PUBLIC HEALTH ALERT

From Medical News Today:
[quote]
New York City Health Officials Announce Detection of Rare Drug-Resistant HIV Strain, Issue Alert
14 Feb 2005


New York City... Department of Health and Mental Hygiene officials on Friday at a news conference announced they have detected in a local patient a rare strain of HIV that is highly resistant to most antiretroviral drugs and causes a rapid onset of AIDS, the New York Times reports. The city health department also issued an alert to physicians, hospitals and medical providers asking them to test all HIV-positive patients for evidence of the strain (Santora/Altman, New York Times, 2/12). City Health Commissioner Thomas Frieden said, "We have not seen a case like this before. It holds the potential for a very serious public health problem" (Goldman, Bloomberg News/Philadelphia Inquirer, 2/12). Although drug-resistant HIV strains are common in patients who have been treated with antiretroviral drugs, multiple-drug-resistant HIV is "extremely rare" in patients who are newly diagnosed and previously untreated, according to a health department release (New York City Department of Health and Mental Hygiene release, 2/11). In addition, HIV infection usually takes about 10 years to progress to an AIDS diagnosis, but this patient apparently progressed to AIDS in a matter of months. This combination of highly drug resistant HIV and rapid disease progression has not been identified before, Long Island Newsday reports. Dr. David Ho, director of the Aaron Diamond AIDS Research Center -- where the patient was diagnosed as HIV-positive in December 2004 -- said the combination of drug- resistant HIV and the patient's "rapid clinical and immunological deterioration is alarming" (Kerr [1], Long Island Newsday, 2/12). "We're talking about a single case," Ronald Valdiserri, deputy director of CDC's National Center for HIV, STD and TB Prevention, noted, but he added that the case is "quite alarming" and should serve "as a wake-up call to remember that HIV is still a formidable adversary" (Edozien, New York Post, 2/12).

New York City Patient
The virus was discovered in a New York City man -- whose name has not been released -- in his mid-40s who had frequent, unprotected anal intercourse with other men, often while using crystal methamphetamine, the AP/Yahoo! News reports (Dobnik, AP/Yahoo! News, 2/12). The strain, which is being called 3-DCR HIV, is resistant to three of the four classes of antiretroviral drugs, which means that 19 of the 20 available antiretroviral drugs would be ineffective for a person with this HIV strain (New York Post, 2/12). The patient was diagnosed as HIV-positive in December 2004 and already showed symptoms of AIDS despite a relatively recent infection. The man had tested HIV-negative as recently as 2003, according to the New York Times (Perez-Pena, New York Times, 2/12). Frieden said that based on early investigations, the patient could have developed AIDS in as little as two months or as much as 10 months after infection (Santora/Altman, New York Times, 2/12). Doctors at the Diamond AIDS Research Center recognized that the virus seemed to be a rare and "more dangerous" strain of HIV, and contacted city officials on Jan. 22, the New York Times reports. City officials repeatedly analyzed the conclusions before making a public announcement, according to the New York Times. Efforts to locate the man's sexual partners began immediately (Perez-Pena, New York Times, 2/12). The patient has been "extremely cooperative" with officials in tracking down his sexual partners, possibly "hundreds of them," the city health department said on Saturday, according to the New York Post. Officials said some of the man's partners already have been contacted and tested but locating everyone is an "ongoing effort," according to health department spokesperson Sandra Mullin, who added that no one else had tested positive for the new strain (Montefinise et al., New York Post, 2/13).

Warnings
Frieden said the case should focus increased attention on the importance of using protection during sexual intercourse, according to the AP/Albany Times Union (Dobnik, AP/ Albany Times Union, 2/12). Men who have sex with men and especially MSM who use crystal methamphetamine should be particularly careful to practice safe sex, he added (Talaga, Toronto Star, 2/12). "It's a new warning ... that safe sex practices remain the most effective way of preventing any HIV infection," Dr. John Greenspan, director of the AIDS Research Institute at the University of California-San Francisco, said (Perlman, San Francisco Chronicle, 2/12). New York City Mayor Michael Bloomberg (R) said the new strain was "very worrisome," adding, "More than ever ... try not to engage in the drug culture at all, and in terms of unprotected sex, you are putting your life in jeopardy, and if you are infected, you are putting other people's lives in jeopardy" (Burdi, Long Island Newsday, 2/13). Ana Oliveira, executive director of Gay Men's Health Crisis, said, "We need to practice safer sex," adding, "New Yorkers must be vigilant and know that infection with resistant strains of HIV can be avoided" (Kerr [2], Long Island Newsday, 2/12).

Scope Unknown
The "ultimate significance" of the new strain is still "unknown," the Washington Post reports. "Only time will tell whether this was an isolated case or part of an outbreak of similar cases," Frieden said on Saturday, adding, "Only time will tell how widespread it becomes. But it is certainly possible to reduce its spread through prompt action, and that is what we are trying to do." Terje Anderson, executive director of the National Association of People with AIDS, said he is "uncertain" about the case's importance, according to the Post. "It really isn't clear what one case means," he said, adding, "It is premature to be talking about a 'supervirus' circulating out there in the population." Anthony Fauci, director of NIH's National Institute of Allergy and Infectious Diseases, said the discovery is "not good news no matter how you slice it," but the new case will not necessarily transform the HIV/AIDS epidemic, according to the Post. The case could "turn out to be a rare event highlighting the need for better AIDS prevention strategies," or "it may mark the emergence of a very dangerous HIV strain whose spread could have global health implications," the Post reports (Brown, Washington Post, 2/13).

Search for Source, Spread
The search for the source of the new HIV strain has widened, and officials on Sunday said two other men were being studied to determine if they also had the rare form of the virus, the New York Times reports. One of the men, who was a sexual partner of the New York City man in October 2004, could be a potential "source" of the strain because it is known that he was HIV-positive before sexual contact with the New York City man, according to Ho. The other case is an unidentified San Diego patient who was found by searching the records of the commercial laboratory ViroLogic. Additional tests are needed to determine if the strains are the same, a process that could take more than one week, Ho said. He added that even if tests prove that the three cases are linked, it would "not necessarily mean that a super virus is on the loose" because genetic factors in the first man may have made his infection progress at an increased rate, according to the Times. The health department so far has contacted about 12 of the New York City man's sexual partners, according to Mullin. However, the man had sex with hundreds of men in recent weeks and does not know all of their names, according to the Times. Mullin said she did not know how many partners had agreed to participate in the epidemiological investigation or what the findings were. At least one man who was a sexual partner of the New York City man has declined to participate in the investigation, according to Ho. Frieden reiterated that the city cannot determine whether the strain is an isolated event in one man or whether it had spread to a small or large cluster of people (Altman, New York Times, 2/14).

More Research Needed
Following the announcement, experts have said that more study is needed to assess the danger of the virus, including whether it could be transmitted easily, if it could weaken others' immune systems as quickly and be as resistant to antiretroviral treatment as it has been in the New York City man, the New York Times reports. Experts said the disease may have progressed so rapidly because of the individual patient, not because of the particular strain. Laboratory tests in which the HIV is added to immune system cells to see if it replicates faster than other strains and mixed with other strains to see if it attacks immune cells more effectively should be conducted, experts said, according to the Times. Scientists emphasized that it is "still too early to tell" how rare the HIV strain might be or whether it would spread, according to the New York Times (McNeil/Altman, New York Times, 2/13).

Recommendations
Frieden at the conference issued several recommendations:

* MSM must work to reduce the risk of HIV infection and the spread of the drug-resistant strains;
* New York City physicians must increase HIV prevention counseling and testing and perform drug susceptibility testing for HIV-positive patients;
* City physicians should work to improve antiretroviral drug adherence and notification of partners of HIV-positive patients;
* The public health community must improve monitoring of HIV treatment and drug resistance and must implement effective prevention strategies;
* HIV-positive patients currently taking antiretroviral medications do not need susceptibility testing unless they are advised by their physician.

Dr. Antonio Urbina, medical director of HIV/AIDS education and training at St. Vincent's Medical Center in New York, warned that the growing crystal methamphetamine epidemic is playing a "significant role" in HIV transmission, adding, "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" (Windsor, 365Gay.com, 2/11). Physicians disagree about the role methamphetamine might play in making drug users more susceptible to HIV infection, although most agree that it lowers a person's inhibitions and can lead to more frequent, unprotected sex with multiple partners, the New York Times reports (Perez-Pena/Santora, New York Times, 2/13). The city health department is monitoring laboratories for other cases of the new HIV strain and is working with the state to establish a long-term system for monitoring drug resistance in HIV- positive patients who have not yet started treatment (365Gay.com, 2/11).

Alert Draws Criticism
Some experts questioned the need for the public health announcement based on a single case. "This is not novel and the odds are enormous that it is not going to go anywhere," Dr. Robert Gallo, director of the University of Maryland's Institute for Human Virology, said (Reuters, 2/12). One case is "not enough to warrant a public health alert," Gallo, who co-discovered HIV, said, adding, "It's irresponsible and outrageous. We've already heard past claims about superviruses that all turn out to be nonsense. From the science, I would say the probability is very high that you won't see this virus again." Dr. John Moore, an AIDS researcher at Cornell University Weill Medical College, agreed that city officials had " overblown" the danger presented by the new strain. "My guess is this is a relatively poorly transmitted virus," Moore said. However, Bloomberg said the city was correct in issuing a warning because it has "first and foremost a responsibility to educate the public as to what they can do to save their lives" ( Kerr, Long Island Newsday, 2/13).

Reaction Mixed
People reacted with "fear and skepticism" to reports of the new HIV strain, but "few were surprised" that a potentially more dangerous strain had arisen because the "sense of urgency about the disease has waned" in recent years, the New York Times reports. The "prevailing attitude" of complacency -- partly attributable to the availability of antiretroviral treatment for HIV/AIDS -- had many people worried about a new strain emerging, according to the New York Times (Perez-Pena/Santora, New York Times, 2/13). Thomas Farley, a community health expert at the Tulane University School of Public Health and Tropical Medicine, said, "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. That sets us up for new sexually transmitted infections to emerge and for any old ones to reemerge" (Confessore, New York Times, 2/12). Some physicians said they are worried about the lack of treatment options available for the new HIV strain and the potential implications if the strain spreads to other patients. "This may be the tip of the iceberg," Dr. Charles Gonzalez, an AIDS specialist at the New York University Medical Center and Bellevue Hospital, said, adding, "If this one starts getting around, we're back to the early '80s." He continued, "In the beginning of the AIDS crisis, we had no treatment. Again, we have absolutely no treatment" (Shin, New York Daily News< /a>, 2/12). Jay Dobkin, medical director of the AIDS Center at Columbia Presbyterian Medical Center, said, "Many of us here remember the dark days before there was any effective treatment for HIV, and I think ... [the discovery of the new HIV strain] should at least be a reminder that those days could come back" (Lombardi, New York Daily News, 2/12). The New York Times on Monday examined reaction to the announcement in gay chat rooms, Web logs and dating sites, where "a touch of anger and fear" existed, but with most people " advising against panic" (Cave, New York Times, 2/14).

Conference Planned To Study Meth-HIV Link
The Salt Lake Tribune on Monday examined the issue of methamphetamine use as it relates to higher prevalence rates of HIV and hepatitis C. Researchers in August are scheduled to gather at the Science and Response in 2005 Conference for what is being called the first national conference on the issue of meth use and HIV and hepatitis infection (Guidos, Salt Lake City, 2/14). The complete article is available online.
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From Medical News Today:
[quote}

Why there is multi-drug resistant HIV in New York, Terrence Higgins Trust statement
13 Feb 2005


Lisa Power, Head of Policy at Terrence Higgins Trust said: "Multi-drug-resistant HIV is known, both in the US and in Canada. It is the result of treatment, which fails, either because the drug is not strong enough, or because it is not taken at the right time. Multi-drug-resistant strains of HIV can be passed on.

"This case is certainly worrying, but it is important to bare in mind that complete drug resistance is still very rare, and that people with the same strain of HIV can progress at very different speeds to AIDS symptoms."

Oliver Wright
Terrence Higgins Trust
Terrence Higgins Trust 52-54 Grays Inn Road
London
WC1X 8JU
United Kingdom
Tel: 020 7831 0330
Fax : 020 7242 0121
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