Eradication of the (HIV) SuperBug, by Martin Delaney, Project Inform

[pinto]

great article about the eventual scientific review of this case and the hysteria generated by the premature press releases..Martin Delaney is a founder of Project Inform, the country's premier patient advocate organization for informed HIV treatment options. (article is not under copyright).

Eradication of the SuperBug, Written by Martin Delaney, Project Inform

Twelve days after a press conference in New York launched a wave of
hysteria-inducing claims about a virulent new super strain of HIV, the
scientific process has finally had its say. The case of the single patient followed for about a month after he was shown to be HIV positive was presented to an audience of two thousand or more scientists at the annual Conference on Retroviruses and Opportunistic Infections in Boston. This was the venue that many scientists and commentators said should have been the first place for presentation of the case, instead of a hastily called press conference. Unlike the press conference, the presentation at the scientific meeting was immediately followed by four additional presentations by other
scientists who were asked to put the New York report in perspective.
Putting it in its place might have been a better description of what
happened.

The show started with the somber academic atmosphere typical of such
events. Dr. Ho was the center of attention as the moderator invited him to the microphone. It was a little surprising to see Ho on call, since the lead author on the elaborate poster they had been passing around the conference for days was Dr. Marty Markowitz, not his boss, Dr. Ho. Whatever.

Ho made no mention of the controversy that had been raging since the press conference a week ago nor made any apology to the thousands of people who had been scared out of their wits. He did manage to say though that he still stood behind the decision to go the media. There were, however, a number of obvious shifts in perspective compared to the things that had been said in the earlier press conference and the Alert sent to physicians. In particular, Ho was no longer claiming the patient was “untreatableor even resistant to 3 classes of HIV medications. Instead he mentioned, as had critics, that the patient was readily treatable with at least two major hi-potency drugs, Fuzeon and Sustiva. Moreover, he now described the resistance as primarily affecting protease inhibitors, while there was reduced sensitivity to some nucleoside drugs.

Was this is the same case that was described as untreatable last week? I have several friends who would give their left nut to have two hi-potency drugs they could still use.

Another change of perspective appeared around the question of whether the supposed rapid disease progression of the patient was due to the virus or due to other factors, such as the patient's heavy use of crystal meth or to genetic factors. Last week, it was all due to the virus, stupid. This week, it seemed there were many possible explanations, just as we critics had claimed.

Next, he went on to admit that rapid disease progression was nothing new, nor was transmission of multi-drug resistant virus. Finally, he pointed out, as if it were a new idea, that a single case did not carry the weight of a whole cluster of people with similar viral and disease characteristics. I'm sure I wasn't the only one in the audience that had to resist shouting out. So why did you call a goddam press conference and scare half the world last week?

Dr. Ho finished his talk and passed the baton to a scientist who was to report on the experiences gained in following thousands of HIV positive men and women in the MACS (Multiple AIDS Cohort Study) and the WIHS (Womens' Interagency Health Study). The speaker had polled the two databases looking to see whether there had been previous cases of rapid disease progression simile to that claimed in the New York case. Well, of course there were, as just about anyone the audience could have confirmed even without studying a database. Still, the databases made the point beyond the shadow of doubt.

Though very rapid progression wasn't common, it has been seen for as long as anyone has been looking. Nothing new in New York, apparently.

Next up was a representative of the US military AIDS research, which there has been plenty over the years. After all, they wouldn't want an army full of HIV positive people. So the military also has a database tracking such matters. It's conclusion - they too have seen rapid disease progression, even somewhat more often in the civilian databases. Moreover, they've seen transmission of multi-drug resistance. Funny they should mention that. Once again, nothing new about the New York case.

Next speaker was an expert in the transmission of multi-drug resistant
virus. Perhaps to Dr. Ho's displeasure, he described how the transmission of single and multi-drug resistant virus, seen worldwide, had increased steadily between 1996 and 2000 and then leveled off. It happens every year, apparently with great regularity. So, nothing new about that. But of much greater interest was data he presented that showed how drug resistant virus was more difficult to transmit than old fashioned, normal, wild type virus.

Virus resistant to a single class of drugs was only about 20% as able to be transmitted as wild type virus. Multi-drug resistant virus was even less likely to be transmitted.

Wrapping up the show was a former CDC official, Harold Jaffe, who has been a player in AIDS prevention work for as long as there's been an epidemic. His job was to talk about the impact of this new case on issues of prevention. In short, his answer was there shouldn't be an impact based on single case riddled with so many uncertainties. He said that based on the data presented, we don't really know yet whether this was a case of rapid progression, whether the virus was transmissible, or what's it's prevalence might be. He directly took on the question of whether it was wise to or useful at least to employ reports of a case with such uncertainty to create fear that might motivate people to change their evil drug using and sexual
behaviors. His answer, like the ones given to the same question by a few of the earlier speakers, was simply NO.

Fear might motivate short term behavioral change, but it makes a very poor motivator over the long term. It often leads to people simply not trusting any messages on prevention.

At the risk of giving away my age and musical tastes, the evening's program reminded me of the last live performance of Pink Floyd's The Wall, performed at the Potsdamer Platz in Berlin shortly after the fall of the Berlin Wall. Near the end of concert, the giant wall, constructed of huge Styrofoam blocks, once imposing and a 100 yards wide, came tumbling down one giant brick at a time. Phony plastic brick by brick, the theory of the giant new Superbug came apart.

Or shall we say, it was eradicated?

Threats of the Superbug aside, this still leaves us as a community with the problems of crystal meth and related unsafe sexual activity. But as Gregg Gonsalves of GMHC angrily shouted into the public microphone at the end of the SuperBug symposium in Boston, this isn't just a problem of people being bad little boys. Yes, personal responsibility is one of the issues, but so are things like cuts in federal funding for AIDS prevention programs, gross federal meddling in the content of such programs, failure to fund drug treatment programs, and a society that teaches its gay children to hate themselves. Is it any surprise to see self-destructive behavior emerge from this mess?

Hopefully, this weeks episode of Scare Tactics - featuring the SuperBug is over and won't show up in the reruns. I have a lot less confidence though that any of these other problems will be solved, especially when it's so much easier to just blame people without offering them the slightest help.

[Warpy]

1. I've read about 3 cases in the journals

One was in NYC and two were in San Diego. None of the three had any contact with each other, so there was no clear route of transmission established for any of them. All were known to be HIV positive, and all had been on medication.

What may be happening is the mutation into a more lethal form in patients who are on long term drug therapy but whose substance abuse problems made them a lot less likely to be compliant with it.

At any rate, HIV is a rapid mutator. It could just as easily mutate into a less deadly, chronic but debilitating disease as it could into the deadly "superbug" that the journals were sounding the alarm over.

The one thing we can be sure it won't do is go away.