Project Inform - September, 1998

In the case reported, a person began suffering classic symptoms of acute HIV infection (fever, night sweats and fatigue) a few days after an unsafe sexual exposure (receptive anal intercourse without a condom, including withdrawal prior to ejaculation). Although the new patient was initially negative for HIV antibodies (as expected so early on), evidence of infection was established by the more sensitive quantitative p24 antigen test, and subsequently on a quantitative PCR (polymerase chain reaction) test. Treatment was begun a few weeks after the patient joined the Options Project, a study of primary HIV infection at the University of California. Unlike 36 other primary infection patients treated there, this patient did not respond to triple drug therapy nor to subsequent change to a second protease inhibitor. Since there was little or no doubt about the initial source of infection, researchers sought out the source patient. Upon contact, he volunteered to be studied. Researchers quickly learned he had been failing on the same treatment regimens as the other patient. Furthermore, he acknowledged poor adherence in his use of the treatments. Extensive resistance analysis of the virus present in each patient showed them to have nearly identical strains of virus and nearly all the same mutations and patterns of drug resistance.

Some researchers had hoped that mutated virus might be so crippled by the presence of the many mutations needed to achieve multi-drug resistance that it might not be capable of easily establishing infection in a new person. These data end that theory conclusively. It may still be that multi-drug resistant virus is less fit or less harmful in some undiscovered way, but it is clear that it remains capable of causing new infections. European researchers at the conference in Geneva reported similar cases, and a magazine article described the case of a man in the US who believed he had recently infected his lover with drug resistant virus. Thus, the theoretical concerns voiced about transmission of resistant virus when protease inhibitors first came to market are now proven facts. The need for careful adherence to therapy regimens and the need to pick the most appropriate regimen in the first place is now dramatically emphasized.

Despite these disturbing data, it's important not to stir public panic over the issue. We do not know whether such transmission is or will ever be common. All researchers can say for sure is that it has happened a few times. Undoubtedly, there are more cases that have not been studied or reported, but it would be a mistake to believe that such transmission has become a routine occurrence. It is far too early to define the scope of the public health issues concerned.

What about "Positive to Positive" Transmission?

These cases emphasize the importance of a second related question: whether or not it is possible to transmit drug resistant virus from one HIV-positive person to another. This has become a critical question because many have convinced themselves that sexual precautions are not necessary between two positive partners. Somewhere, many people acquired the belief that infection with one strain prevented later infection by a different or mutated strain. There is plenty of evidence to the contrary—the fact that there are many cases of people infected with both HIV1 and HIV2. Other examples include people who harbor both syncitium inducing HIV (SI virus, usually seen in people with advanced stage disease and considered more infectious) and non-syncitium inducing virus (non-SI virus) at the same time. However, the belief that sexual play need not be safeguarded between infected partners is strongly held by some, for whom this view is perhaps seen as the only "good" thing about being HIV positive. Sadly, this "good thing" very likely is untrue. In light of the new findings from the Options Project proving the transmissibility of multiple mutated HIV, it is critical research be done to determine whether such drug-resistant virus is also being passed back and forth between infected partners. If so, as most scientists suspect, it will be an emotional blow to those engaged in such practices. But the answer must be known. Researchers at the Options Project and elsewhere are currently discussing potential protocols for ethically testing this concept. The sooner we get an answer, like it or not, the better.

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The original of this article can be found at http://www.projinf.org/pub/25/resistanthiv.html