By Bob Roehr
BOSTON – The controversial claim of a "super strain" of HIV, announced at a news conference in New York City on Feb. 11, had its first scientific review at the 12th Annual Retrovirus Conference in Boston.
David Ho, director of the Aaron Diamond AIDS Research Center and chairman of the conference, presented his data at an extraordinary special session on the evening of Feb. 24. Five other presenters then offered briefings on drug resistance and rapid disease progression to provide a context for interpreting data from the NYC case.
Ho described the patient as a gay man, 46, who acknowledges having anonymous unprotected anal sex with hundreds of men, often while using crystal meth. He believes the man became infected with HIV in October and by January his CD4 cell count declined to 80. Laboratory tests detected viral RNA mutations that confer resistance to 19 of the 20 drugs commonly used to treat HIV.
Even more unusual was the swarm of virus infecting the patient. About 60 percent of the virus used the CCR5 coreceptor to enter cells and 40 percent could use either CCR5 or the CXCR4 coreceptor. The later variant is rarely transmitted sexually. It is characteristic of late stage disease and rapid decline in health.
Ho feared the possible public health implications of these findings and notified New York City public health commissioner Thomas R. Frieden. The ensuing news conference set off a frenzy of media coverage.
The other presenters at the special session saw the case as rare and worthy of investigation but not cause for a public warning. They believe the rapid progression was more likely the result of factors unique to the patient's genetics and health, not the virus. Ongoing contact tracing has yet to find evidence of another person infected with a similar virus.
Stephen Gange is the principle statistician for the ongoing MACS and WIHS HIV cohort studies. The first has followed gay men since 1984; the second primarily minority women since 1994. More than 10,000 participants in the two cohorts are examined and their blood is drawn every six months.
He said data from the cohorts and from computer modeling indicate that 7 in 10,000 of those infected with HIV will progress to AIDS within the first six months. A similar pattern was seen in the US Military Cohort of about 4,500 people.
Gange pointed to two examples within the MACS cohort where rapidly progressing patients had been infected with a dual tropic CCR5/CXCR4 virus.
Matthew Dolan offered a snapshot of the impact of host genetic variations on disease progression drawn from the military's HIV program. He concluded, "While therapy has been very beneficial, it still does not overcome the genetic bias that people go into the battle with HIV with."
A major point in Ho's case is that the virus in the newly infected patient is resistant to all three classes of anti-HIV drugs. But another study at the conference by a colleague showed that Aaron Diamond had detected transmission of similar resistance in at least a dozen patients, dating back as early as 1999.
The frequency of transmission of multiple drug resistant virus was explored by Andrew Leigh Brown, a professor at the University of Edinburgh. He pointed to one study suggesting, "The prevalence did increase, has peaked, and is declining." He reminded the audience, "Drug resistant virus is frequently less fit than drug susceptible virus" and often is more difficult to transmit.
The former director of HIV prevention programs at the CDC, Harold Jaffe, reminded the audience that it wasn't known when the patient in question was infected, who infected him, or if he has infected others.
Moving on to the broader question of HIV prevention he said, "If lack of fear [of HIV] has really become a driver of the epidemic, we have to ask ourselves, should cases like this be used to scare people at risk? I personally don't think so."
Much of the spirited questioning from the floor was directed to David Ho. He said their limited and incomplete genetic analysis reveals "a swarm of highly related viruses," though he conceded it was possible that the virus was a product of recombination or secondary infection rather than a single infection.
He did not know if the patient might have injected methamphetamine. Sharing a syringe in injecting meth might help explain the transmission.
"We have to point the finger at the people who have been trying to destroy HIV prevention," said Gregg Gonsalves, with the Gay Men's Health Crisis. He decried attacks from the right wing and "chronic underfunding" of CDC HIV prevention programs as having contributed to this infection.
COMMUNITY NEWS CONFERENCE
"There is nothing really dramatically new about this virus," Stephen Boswell said at a community news conference the next morning. "If we reacted every time we saw this virus, there would have literally been thousands of press conferences around the world." He is executive director of Fenway Community Health in Boston and a professor at Harvard Medical School.
"To take a single case, a case where there is no evidence that this virus has been transmitted, and call a press conference, is not a responsible approach to take." Boswell fears that this will only serve to drive people underground and not seek out care.
Howard Grossman criticized the lack of local physician involvement in the initial decision to publicize this case. "We were called the night before and not well briefed," said the New York physician and executive director of the American Academy of HIV Medicine. He argued that the doctors at Aaron Diamond "really arenÕt clinicians," they are researchers.
"We need to look at the supply chain of HIV prevention," said Julie Davids, executive director of the Community HIV/AIDS Mobilization Project (CHAMP). That includes better understanding of substance abuse and how to address it as an integrated part of HIV prevention.
She criticized abstinence only programs that don't work and "stigmatize the lives of gay people," even while right wing members of Congress are harassing innovative programs such as needle exchange that do work at reducing new infections.
Grossman pointed to a call in one newspaper article to publish all of the names of those who are HIV-positive. He said, "It goes back to the panic of the 1980s."
