In Boston, Dr. David Ho answers some, but not all key questions
y DUNCAN OSBORNE
More details about a New York City man recently infected with multi-drug resistant HIV have not quieted critics who say the science behind the case is incomplete and that the press announcement on it was premature.
“I’ve certainly seen nothing to change the view I had,” said Richard Jefferys, basic science project director at the Treatment Action Group, an AIDS organization. “If anything the story just seems to become murkier.”
Dr. David D. Ho presented data on the case on February 25 at the Conference on Retroviruses and Opportunistic Infections, held in Boston. Ho heads the Aaron Diamond AIDS Research Center (ADARC), which did the testing on the virus, along with ViroLogic, a California company.
The man, who is in his 40s, had five negative HIV tests between September of 2000 and May of 2003, according to a “poster session” held on the presentation in Boston. In early November of last year, he experienced flu-like symptoms that persisted into December when he tested positive for HIV, the virus that causes AIDS.
By late December, his T cell count, a measure of immune system health, was 80. That count strongly suggests that the man has AIDS, which is diagnosed when a T cell count is at 200 or below. A normal T cell count ranges from 700 to 1,200. The man’s viral load, a measure of the amount of virus in his blood, was 280,000. According to city health department data presented at a February 15 meeting here, the man’s T cell count is currently 13 and his viral load is more than 600,000.
The Ho presentation also included data on drug resistance in the virus. While press reports have characterized the bug as resistant to three of the four classes of drugs used to treat HIV, the poster suggests that the virus is resistant to all of the drugs in two of those four classes with susceptibility to some drugs in the other two classes. Drug resistance is increasingly common even among people who are newly infected.
Drug-resistant viruses replicate poorly and are less effective at infecting others. That is important because the man reportedly had many sex partners, but Ho’s poster presentation concluded that “this multi-drug resistant virus replicates as well as most wild-type viruses.”
The New York City man remains the only known case of an infection with this type of HIV.
The virulence of the virus is an unresolved question. While it seems definitive that the man went from HIV infection to AIDS—a process that typically takes years—in as little as four months or as many as 20 months, the testing could not prove if it was the virus or the man that was responsible for that rapid progression.
Dr. John P. Moore, professor of microbiology and immunology at the Weill Medical College of Cornell University, said that there was little that was new in the presentation.
“I think the fundamentals on the poster were similar to what was reported in the news media,” he said. “There is no huge new factoid that changes my perception of the case.”
One question previously debated—whether or not the man has AIDS—appears to have been answered. An early phase of HIV infection, called acute or primary infection, can mimic AIDS with a low T cell count and that could have accounted for the man’s T cell count. Most people rebound from an acute infection.
“It probably is the case that he has AIDS,” Moore said.
That supports the notion that the man is a rapid progressor, but just how rapid he moved to AIDS is unclear. If he went from HIV positive to AIDS in four months that would be remarkable, but doing that in 20 months is not unheard of.
“He certainly has a degree of progressive infection, but the critical question is when was he infected?” Moore said. “He’s a rapid progressor, but is he ultra-rapid or just rapid?”
The presentation did not resolve the most serious question—is anyone else infected with this virus or is this a single, unusual case?
“My initial gut reaction on this was, ‘Is this a transmissible virus that will lead to a new phase of the epidemic?’ and there is nothing to answer that,” Moore said. “There is just no evidence on that.”
A February 25 commentary on retrovirology.com, a peer-reviewed online journal, took issue with just that point, arguing that however dramatic this case may be, it is still just one case.
“Overall, this case seems relatively rare but not necessarily alarming,” said the commentary, which was written by three researchers at the University of Amsterdam in the Netherlands. “Increased attention is not necessarily bad, but press conferences should be reserved for situations when a cluster of such transmissions is apparent. The current hype about super-aggressive HIV-1 strains seems unfounded.”
The case was announced at a February 11 press conference by the city health department. The ensuing media coverage angered some AIDS activists and they remain angry.
“There’s nothing that was presented in Boston that presents any justification for what happened,” Jefferys said. “It could have been done in a way that didn’t provoke a media frenzy because the people who bear the brunt of that are community organizations that get scared and panicked phone calls.”
Julie Davids, executive director at the Community HIV/AIDS Mobilization Project, said the Boston data did not justify the press conference.
“It doesn’t mean that you need to do an APB and it doesn’t mean that you need to stigmatize people who have drug resistant virus,” she said. “It’s clear that there was no secret data that is likely to change anyone’s mind about how this was handled.”
The HIV Forum, which has held a series of town meetings in Manhattan on prevention issues facing gay men over the past 18 months, will host a panel that will include top research experts from Aaron Diamond and the city’s health department, one of the infected man’s treating physicians from Cabrini Medical Center and leaders of a number of New York AIDS prevention and service organizations. The forum will be held at FIT’s Haft Auditorium, on Thursday, March 3 at 227 W. 27th Street between Seventh and Eighth Avenues at 7 p.m.