrovirals.

Scientists at the Aaron Diamond AIDS Research Center in Manhattan are studying samples of virus from the man and some of his partners to determine where the strain came from and how widespread it is.

One sample they are testing came from a San Diego man. The HIV testing company Virologic notices similarities in the genetic makeup of the two samples.

�This case is a wake-up call,� said New York City health commissioner Dr. Thomas R. Frieden. �First, it�s a wake-up call to men who have sex with men, particularly those who may use crystal methamphetamine.�

�Second, doctors . . . must increase HIV prevention counseling, increase HIV testing, obtain drug susceptibility� testing for patients testing HIV-positive who have not yet been treated, improve adherence to antiretroviral treatment, and improve notification of partners of HIV-infected patients,� he said. �Third, the public health community has to improve our monitoring of both HIV treatment and. . . drug resistance, and. . .  implement prevention strategies that work.�

Not all in the medical community, however, believe that all of Frieden�s concerns are justified.

Dr. Robert Gallo, one of the earliest researchers dealing with HIV, argued that one case did not justify the alert, since earlier reports of �superviruses� did not pan out. He posited that the health department should have waited for a cluster of reports before issuing a public health warning.

Dr. John Moore of Cornell University noted that strains of the virus that progress and kill their hosts rapidly are less likely to spread widely.

�My guess is this is a relatively poorly transmitted virus,� he told Newsday.

Frieden, however, said that Gallo and other critics show �a fundamental misunderstanding of the role of public health. This has occurred in a man who was using crystal meth and probably got it from somebody he had sex with.�

Earl Pike, executive director of the AIDS Taskforce of Greater Cleveland, is taking a middle-ground approach on this case.

�I think that it�s one case, and the facts of the case represent an extreme set of circumstances,� he said, noting that crystal meth use can also depress the immune system.

However, the underlying cause for concern, drug resistance, is very real to Pike.

�We�ve been saying, �let�s pay attention to resistance,� for three or four years now,� he noted. �Close to 20% of newly-diagnosed are resistant to at least one class of drugs.�

He pointed to new CDC guidelines on treating sexually transmitted diseases, as well as his own battles against a sinus infection. That malady took three rounds of antibiotics to clear up, a sign of drug resistance, in this case to antibiotics.

�This is not just about HIV, it�s about the revenge of the microbe,� he stated.

Adherence is major concern, since laxity in following a drug regimen can more easily lead to drug resistance. However, unlike antibiotics� effects on a sinus infection, antiretrovirals don�t kill HIV, they suppress it, meaning that even with 100 percent adherence, there is still a strong chance for the development of resistant strains.

�The message in this is: Be fucking careful because it�s been going on for a couple of years,� Pike insisted. �We have to do genotyping and phenotyping because we don�t know how to prescribe.�

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