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Date: Tue 22 Feb 2005

From: ProMED-mail <promed@promedmail.org>

Source: The New York Times, Tue 22 Feb 2005 [edited]

<http://www.nytimes.com/2005/02/21/health/21aids.html?>

Alarm over single AIDS case is challenged by questioners

New York City's health commissioner, Thomas R Frieden, had barely stepped away from the microphone on 11 Feb 2005 after announcing the discovery of a possibly new and deadly human immunodeficiency virus (HIV) strain when the storm started. More than a week later, it has not abated.

One group of scientists not involved in the research was quick to dismiss the news as isolated to one man and unworthy of alarm. Other scientists said not enough research had been done to warrant a public health announcement, and accused Dr Frieden of excessive haste. Gay activists worried that Dr Frieden's use of the announcement to emphasize safe-sex practices would set up gay men as culprits, reviving a concern as old as the disease. Long-standing rivalries among top AIDS researchers resurfaced, and one of the researchers who discovered the possible strain was accused of using a test developed by a company to which he had close ties.

To those who expect government officials to keep diseases at bay, it might seem surprising that a public health announcement about a deadly virus would be attacked, but AIDS is not like tuberculosis or polio. From the moment that HIV was discovered, it caused political chasms and profound disagreements among experts, and in recent weeks the virus seemed to be proving that it could still be treacherous and surprising, both as a deadly disease and a political fuse.

"The old jealousies, rivalries and big egos," said Kevin Robert Frost, vice president of the American Foundation for AIDS Research, when asked why the response was so furious. "Scientists in general react negatively to news by press conference." At one level, the reaction illustrates the intense competition among scientists and their institutions to communicate new findings and get credit, crucial in obtaining money to expand their research. Many experts have been involved in the field for years, and in some cases their professional disagreements have developed into the animosities and outright personal hatreds that are common in academia.

Nonetheless, scientists, skeptics by nature and training, have a fundamentally different role than public health officials, who often have to take emergency measures to stop the spread of disease.

As a result, some research scientists said the appearance of a possible drug-resistant and virulent strain of the virus in one 46 year old man meant little. The man's immune system might have been compromised by the crystal methamphetamine he had taken, they said, or the virus could have rapidly led to full-blown AIDS for other reasons that needed additional investigation before the public was alerted. "This is a non-story," Dr Paul Volberding, director of the Center for AIDS Research at the University of California, San Francisco, said in an interview, noting that the pace of change from HIV to AIDS depended not only on the virus but also the patient. "There have been many cases of rapid progression. The New York case is only that, a case report."

But public health officials said that with the battle against AIDS possibly on the verge of a new phase, where drug-resistant strains become harder to treat, Dr Frieden was right to go public. Dr Alfred Sommer, dean of the Bloomberg School of Public Health at Johns Hopkins in Baltimore, said health officials often did not have the luxury of waiting for full scientific information before acting. "For most things we do, we do not have ironclad proof one way or the other," he said.

Dr Frieden said that his initial announcement clearly contained cautions and unknowns, but that his actions were necessary given the potential public health effects. "We had enough clinical and scientific information to warrant making the announcement because of the immediate implications for the community, and for doctors practicing in New York City," he said. "We run the risk of either being a dollar short and a day late, or shouting fire in a crowded theater," said Dr Michael T Osterholm, director of for the Center for Infectious Disease Research and Policy at the University of Minnesota. "The question is," he said of Dr Frieden, "is he a prophet today or is he a prophet 10 years from now?"

The debate is likely to grow louder beginning tomorrow in Boston when 3800 of the world's top AIDS experts are to meet in a conference to discuss an array of new scientific findings. Long after the deadline for submissions of reports had passed, the doctors who handled the New York City case, Dr David D Ho and Dr Martin Markowitz, asked for a waiver to discuss the findings about the possible strain they had made at the Aaron Diamond AIDS Research Center in Manhattan. After much wrangling, the organizers of the meeting agreed to hold an unusual special session for the disagreement about the city's announcement.

But scientists were not the only ones upset about the city's actions. Some gay activists asserted that Dr Frieden was using the possible new strain as a scare tactic to get gay men to practice safe sex, an accusation he denied. Charles King, the president of Housing Works, an AIDS support group, said the announcement could be used to demonize the gay lifestyle and accused Dr Frieden of having wanted to change regulations regarding HIV testing for a long time.

The Community HIV/AIDS Mobilization Project, based in New York, said the link between the spread of the possible new strain and the use of crystal methamphetamine was unproven, and suggested that the city had ignored the "underlying issues" behind the spread of the virus, like discrimination, poor housing and unemployment. "Rather than increasing awareness of the risks of unsafe sex and crystal use, the Health Department risks stigmatizing gay men as crazed drug addicts carelessly or wantonly spreading a killer bug," Community HIV/AIDS Mobilization Project said in a statement. "In this case, the Health Department seems to offer little to the understanding of the root causes and potential solutions to drug use apart from the discredited strategy of Nancy Reagan, 'Just say no.'"

Martin Delaney, the founding director of Project Inform, a nonprofit AIDS foundation, said the city had been needlessly alarmist. "By pushing this out early, the public health department set off panic nationwide, before the scientific community had a chance to see the scientific data," Mr Delaney said.

Several gay activists said Dr Frieden was motivated, in part, by a close relationship with the Aaron Diamond Center, a charge that city officials dismissed as ridiculous. The center was created in 1988 to study the basic science of AIDS as a joint venture of the city's Health Department, the New York University School of Medicine, and the Aaron Diamond Foundation, a philanthropic organization. Upon becoming commissioner in 2002, Dr. Frieden joined the center's board, as had all his predecessors since the founding of the institution. Health Department officials say he has no financial interest in the center.

Dr Ho, then a relatively unknown 37 year old researcher fresh from Harvard and UCLA, was hired to run the center in 1989 and immediately attracted attention. With more money at his disposal than most other research institutions, Dr Ho became the object of envy as top-flight scientists lined up to join his center. Within a few years, Dr Ho's team won international publicity, challenging long-held theories about AIDS and reporting new evidence about the way the AIDS virus works in the body. However, Dr Ho has been criticized for trumpeting findings that other scientists say later proved wrong. For instance, Dr Ho and colleagues strongly suggested, without explicitly stating it as fact, that a treatment with drug cocktails could cure AIDS by eradicating the virus from a patient's blood. Since then, it has become clear that the virus lurks in hidden sanctuaries in the body, making it all but impossible to eradicate HIV with currently licensed drugs.

Critics have also charged that ViroLogic, the lab that did some of the testing for the Diamond Center and the Health Department in the most recent case, is using the case to promote its services. The Monday after Dr. Frieden's Friday news conference, ViroLogic issued a news release calling attention to its work performing the test for drug resistance. Dr. Ho, who was quoted in the release, serves on the scientific advisory board of ViroLogic. His brother, Sidney Ho, does marketing work for the company and once was the head of its communications department. William D Young, the chairman and chief executive of ViroLogic, said there was no effort by Dr Ho to promote ViroLogic through this case. He said the company's scientific advisers "are very aware of their scientific reputations and that's paramount to them. At some times I prefer them to be promotional but they are not." Mr Young said ViroLogic issued the news release to make the public aware of its role in the testing and its extensive nature. Dr Ho said that he has disclosed all of his ties to the company and that any suggestion of impropriety was false.

After Dr Frieden disclosed the case, reports of similar cases quickly emerged, some of which had been published earlier. For example, Dr Julio Montaner, a professor of medicine at the University of British Columbia in Vancouver, reported in 2003 in the scientific journal AIDS that 2 men with a highly drug-resistant strain of HIV might have progressed rapidly to AIDS. [See also comment below. - Mod.CP]. Dr Ho did not contact Dr Montaner about the case until 3 days after Dr Frieden's news conference. Dr Ho said he had searched standard databases for similar cases but did not find Dr Montaner's report. After being made aware of the cases and looking into them, he said there were similarities but also significant differences. "Our case was much more dramatic in the history of progression and resistance," Dr Ho said. Dr Ho, for his part, said, he was accustomed to criticism, but insisted, "We did the right thing in this case."

[byline: Marc Santora and Lawrence K Altman: Andrew Pollack in Los Angeles and Carol Pogash in San Francisco contributed reporting for this article]

ProMED-mail <promed@promedmail.org>

[The question unresolved is whether the 2 phenomena -- triple drug resistance and accelerated progression to AIDS -- are related. It may be that the patient has been infected by a rare HIV variant that transmits poorly and is present at such low frequency that it has not been detected previously. Similarly, it is possible that the rapid progression to AIDS may be a feature of the patient's genetic make-up rather than a property of the virus. It was reported earlier (but not mentioned in the above report) that the patient had not been treated with anti-retroviral drugs; if this is the case, selection of multiple drug-resistant variants in the index patient is unlikely.

The work of Dr Julio Montaner's group at the St Paul's Hospital and the University of British Columbia has been referred to previously in ProMED-mail (see: HIV, multi-drug resistant - Canada (British Columbia) 20010810.1892). Research workers at St Paul's documented about a half-dozen cases in 2001 of newly infected people whose strain of the virus is resistant to all 3 classes of anti-HIV drugs. It is common for AIDS patients to develop a resistance to some of the drugs they are taking, and 5 to 10 per cent of new infections in the US involve a form of HIV resistant to some types of drugs used in treatment of AIDS. But there had been only a handful of reported cases in the world in which a person was newly infected with a type of HIV resistant to all 3 drug classes. In most of those cases, it was concluded at the time that in becoming triple drug-resistant, the virus had mutated in a way that made it less effective and less dangerous. - Mod.CP]

[see also:

HIV, multi-drug resistant - USA (New York City)(02) 20050216.0522

HIV, multi-drug resistant - USA (New York City) 20050212.0476

2004

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HIV/AIDS, global epidemic escalates 20040706.1814

2003

---

HIV-1: origin & history 20030614.1463

HIV-2: origin and history 20030514.1201

2002

---

HIV recombinants, global spread 20020520.4283

HIV/AIDS, origin and evolution 20020119.3310

2001

---

HIV, multi-drug resistant - Canada (British Columbia) 20010810.1892]

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