Rare and Aggressive HIV Strain Reported in New York City

By Marc Santora and Lawrence K. Altman 
Reprinted with permission from The New York Times

A rare strain of HIV that is highly resistant to virtually all antiretroviral 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. It was the first time a strain of HIV 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.

"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 HIV 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 HIV.

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 HIV that is difficult or impossible to treat and which appears to progress rapidly to AIDS."

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 HIV 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 HIV/AIDS treatment needed further testing, unless ordered by a physician. They did warn, however, that people with HIV/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, [an injectible drug called] enfuvirtide [Fuzeon], 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 January 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 HIV, health officials said. Investigators believe he contracted HIV 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 HIV 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 HIV test. The test came back positive in December. By January, the HIV 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 HIV

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 HIV testing.

In fact, Dr. Frieden said, all people with newly diagnosed HIV 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 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," Dr. Braun said. "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."

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 HIV/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 HIV 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.

Donald G. McNeil Jr. contributed reporting for this article.

From The New York Times on the web © The New York Times Company. Reprinted with Permission.

02/14/05

Source
The New York Times. February 12, 2005. A 1.

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