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Multi-Drug-Resistant, Fast-Progressing Strain of HIV Discovered in a NYC Resident
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Press Release
New York City Department of Health and Mental Hygiene
NEW YORK CITY RESIDENT DIAGNOSED WITH RARE STRAIN OF MULTI-DRUG RESISTANT HIV THAT RAPIDLY PROGRESSES TO AIDS
Highly Virulent Strain Resistant to Three Types of HIV Drugs Is Rare In Patients Not Previously Treated for HIV; Strain Is Also Associated with Rapid Onset of AIDS
Health Dept. Urges At-Risk Groups To Stop Risky Sexual Behavior; Patients Who Are On Treatment For HIV/AIDS And Are Doing Well Do Not Need Susceptibility Testing Unless Advised By Their Physician
NEW YORK CITY - February 11, 2005 - A highly resistant strain of rapidly progressive human immunodeficiency virus (HIV) has been diagnosed for the first time in a New York City resident who had not previously undergone antiviral drug treatment, according to the Department of Health and Mental Hygiene (DOHMH). The strain of three-class antiretroviral-resistant HIV - or 3-DCR HIV - does not respond to three classes of anti-retroviral medication, and also appears to greatly shorten the interval between HIV infection and the onset of AIDS.
The patient is a male in his mid-40s who reported multiple male sex partners and unprotected anal intercourse, often while using crystal methamphetamine (crystal meth). He was first diagnosed with HIV in December 2004 and appears to have been recently infected. The diagnosis of 3-DCR HIV was made shortly thereafter at the Aaron Diamond AIDS Research Center. Since then, the patient has developed AIDS. DOHMH is counseling and offering HIV testing to those contacts of the patient who have been identified.
While drug resistance is increasingly common among patients who have been treated for HIV, cases of 3-DCR HIV in newly-diagnosed, previously untreated patients are extremely rare, and the combination of this pattern of drug resistance and rapid progression to AIDS may not have been diagnosed previously. Strains of 3-DCR HIV are resistant to three of the four available types of antiviral drugs that are most commonly prescribed: nucleoside reverse transcriptase inhibitors, non-nucleoside reverse transcriptase inhibitors, and protease inhibitors. This strain also caused a rapid onset of AIDS, which usually occurs more than ten years after initial infection with HIV. In this patient's case, onset of AIDS appears to have occurred within two to three months, and at most 20 months, after HIV infection.
Health Commissioner Thomas R. Frieden, MD, MPH said, "This case is a wake-up call. First, it's a wake up call to men who have sex with men, particularly those who may use crystal methamphetamine. Not only are we seeing syphilis and a rare sexually transmitted disease - lymphogranuloma venereum - among these men, now we've identified this strain of HIV that is difficult or impossible to treat and which appears to progress rapidly to AIDS. This community successfully reduced its risk of HIV in the 1980s, and it must do so again to stop the devastation of HIV/AIDS and the spread of drug-resistant strains. Second, doctors in New York City 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. Third, the public health community has to improve our monitoring of both HIV treatment and of HIV drug resistance, and we have to implement prevention strategies that work."
The Health Department recently issued a Health Alert to physicians, hospitals and other medical providers asking them to test all previously untreated patients newly diagnosed cases for anti-HIV drug susceptibility. The Department is monitoring laboratories for additional cases of 3-DCR HIV in newly diagnosed persons. DOHMH is also working with New York State to establish a long-term system for monitoring drug resistance in HIV-positive patients who have not yet undergone treatment.
Dr. Frieden added, "Patients who are on treatment for HIV/AIDS and are doing well do not need susceptibility testing unless advised to by their physician."
REMARKS BY MEDICAL AND COMMUNITY LEADERS
Dr. David Ho, CEO and Director of the Aaron Diamond AIDS Research Center, said "This patient's infection with an HIV-1 strain that is not amenable to standard antiretroviral therapy, along with his rapid clinical and immunological deterioration, is alarming. While this remains a single case, it is prudent to closely watch for any additional possible cases while continuing to emphasize the importance of reducing HIV risk behavior."
"The rapidly growing crystal meth epidemic in New York city continues to play a significant role in facilitating the transmission of HIV. In light of the emergence of this virulent new strain, health care providers must be especially vigilant in not only recognizing and diagnosing HIV infection, but also in recognizing the signs and symptoms of crystal methamphetamine use in their patients," said Dr. Antonio Urbina, Medical Director of HIV education and training, at St. Vincent's Catholic Medical Center.
"Callen-Lorde is deeply concerned about this newly identified case of multiple drug resistant HIV," said Jay Laudato, Executive Director of the Callen-Lorde Community Health Center. "We urge all persons, both HIV negative and positive, to only engage in safer sex practices in order to prevent new infections or re-infection. For those persons who don't know their status, we urge HIV testing and obtaining the information and support necessary to reduce their risk for HIV infection. We also ask all gay and bisexual men to become knowledgeable about the dangers of crystal methamphetamine and in particular its relationship to sexual risk taking."
Dr. James Braun, President of the Physicians Research Network, said "We believe that the transmission of treatment-resistant HIV was a disaster waiting to happen, particularly in communities where safer sex is not practiced regularly and in light of people using drugs like crystal meth. All primary care providers in acute care settings need to know how to diagnose HIV in its earliest stages and where to refer people so that new infections are properly worked up and treated."
"HIV prevention is an ongoing process," said Ana Oliveira, Executive Director of Gay Men's Health Crisis. We have to double our efforts and resources to maintain treatment and prevention education for people who are infected as well as for those who are not. New Yorkers must be vigilant and know that infection with resistant strains of HIV can be avoided. People living with HIV can live healthy and satisfying lives by protecting themselves and their partners, regardless of HIV status."
Tokes M. Osubu, Executive Director of Gay Men of African Descent, said, "This is the news we have all been fearing. While the recent advances in HIV treatment have led to the improvement of countless lives, we have always known that many people respond poorly to these therapies and for many others, the side effects are devastating. Continued education about staying safe and avoiding HIV remains our most potent weapon."
Dr. Jay Dobkin, Director of the AIDS Program at Columbia University Medical Center, said, "This case is a striking reminder that the risk of getting infected with HIV has not gone away. In fact, risky behavior may be even more dangerous now since there is a chance of infection with a virus we may not be able to treat."
"This case should drive home the point that substance use can lead to unsafe sex, and unsafe sex can lead to infection with a highly drug-resistant strain of HIV that can be extraordinarily difficult to treat and may cause rapid progression to AIDS," said Roy M. Gulick, MD, Associate Professor of Medicine at Weill Cornell Medical College in Manhattan.
Dr. Jack DeHovitz, Professor at SUNY-Downstate Medical Center said, "This finding supports the need for enhanced availability of HIV testing, as well as preventive interventions, which are effective in reducing subsequent HIV transmission."
Know Your HIV Status
There is an epidemic of HIV and AIDS in New York City: more than 88,000 New Yorkers are known to be living with HIV/AIDS, and an estimated 20,000 more are believed to be living with HIV/AIDS and don't know it.
By knowing your HIV status, you can protect yourself, anyone you are having sex with, and, if you are pregnant or planning pregnancy, your baby. Free and fully confidential STD exams and treatment, as well as confidential or anonymous HIV testing, are available at Health Department clinics throughout New York City. Health insurance, proof of citizenship and/or parental consent are not required to receive these services. Please call 311 or visit http://www.nyc.gov/health for a list of clinics and hours of operation.
Rare and Aggressive H.I.V. Reported in New York
NY Times
February 12, 2005
By MARC SANTORA and LAWRENCE K. ALTMAN
A rare strain of H.I.V. that is highly resistant to virtually all anti-retroviral drugs and appears to lead to the rapid onset of AIDS was detected in a New York City man last week, city health officials announced on Friday.
It was the first time a strain of H.I.V. had been found that both showed resistance to multiple drugs and led to AIDS so quickly, the officials said. While the extent of the disease's spread is unknown, officials called a news conference to say that the situation is alarming.
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"We consider this a major potential problem," said Dr. Thomas R. Frieden, the commissioner of the New York City Department of Health and Mental Hygiene. The department issued an alert to all hospitals and doctors in the city to test all newly detected H.I.V. cases for evidence of the rare strain.
The virus was found in a New York City man in his mid-40's who engaged in unprotected anal sex with other men on multiple occasions while he was using crystal methamphetamine. Health officials have long said that the drug's stimulating effect and erasure of inhibitions contributes to sex marathons that have increased the spread of H.I.V.
The man, whose name was not released to protect his privacy, is believed to have had unprotected sex with hundreds of partners, according to one person briefed on the case who insisted on anonymity because the investigation is continuing.
Some AIDS specialists outside New York City expressed skepticism about the alarm, believing that it might be an isolated case related to the patient's immune system. But Dr. Frieden said the case heightened the importance of using condoms.
"This case is a wake-up call," Dr. Frieden said. "First, it's a wake-up call to men who have sex with men, particularly those who may use crystal methamphetamine. Not only are we seeing syphilis and a rare sexually transmitted disease - lymphogranuloma venereum - among these men. "Now we've identified this strain of H.I.V. that is difficult or impossible to treat and which appears to progress rapidly to AIDS."
While H.I.V. strains that are resistant to some anti-retroviral drugs have been on the rise in recent years, both in New York City and nationally, city and federal officials said that the new case was worrisome for several reasons.
The viral strain in the unnamed patient was resistant to three of the four classes of drugs used to treat H.I.V. from the start of treatment. Typically, drug resistance occurs after a patient is treated with retroviral drugs, often because the patient veers from the prescribed course. And more often than not, a person is resistant to only one or two classes of drugs.
But in this case, the drug resistance is combined with a rapid transformation into AIDS. Both of those phenomena have been seen before, but are not believed to have occurred together.
"What's unique about this is the combination of multiple drug resistance and a rapid course," said Dr. Ronald O. Valdiserri, the director of H.I.V./AIDS prevention at the Centers for Disease Control. "To folks in the public health community, that is a particularly dangerous combination." He said that while it was an isolated case at this time, the C.D.C. had informed other health departments around the country out of concern.
Dr. David Ho, the director of the Aaron Diamond AIDS Research Center, which did the testing that identified the rare strain, described the convergence of the two problems as "a scary phenomenon."
But not everyone agreed. Dr. Robert C. Gallo, a co-discoverer of the AIDS virus and director of the Institute of Human Virology at the University of Maryland, was very skeptical of yesterday's announcement.
"My guess is that this is much ado about nothing," he said. "Though it's prudent to follow it, I don't think it's necessary to issue a warning or alert the press."
Dr. Gallo said that it was well known that some patients progressed from initial infection to AIDS very rapidly, but that it was usually because they were highly susceptible, not because the virus was virulent. He said that this case, in which the virus is drug-resistant and the progression rapid, was rare but not necessarily alarming.
Dr. John P. Moore, an AIDS researcher at Cornell University's Medical School, agreed.
"If there was a cluster of these, that would be different," he said. "But I wouldn't get bent out of shape about what is literally an anecdotal case right now."
The limited epidemiological investigation in this case shows that the patient could have developed AIDS in as little as 2 months, but that it might have taken as long as 10, Dr. Frieden said. On average, it takes 10 years from the time a person is first infected with H.I.V. for AIDS to develop. But it can take only months for some people, and 20 years for others.
At the news conference in Lower Manhattan, Dr. Frieden was joined by nearly a dozen AIDS experts and community leaders. Several participants said they were experiencing the same worried feeling they had more than two decades ago, when AIDS first appeared and there was no treatment.
Health officials cautioned that the emergence of the rare strain did not mean that people who are currently responding well to H.I.V./AIDS treatment needed further testing, unless ordered by a physician. They did warn, however, that people with H.I.V./AIDS could be re-infected with a different and more dangerous strain if they practiced unprotected sex.
More tests need to be completed before it is clear if any combination of drugs can effectively treat this strain of the virus, but Dr. Frieden said that therapy now appeared to be extremely difficult.
The man is currently receiving a cocktail of drugs, including one, Enfuvirtide, that is believed to be effective. Doctors cautioned, however, that single-drug therapy was rarely effective against AIDS in the long term.
From the moment the Health Department learned about this case on Jan. 22, its scientists have been studying complex laboratory tests to decipher the patterns of resistance, and epidemiologists have tried to trace the man's sexual partners and notify them of the potential risk.
In May 2003, the man tested negative for H.I.V., health officials said. Investigators believe he contracted H.I.V. in October 2004, when he engaged in unprotected anal sex with multiple partners while using crystal methamphetamine. The man found some of his partners on an Internet Web site, officials said, though they would not identify the site. Health officials said they were working with those who used the Web site to reach as many people as possible who might have been infected or are worried that they could have been.
Dr. Frieden said in an interview that it was probable that the man had sex with someone who had a strain of H.I.V. that was resistant to multiple drugs.
"Whoever gave it to him most likely did not have sex only with him," Dr. Frieden said.
Health officials became aware of the situation after the man began to feel sick in late November and the next month went to see his doctor, who had him get an H.I.V. test. The test came back positive in December. By January, the H.I.V. had progressed to AIDS.
The man's doctor referred him to the Aaron Diamond AIDS Research Center in Manhattan, where for many years Dr. Martin Markowitz has been conducting a study of patients in the earliest stages of H.I.V.
The Health Department asked doctors to be alert for patients experiencing flulike symptoms who had engaged in high-risk sexual activity. Such symptoms might indicate acute retroviral syndrome, indicating a need for H.I.V. testing
In fact, Dr. Frieden said, all people with newly diagnosed H.I.V. should be tested to see if the strain is drug resistant. But the tests are complex and expensive. Dr. Frieden asked physicians to report any case in which a strain is resistant to three classes of drugs.
Dr. James Braun, the president of the Physicians Research Network, a nonprofit organization formed in 1990 to serve clinicians who treat tens of thousands of AIDS patients, said doctors have been worried for some time about something like this.
"We believe that the transmission of treatment-resistant H.I.V. was a disaster waiting to happen, particularly in communities where safer sex is not practiced regularly and in light of people using drugs like crystal meth," Dr. Braun said. "All primary care providers in acute care settings need to know how to diagnose H.I.V. in its earliest stages and where to refer people so that new infections are properly worked up and treated."
Health officials have been worried for some time that city residents, particularly gay men, are growing lax in their attitudes about sex practices, lulled into complacency by the success of antiviral drugs. In the past four years, the number of new syphilis cases in the city has slowly increased, with gay men accounting for most of them. Only 45 percent of gay men surveyed by the Health Department in 2003 said they used a condom during sex.
An estimated 88,000 New Yorkers have H.I.V./AIDS, and health officials estimate that another 20,000 people are infected but do not know their status. The officials urged all New Yorkers who are sexually active to check on their H.I.V. status.
"Risky behavior may be even more dangerous now, since there is a chance of infection with a virus we may not be able to treat," said Dr. Jay Dobkin, director of the AIDS Program at Columbia University Medical Center.
RISKS
Rare Strain of H.I.V. Raises Fear of a Resurgence in AIDS Cases
NY Times
February 12, 2005
By NICHOLAS CONFESSORE
An old fear returned yesterday to those fighting the spread of AIDS among gay men: fear itself.
For a decade, AIDS educators and activists have been fighting the growing complacency among gay men about the risks of unprotected sex, complacency fueled by medications that have drastically reduced the death rate of those infected; by the use of the Internet to enable casual sex; by the growing popularity of inhibition-lowering recreational drugs; and by the sheer emotional fatigue of those who had grown tired of confronting death.
But yesterday's announcement that a New York City man had contracted - and possibly spread - a deadly rare strain of fast-developing and drug-resistant H.I.V. may have the potential to change perceptions yet again.
"There's a growing perception that H.I.V. is a chronic and manageable disease, and so there's less fear of it," said Jay Laudato, executive director of the Callen-Lorde Community Health Center in Manhattan. "If anything, the case today should remind us how fearful we should be."
Other AIDS activists echoed his sentiment. "For the last 10 years," said Ana Oliveira, executive director of Gay Men's Health Crisis, "it's been challenging to create relevant and attractive ways to talk to the gay and bisexually active community about affirming life, preventing H.I.V., in ways that are not old. The dialogue just got more complicated."
According to a 2003 survey of sexually active New Yorkers by the city's Department of Health and Mental Hygiene, only 45 percent of men who had sex with men reported using condoms, though they were three times more likely to have risk factors associated with contracting H.I.V. than sexually active New Yorkers as a whole.
"There's a lot of evidence that gay men have backed away from safe sex practices. And as a nation, both gay men and the rest of us have become much more complacent about AIDS," said Dr. Thomas Farley, an expert in community health at the Tulane University School of Public Health and Tropical Medicine. "That sets us up for new sexually transmitted infections to emerge, and for any old ones to re-emerge."
The rare drug-resistant strain poses a particular challenge for activists serving groups in which contracting H.I.V. carries with it a much greater stigma than it does among openly gay men, leading people to avoid even being tested for the virus.
"The African-American and African immigrant communities that we serve are less likely to utilize H.I.V. testing than the gay community and less likely, therefore, to know their H.I.V. status," said Kim Nichols, co-executive director of the African Services Committee. "One of the hooks we've been using to get people to learn their H.I.V. status is the availability of effective H.I.V. treatment. So if this recent phenomenon calls into question the effectiveness of that treatment, it's a disincentive for learning one's H.I.V. status."
Among health experts focusing on the gay population, it is the combination of recreational drug use - the chief culprit is crystal methamphetamine, which has steadily gained in popularity among gay men since the 1990's-and the Internet that until now has provoked the most worry.
Web sites like gaydar.com, manhunt.net and chat rooms on America Online make "hooking up," as it is known, much easier than before. The drugs lower users' inhibitions against unprotected sex and encourage promiscuous behavior. Indeed, crystal meth users surfing the sites will often flag their drug habit with the tagline "PNP," short for "party and play."
Dr. Perry N. Halkitis, a psychologist at New York University is who studying the relationship between crystal meth use and H.I.V. infection in gay men, said he believes that the Internet also makes it much easier for like-minded partners to connect, compounding the spread of H.I.V.
"If you think of the traditional way that guys meet each other in bars, there are social norms," he said. "But when you're home alone, potentially getting high by yourself, those social norms go out the window."
Some AIDS activists stressed that they were waiting for more information about the rare strain before making definitive pronouncements about its impact. Walter Armstrong, the editor in chief of Poz, a magazine about AIDS and H.I.V., said he was not entirely convinced that the alarm sounded yesterday by health officials was warranted. "A handful of cases does not an epidemic make," he said.
But Dr. Halkitis and other researchers who have long predicted the outbreak of a so-called supervirus that resists the existing crop of drugs believed there was ample cause for worry. "This is what we were fearing all along," he said.
Chilled by Findings, Investigators Dreaded the Mounting Evidence
NY Times
February 12, 2005
By RICHARD PÉREZ-PEÑA
Word that an especially menacing form of H.I.V. might have appeared in New York set the city's public health machinery into motion last month on parallel tracks, with scientists studying the virus, shoe-leather detectives tracking people who might have been exposed and officials wrestling with when to go public.
Officials at the city's Department of Health and Mental Hygiene - along with private sector researchers, and state and federal officials - struggled to find the balance between aggressiveness in the face of a threat and fear that some misunderstood detail could provoke them into raising a false alarm.
Doctors at the Aaron Diamond AIDS Research Center strongly suspected by mid-January that they were seeing a rare, more dangerous strain of H.I.V., and told city officials on Jan. 22. It had been detected in one man - in his 40's with a history of methamphetamine use and unprotected sex.
Efforts to find the infected man's sexual partners began promptly, but a public warning did not come until 20 days after the city was notified, as city officials double- and triple-checked conclusions.
"Every doctor and every epidemiologist who hears about this situation first asks, is this real?" said Dr. Thomas R. Frieden, the city's health commissioner. "Is it really unusual? Is there another explanation?" All those questions, he said, had to be answered repeatedly before going public.
The case began in late December, when the man, whose name has not been released, tested positive for H.I.V., said Dr. David Ho, director of the Diamond center. The patient had tested negative in 2003, yet he already had symptoms of AIDS, and blood tests showed a high level of the virus and a dangerously low level of CD4 immune system cells - an astonishingly quick assault by an infection that often goes unnoticed for a decade.
In early January, Dr. Ho said, the man's doctor referred him to the Diamond center, where Dr. Martin Markowitz, the clinical director, analyzed the patient's blood and sent samples to a California laboratory. By mid-January, results of those tests showed viral resistance to three of the four classes of drugs used against it, and a high proportion of a highly aggressive viral strain known as X4. Both conditions are normally found only after many years of infection.
"All the evidence led to the conclusion that it was a very recent infection that led to very rapid progression, and was already highly drug resistant," Dr. Ho said.
The case was of particular concern because the man had been very sexually active, Dr. Ho said. "If he had no sexual partners in the last six months, you wouldn't worry as much," he said. The center notified city health officials, a call that Dr. Frieden said came on Jan. 22, a Saturday.
"My first reaction was to get chills up and down my spine," Dr. Frieden said, remembering the outbreak of drug-resistant tuberculosis that hit New York in the early 1990's. But he also reminded himself that four decades ago, city officials raised the alarm about drug-resistant tuberculosis, and they were wrong.
His department's first step was contact-tracing - the old-fashioned work of coaxing patients with sexually transmitted diseases into identifying sexual partners, then tracking down those partners and persuading them to get tested and treated.
This is work the department does every day, but this time the task had far more urgency. On Jan. 27, Dr. Frieden said, two department employees interviewed the patient - who he said has been cooperative - and started searching for his partners.
Dr. Frieden would not say how many partners have been contacted nor how many remain to be found, but the process goes on.
City officials wanted to do some research of their own on the patient's infection, but first they had to confront a legal barrier, a vestige of 1980's concerns about discrimination against people with AIDS. Under state law, the city is generally prohibited from collecting information about H.I.V. infection, and health officials wanted to know if that law would bar them from learning more about this man's case.
The city consulted its lawyers, who gave approval, and the department ordered another round of tests, in part to confirm the Diamond center's results. The department also got the go-ahead to start retesting blood samples it had collected over months and years to see if they shared the same troubling characteristics.
City officials also wanted to rule out the remote possibility that this virus was a strain of H.I.V.-2, a form usually found in West Africa, which could have led to some mistaken conclusions. "All of these tests are complex, and they take time," Dr. Frieden said yesterday. "As late as this morning we were still getting important test results."
On Feb. 4, for the first time, Dr. Frieden said, "we had a clear sense that this was something new and different, and even then it wasn't entirely clear."
Dr. Frieden called several infectious disease experts to get their views. He called Dr. Guthrie Birkhead, director of the New York State AIDS Institute, and they discussed plans for wider testing for drug resistance. His department contacted the federal Centers for Disease Control and Prevention in Atlanta, and the two agencies held a conference call on Monday.
On Wednesday, Dr. Frieden and Dr. Julie Gerberding, director of the federal centers, happened to be together on a panel discussion and took a few private minutes to go over the case again. Each conversation went over the same set of questions, hunting for some way the apparent danger might be explained away, until Dr. Frieden said he grew confident that it could not.
"I briefed Mayor Bloomberg on this Wednesday evening," he said yesterday. "We informed community organizations and physicians' organizations yesterday and today."
Yesterday morning, the department sent an alert to doctors around the city, and posted an alert on a computer system used by epidemiologists around the country. Then Dr. Frieden held his news conference.
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