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UPDATE ON THE INVESTIGATION OF A RARE STRAIN OF HIV IN A NEW YORK CITY RESIDENT
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...High rates of HIV drug resistance reported among MSM...
"Whether one is HIV negative or HIV positive, safe sex is critical... Nationally and in New York City, syphilis, LGV, and gonorrhea among MSM have increased over the past few years"
Following this extract from AIDS Clinical Care's interviews with Dan Kuritzkes & Stephen Boswell is the NYC Dept of Health Update.
AIDS Clinical Care (March 2005) discussed this situation.
Dr Stephen Boswell, Executive Director of Fenway Community Health Center in Boston said to ACC: "In addition, we've known that there's a tremendous variability in the way the virus interacts with the host-it's not particularly surprising to find both problems in a single patient".
Dr Dan Kuritzkes, Director of AIDS Research at Brigham and Women's Hospital in Boston and an expert in resistance, concurred: "We reported a case of transmission of synctium-inducing AZT-resistant virus back in 1994." (AIDS 1994; 8:1017). "If you figure that a small percentage of new infections in the New York City area might have multidrug resistance, and a small percentage of transmissions involve an X4-tropic virus associated with rapid progression, it's just a matter of multiplying the probabilities _ it was likely we would find a case sooner or later".
Researchers have hypothesized that because the presence of multiple drug-resistance mutations results in reduced replicative capacity, transmission of such viruses might be associated with a more benign disease course. "The bottom line", according to Dr Kuritzkes, "is that transmission of drug-resistant virus is common, transmission of X4 virus is rare, and nobody should be surprised that X4 tropism trumps whatever defects in replication capacity might be conferred by multiple drug-resistant mutations." Asked whether this case then demonstrates the virulence of X4-tropic viruses, Dr Kuritzkes responded that researchers still don't know whether there is something inherently different about the rare patients to whom X4-tropic virus is successfully transmitted, or whether the rapid progression is due to the X4 virus itself.
Dr Boswell said there is one important take home message for HIV-care providers: "Clinicians need to be aware of the intersection of the methamphetamine & HIV epidemics, especially in the gay community. Public health interventions and community outreach are urgently needed". Regarding the media attention given this case & how it might be perceived by HIV-positive and HIV-negative individuals engaging in high-risk behavior: "you might think that a story like this would scare everyone, but some people might write it off or even be emboldened by such a doomsday scenario. It's important to remember that prevention messages need to be tailored to the individual".
NEW YORK CITY _ March 29, 2005 - The New York City Department of Health and Mental Hygiene is continuing its investigation of a multi-drug-class resistant strain of HIV that appears to have rapidly progressed to AIDS in a New York City man. This is an update on the status of the investigation.
* The source of the New York City man's infection is still unknown and remains under investigation.
* Although the patient's strain of HIV is highly drug resistant, the patient is responding to treatment thus far that includes the two drugs to which his strain appears to be susceptible, as well as other drugs which may be effective.
* The extent to which this strain has spread remains under investigation. As of today, no other cases of multi-drug-class resistant, rapidly progressive HIV have been identified.
* We have reached most of the named contacts of the patient. Many were previously HIV-infected. Obtaining blood samples for resistance testing, and testing of these samples to determine the genetic relatedness of strains is continuing and may take weeks to months to complete.
* Laboratories have identified several patients whose strains may be related to this patient's strains. However, database matching and laboratory analysis of these strains is complex and we do not expect to have results of genetic analyses of these strains for weeks or months. No patients with identical strains have been identified.
* The Aaron Diamond AIDS Research Center recently presented findings from a study of a group of men who have sex with men who were tested for HIV between 1999 and 2004, which indicated that more than one quarter of those with recent infection have resistance to one or more drugs. Resistance to any 2 classes of antiretroviral drugs increased from 2.6% in 2000 to 9.4% in 2004.
In summary, there is good news and bad news , and there are many things that we still don't know .
The good news:
* The patient is responding to treatment thus far. This indicates that the strain, while difficult to treat, appears to be treatable at this point. However, the patient remains critically ill and must continue to be monitored closely.
* To date, no other patients have been identified with the same strain
* Through efforts of the Health Department, physicians, laboratories, and others, there is now a monitoring system in place to identify similar cases if they occur.
* The Health Department has learned from physicians that they are testing patients for this strain of HIV. This means that we have a better chance of identifying additional cases in the coming months and years if they occur.
* Community organizations and physicians report an increased discussion of the need for safer sex and HIV prevention
* The patient is responding to treatment thus far. This indicates that the strain, while difficult to treat, appears to be treatable at this point. However, the patient remains seriously ill and must continue to be monitored closely.
The bad news:
* Many of the patient's partners were anonymous and the Health Department will not be able to reach them. Therefore, they may not be tested for HIV and, if infected, may not be diagnosed for months or years.
* Investigation of the social network surrounding this case indicates that unsafe, anonymous sex along with the use of drugs including crystal methamphetamine remains common. Many of the patient's partners already knew they were HIV-positive, some for many years. Nevertheless, they had unsafe sex and used drugs. Many had a recent history of other sexually transmitted diseases, such as syphilis and gonorrhea.
* Many unsafe sexual encounters occurred in public sex venues and through Internet contacts.
What we don't know (a partial list)
* The precise time of this patient's infection, which occurred sometime between 4-20 months prior to his first positive HIV test.
* How many other people have similar strains of HIV
* Whether there have been additional patients with this strain who remain undiagnosed;
* Whether there will be such cases in the future.
This is a complex investigation and can take months. We will continue to provide periodic updates throughout this process.
Public Health Messages
* Whether one is HIV negative or HIV positive, safe sex is critical. Medications can lose their effectiveness if resistance occurs.
* All New Yorkers should practice safe sex. There are several indications that unsafe sexual behavior, especially among men who have sex with men, may be increasing. Nationally and in New York City, syphilis, LGV, and gonorrhea among this population have increased over the past few years .
* Doctors caring for HIV-infected people should promote adherence by simplifying regimens and ensuring access to mental health and substance abuse services and housing. People being treated for HIV should adhere to their medication regimen to reduce their viral load and to prevent the development of resistance.
* Doctors should routinely offer HIV counseling and voluntary testing, and should consider the diagnosis of acute retroviral syndrome among people who have risk factors for HIV and present with flu-like symptoms , fever, swollen glands, sore throat, rash, muscle aches, diarrhea, headache, nausea and vomiting. People with acute HIV can be very infectious because they are not aware that they are positive and the viral load (amount of HIV in the blood and body fluids) can be very high during acute retroviral syndrome.
* People at risk for HIV should learn their status so that they can access treatment if they are infected and take steps to prevent transmission of the virus to others.
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