Researchers Still Divided Over Significance of New York City Case of Rare, Drug-Resistant HIV Strain

Experts on Thursday at the 12th Annual Conference on Retroviruses and Opportunistic Infections in Boston remained divided about whether the detection of a rare, drug-resistant HIV strain in a New York City man represents "a scientific oddity or a public health menace," the San Francisco Chronicle reports (Russell, San Francisco Chronicle, 2/25). Officials from the New York City Department of Health and Mental Hygiene on Feb. 11 announced they had detected in a local man a strain of HIV that is resistant to most antiretroviral drugs and possibly causes a rapid onset of AIDS. The city health department issued an alert to physicians, hospitals and medical providers asking them to test all HIV-positive patients for evidence of the strain. This combination of highly drug-resistant HIV and rapid progression to AIDS had not been identified before (Kaiser Daily HIV/AIDS Report, 2/22). The "mystery" case remains "unsolved" despite receiving the "attention of several thousand AIDS researchers from around the world" at the conference on Thursday, the Washington Post reports (Brown, Washington Post, 2/25). The strain has been detected in only one case, there is "no evidence" that the virus is "readily transmissible" and scientists are still uncertain if the man might be infected with several HIV subtypes that each are resistant to some antiretroviral drugs, according to the Chronicle (San Francisco Chronicle, 2/25). Dr. David Ho, director of the Aaron Diamond AIDS Research Center -- where the patient was diagnosed in December 2004 -- on Friday is expected to discuss the case in detail at the conference, the New York Daily News reports (Shin, New York Daily News, 2/25).

Researchers Defend Alert
Researchers on Thursday defended their decision to notify city officials and alert the public about the case as a potentially serious health threat, the New York Times reports. Some scientists and gay rights advocates have criticized the public health alert as "premature and unnecessarily alarmist," according to the Times (Altman/Santora, New York Times, 2/25). Advocates also are concerned that highlighting the case could create a "backlash" against men who have sex with men, Reuters reports (Fox, Reuters, 2/24). However, alerting the city health department was "the right thing to do," Ho said, adding that scientists remain unsure about whether the case is isolated or "part of a cluster," according to the Times. "That is a decision we stand by today," he said. "I think we have a unique convergence of a very drug-resistant virus, and this infection was very, very rapid," Ho said, adding, "And this man has many, many sexual partners." Ho also reported that his team has not found any of the key genetic indicators that might explain the man's rapid progression to AIDS. He said testing is ongoing but warned that even after all of the testing is complete, "there will still be room for doubt" because the knowledge about genetic markers is "incomplete," according to the Times (New York Times, 2/25).

'Disturbing Traits'
Doctors on Thursday also presented evidence and discussed "an array of disturbing traits" of the HIV strain, the AP/Las Vegas Sun reports. "The unique feature of this case is the convergence of ... the transmission of a remarkably drug-resistant HIV-1 variant and the extremely rapid clinical course to AIDS," the New York City patient's physicians said. The virus is able to use both main entry points to infect cells and grows well in laboratory settings, unlike most drug-resistant strains, according to the AP/Sun. In addition, the virus causes infected cells to clump together, allowing them to more easily attack healthy cells (Donn, AP/Las Vegas Sun, 2/24). HIV penetrates cells through both the CCR5 and CXCR4 portals, a capability that is linked to "aggressive" progression to AIDS, the Wall Street Journal reports. Ho and Martin Markowitz, also of ADARC, said that the strain retains "some sensitivity" to two drugs: enfuvirtide, sold as Fuzeon, and efavirenz, sold as Sustiva. Ho added that the man is being treated with a combination of "a huge number of drugs" (Chase, Wall Street Journal, 2/25).

Next Steps
"The investigation is ongoing and will most likely continue for many weeks," Lucia Torian, New York's director of HIV surveillance and epidemiology, said. New York City Health Commissioner Thomas Frieden plans to send letters to six commercial labs and several smaller labs that conduct most of the country's HIV testing to ask that they report to his department all samples of multidrug-resistant HIV strains taken from city residents, according to Torian. The order is scheduled to run through May 31 and could be extended, she said (Washington Post, 2/25). Ho said that the New York City man had unprotected sex with more than 100 men in the months before his diagnosis, the Daily News reports (New York Daily News, 2/25). Frieden said the city "has been working to identify (the man's) sexual partners and urge them to be tested," the New York Post reports (Edozien, New York Post, 2/25). The New York City patient has given health department investigators the names of his known sexual partners -- a number "in the teens," according to Torian -- and officials have contacted about two-thirds of them, according to the Washington Post. Investigators are asking that the men undergo HIV testing and to be tested for drug resistance if they test positive. Torian would not provide results from any of the testing conducted thus far, according to the Washington Post (Washington Post, 2/25).

Reaction
"These kinds of cases have been reported before," Martin Delaney, founder of San Francisco's Project Inform, said, adding, "A lot of clinicians see this stuff, and they don't call press conferences." AIDS advocate Mark Harrington said, "It's much ado about an anecdote." AIDS physician Steven Deeks said that "host factors" -- patient traits rather than virus traits -- are "almost certainly the cause" of the man's rapid progression to AIDS, according to the Chronicle. However, the case still highlights the need for safer sex in "an environment populated by a still-dangerous virus" and has focused attention on the "out-of-control methamphetamine use in young, gay men," according to Deeks, the Chronicle reports (San Francisco Chronicle, 2/25). Dr. Harold Jaffe, a professor of public health at Oxford University and former director of the CDC's National Center for HIV, STD and TB Prevention, said the case spotlights the problem of people engaging in high-risk behaviors. "More than two decades into the HIV/AIDS epidemic, why are some persons still placing themselves at high risk for infection?" he asked. In some cases, populations are difficult to reach with health education, others incorrectly believe that treatment with antiretroviral medications means a person cannot spread the disease and still others have lost "their fear of the virus," Jaffe said, according to Reuters (Reuters, 2/24). Although using such cases as scare tactics is wrong, the "important thing is to put out the facts," he said, adding, "If the facts are scary, then people will be scared" (San Francisco Chronicle, 2/25).