New York City’s health department has announced that a gay man in his 40s has been newly infected with a strain of HIV resistant to drugs from the three main classes of antiretrovirals, and has experienced rapid disease progression.
In summary, the man was diagnosed with HIV in December 2004, having previously received a negative test result in May 2003. However, the man subsequently had unprotected anal sex with multiple male partners, often after taking the recreational drug methamphetamine.
After his diagnosis, the man experienced rapid HIV disease progression and has received an AIDS-diagnosis.
On both sides of the Atlantic, the media have been quick to pick up on the story, warning of a new, ‘impossible’ to treat strain of HIV, and the consequences of promiscuous sex and drug use.
But is the alarm generated by this case really justified?
In actual fact, very few details are available. Information about the man’s case is provided not in an article in a medical journal where the facts have been verified by other doctors and researchers, but in a press release which contains scant information.
In this press release, New York City health officials announced the man was infected with "3-DCR HIV", a strain of HIV resistant to three of the four classes of antiretroviral drugs, which is "difficult or impossible to treat." The press release adds "cases of 3-DCR HIV in newly diagnosed, previously untreated patients are extremely rare."
Rapid disease progression also appears to have occurred in this man’s case. New York City health officials state that the individual progressed to AIDS "within two or three months, and at most 20 months, after HIV infection" rather than the usual ten or more years. Details are, once again, thin on the ground. New York City did not provide details of the condition leading to the man receiving an AIDS diagnosis. Once again, it appears journalists did not bother to ask, although in their report the New York Times did state that the man had experienced weight loss, and had a high viral load. Neither of these symptoms necessarily indicates rapid HIV disease progression, indeed, both can be indicative of the early stages of HIV infection. Furthermore, it is well known that the precise rate of HIV disease progression varies considerably from individual to individual. Although it may take ten years or more in some patients, others develop an AIDS-defining condition much more quickly, even when "3-DCR" HIV is not present.
Cases of rapid disease progression after the acquisition of multi-drug resistant virus have been reported rarely, and evidence presented at recent conferences suggests that the transmissibility of MDR HIV is much lower than that of wild-type virus.
Not all media reports accepted the New York City press release at face value. In the UK, The Observer quoted Roger Pomerantz of Thomas Jefferson University in Philadelphia who said "every medical centre in a major metropolitan area will have a case like this. You've got to really prove something before you go on CNN and scream about a super-strain." They also contacted Dr Barry Evans of the UK Health Protection Agency who urged caution, and said he was waiting for the case to be published in a medical journal before reaching any conclusions.
HIV prevention messages have been reiterated due to this case. The City’s Health Commissioner Thomas Frieden calling it a "wake-up call to men who have sex with men", drawing attention to increased rates of syphilis and the emergence of lymphogranuloma venereum (LGV) amongst gay men in the city, and called on gay men to take action to prevent the "devastation" that drug resistant HIV could cause. Concern has also been expressed about the apparent use of methamphetamine by the man. The drug has been associated with increased sexual risk-taking by gay men in the US, and it has been suggested that the man in the New York case may have experienced faster disease progression because of his drug use behaviours.
Sections of the media have used the case as an excuse to revive a tone of moral panic reminiscent of the early days of the HIV epidemic. The New York Times reported that the man’s case had implications for "promiscuous gay men" and sent a reporter to the Big Cup gay coffee shop in the city’s Chelsea district to find that younger gay men who had not had the "searing" experience of seeing friends die of HIV were reporting "complacency" due to the success of antiretroviral therapy. A report in their February 14th edition, found that gay men using the internet to seek sex in the city were paying little attention to the warning of the "new" strain, despite the fact that the man is thought to have met some of his partners on-line.
There is no mention in any of the media reports of research which has found that the recent syphilis outbreaks affecting gay men across the US and Europe have an epidemiology separate from HIV. Nor is there any reference to research actually looking at the sexual behaviour of gay men since the advent of effective anti-HIV therapy which has found little evidence of the complacency suggested by some reporters.
Perhaps the reason for the reaction to this case and its reporting lies not in its medical significance, but in its importance to current US debates on comprehensive or abstinence-only HIV prevention.