Tuesday, July 22, 2008

Remembering the Super Bug of 2005

On February 5, 2005, the New York City Department of Health in conjunction with the Aaron Diamond Aids Research Center called a press conference and issued an urgent health alert to the public. The event was especially targeted towards men who have sex with men. According to health officials, one individual had been infected with what appeared to be a never before seen particularly potent and apparently mutated strain of HIV that had rapidly progressed to full blown AIDS.

Doctors treating the patient said the man was resistant to three out of four classes of drugs available used to treat HIV/AIDS, a condition clinically called 3-DCR-HIV.

At the press conference, New York City Department of Health Commissioner Dr. Thomas Frieden, warned “virtually no one is immune” saying the new super strain virus could quickly progress into full-blown AIDS, perhaps in as little as two to twenty months, a process that normally takes up to ten years.

Health officials described the patient as a man in his mid-forties, who had binged on the drug crystal methamphetamine and had un-protected sex with numerous partners, a number the Department said was 'possibly hundreds.'

The DOHMH said the encounters had occurred at sex parties or individually, arranged through “hook-up” sites on the Internet.

A firestorm of controversy, debate and media sensationalism followed the press conference.

Fault lines erupted both inside and outside the gay community as fingers were pointed at recreational drugs and "reckless" lifestyles. Fear laced with words of caution competed with skepticism over the accuracy of the reported science from Aaron Diamond Institute and the Health Department.

But many condemned the New York City Health Department for issuing a health alert that some called hasty and shrill.

Central to the skepticism were questions and worries about how gay men would react if the science proved false or inconclusive. Further, were worries that the public's perception of gay men would be tainted by reports of reckless behaviors in the age of AIDS. And, if the diagnosis of a new "super-bug" proved false, would the understanding and attitudes surrounding what HIV/AIDS is, a disease littered with a history of misinformation, rumors, prejudice and conspiracy theories become even more misunderstood and misinformed?

Overall immediate public reaction to the press conference and subsequent news reports was grim and flavored with what some saw as patronizing condemnation of the affected community, gay men.

Newspaper headlines were announcing that a new “super virus” had made an appearance in New York. The New York "Daily News" screamed “Super Bug Scary: World’s First Case of Drug Resistant Strain Found Here,” while another Daily News headline read “Super HIV Man Had Sex Binge with 100.” Meanwhile, the “New York Post” warned of a “Super Bug Nightmare Strain” and the “The "New York Times"” said Gays had “Grown Complacent” about HIV, which contributed to reckless behavior.

Within the Gay Community some began to directly link crystal meth use to the “new strain” issuing wholesale condemnations of the highly addictive drug. In the mainstream press, a number of columnists and editorial writers began to scold the reportedly promiscuous behavior and its alleged impacts.

For example, Former “"Newsday"” reporter Laurie Garret wrote “Those who use methamphetamine and prowl for sex need the wake-up call” and "Washington Post" columnist Richard Cohen wrote that when gays “are victims of discrimination they need to be defended, but when they are victims of their own behavior, they need to be condemned.”

But, in the background of the ensuing coverage, doctors and experts began raising skeptical concerns about the timing and tone of the alert.

“In its haste to issue a health alert, the Department of Health and Aaron Diamond failed to consider the impact of such frantic media coverage” said Dr. Michael Saag, Director of the Center for AIDS Research at the University of Alabama in Birmingham.

“The average reader will focus on the behavior of gay men” said Dr. Saag.

He noted that news of the New York Department of Health press conference was the lead story in the next day’s "Birmingham News".

“It is not a helpful message in an era when we are trying to communicate that HIV is a sexually transmitted disease that effects anyone who is sexually active, not just gay men” said Dr. Saag from Birmingham, Ala.

Amid the shrill headlines, controversy and fear, questions were raised about a more probable theory regarding the patient's condition, a theory that appeared to contradict the Health Department's conclusion in the health alert.

“The intersection of the patient’s drug resistance and rapid progression made this man’s condition unique” said Jessica Frickey, a spokesperson at The Centers for Disease Control and Prevention.

HIV is a highly variable disease. It is usually the 'host virus interaction' that determines the characteristics of a case, not the virus itself. In fact, there are individuals who may be more genetically susceptible to a quicker progression to full-blown AIDS. That condition has been called rapid progression.

Was this patient’s condition an unfortunate intersection of two deadly factors, rapid progression and anti-viral drug resistence?

Apparently, that would have indicated that the individual who played host to the virus was genetically pre-disposed to a rapid-fire progression to full blown AIDS.

Futher, could the man’s drug resistance have been a result of being infected by an individual who was infected with a mutated version of the HIV virus, a disturbing but potential cause of his anti-viral reisistence? Doctors say that HIV drug resistance can develop in a patient after taking drugs over an extended period.

Like other viruses or bacteria, HIV strains begin to mutate and show resistance over time, in essence, outsmarting some drugs or drug combinations, similar to anti-biotic resistance. When this happens, doctors usually manipulate, switch or re-evaluate the patient's cocktail of medicine until an effective anti-viral regimen is found.

But the reporting in the "super-virus" case implied that the patient had been infected a new “strain” as if the bug itself had mutated into a newly emerged form of the virus meaning that AIDS, already deadly, had grown into an even more dire threat.

Some supporters of the initial health alert press conference to say that the use of the term new "strain" was incorrect.

“There would need to be evidence of significant biological difference to warrant the designation of a new strain” admitted Dr. Jay Dobkin, Director of the AIDS Center at Columbia University.

Some advocates of full and forthcoming medical information, as well as a few medical experts began to openly and loudly question whether the health alert had indeed been based on inconclusive science. There were rumblings that that the alert was being used as an overly cautious and condescending tactic to try and change what some argue were increasing risky behaviors within the Gay male community?

Martin Delaney, co-founder of the San Francisco based organization “Project Inform” argued that the health alert was meant to scare people into changing behavior.

Delaney also questioned whether the science behind the alert was solid.

“None of the science was sound” and “no matter what Aaron Diamond and The Department of Health think they knew at the time of the press conference, they could not possibly have had any useful information about how widely this “new strain” had spread, or what its clinical consequences would be.”

Some doctors concurred with Delaney's assertion noting that in fact, the reportedly "new" strain was actually nothing new.

“This particular strain has been seen before thus is not new” said University of Alabama Birmingham’s Dr. Michael Saag of the new “super-strain”.

Dr. Harold Jaffe is the former director of the National Center for HIV, STD and TB Prevention at the Centers for Disease Control and Prevention. Since leaving CDC, Dr. Jaffe has been a fellow and Professor of Public Health at Oxford University in London.

Jaffe said the Health Department’s alert was probably a well intentioned but overly cautious approach that used fear to try and curb what most experts charge are risky behaviors.

At the Conference on Retroviruses and Opportunistic Infections Conference in Boston, two weeks after the Health Alert was issued, Dr. Jaffe argued that fear might motivate behavior changes in the short term, but it ultimately leads people to not trust messages of prevention.

Later, during a phone conversation from London, Jaffee further explained his reluctance to support the decision to issue a health alert.

Still, he cautioned that far to many gay men have become more careless, in part because of the false sense of security provided by new HIV drugs.

“A number of factors are probably contributing to increasingly risky behavior among men who have sex with men (or msm), and “lack of fear is probably a factor, but I personally don’t believe the New York case should be used to scare gay men into safer behavior” said Dr. Jaffe.

Still, one of the world's groundbreaking pioneers in HIV/AIDS research defended his institution’s decision to issue the alert.

“We felt it was appropriate to bring such an extreme case to the attention of public health authorities” said Dr. David Ho, Executive Director of The Aaron Diamond Institute.

“ADRAC stands by its decisions involving this case,” said Dr. Ho.

Columbia University's Dr. Jay Dobkin suggested that the decision to issue the alert and the ensuing media coverage linking Crystal Meth use to increasing risk of HIV infection, may have in fact, been constructive by helping to discourage what many see as reckless behaviors.

Still, some question Dr. Dobkin and Ho’s seemingly clinical rhetoric.

Martin Delaney argues that many health officials see the world through academic lenses that is out of touch with the reality “on the ground.”

“People do not engage in unsafe behaviors because they have considered issues of treatment” noting that drug use and unsafe behavior are not “reasoned choices,” said Delaney.

Reasoned or not, according to a one survey by The Center for HIV/AIDS Education Studies or CHEST at New York University, men who used Crystal, were three times more likely to contract HIV through receptive anal intercourse than those who did not use meth. Among gay men who admit to recreational drug use, 62 percent admit to at least having tried crystal.

Debate over how best to affect sexual practices or change behaviors range from harm reduction tactics to zero tolerance approaches. Harm reduction encourages those who do use recreational drugs, to do so responsibly, and be armed with knowledge on how best to protect oneself from increased risk of HIV infection.

Some worry that zero tolerance approaches about certain behaviors, or fear tactics, simply encourage denial and drive behaviors further underground often leading to destructive collective side effects such as increasing rates of HIV.

Over the past 5 years, HIV infection rates have risen among gay men under the age of 30 in New York City according to the City's Department of Health. At the same time, HIV infection rates have fallen by around 22 percent among older gay men.

While some say the complacency over un-safe sexual activity among many gay men may have been temporarily shaken by the super-bug reports, some express worries that collective distrust of medical officials and authorities was the end result.

“If it turns out the ‘super-bug” is really an isolated case, the gay community may feel they were being manipulated” said Dr. Harold Jaffe.

As of 2008, the 2005 “super-strain” was an isolated case.

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