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March 30, 2005
Tests Pending in Cases Tied to Fierce H.I.V.
By MARC SANTORA

Investigators looking into the possible spread of a virulent strain of
H.I.V. detected in a New York City man have identified several patients who
may have a related strain of the virus, but the investigators have cautioned
that they cannot yet say if the cases are connected, health officials said
yesterday.

Because of the complexity of the lab testing involved in matching strains of
the virus, it could be months before health officials will be able to
determine if others have indeed been infected with the dangerous strain, the
officials said.

"The extent to which this strain has spread remains under investigation,"
said the city's Department of Health and Mental Hygiene in its first public
statement since issuing a public warning last month about the man's case.

That warning, on Feb. 11, was provoked by the case of a gay man in his late
40's who engaged in unsafe sex with many partners while he was using crystal
methamphetamine, and whose strain of the virus was at once quickly advancing
and resistant to many drugs. The announcement brought an immediate backlash
from some prominent AIDS researchers who believed that too much was being
made of a single case.

Since that time, investigators have been able to trace all of the sexual
partners the man could remember by name and have now closed that part of the
investigation, said Dr. Thomas R. Frieden, the city's health commissioner.

The effort involved more than half a dozen investigators going door to door,
but Dr. Frieden would not go into detail about how many people were
contacted, citing patient confidentiality concerns. One person briefed on
the investigation said that more than a dozen men were tracked down.

However, because the patient told investigators that he had sex with more
than a hundred people over several months and could not remember many of
their names, the contact tracing is of limited help.

Of those the department has contacted, many were previously infected with
H.I.V., officials said.

"Obtaining blood samples for resistance testing, and testing of these
samples to determine the genetic relatedness of strains is continuing and
may take weeks to months to complete," the department said.

Because the investigation is continuing, Dr. Frieden would not say precisely
how the strains that might be related to the New York City case were found.
Some may have been discovered as a result of identifying men with whom the
New York man had sex, but it is just as likely that they were detected in
the department's canvassing of laboratories that do H.I.V. research and
testing.

In all, one health official said, investigators have identified "fewer than
10" patients whose strains may be related to the New York City man.

Work has already begun, with the help of the Centers for Disease Control in
Atlanta and the Aaron Diamond AIDS Research Center in Manhattan, to sequence
the genome of the possibly related cases, Dr. Frieden said.

The source of the New York man's infection remains unknown, officials said.

Health officials said that his case was particularly troubling because it
was the first in which they had seen a strain of the virus that was both
resistant to nearly all drug treatments and highly aggressive, leading
rapidly from H.I.V. infection to AIDS.

The health department's handling of the case, including the public warning,
came under criticism from some prominent AIDS researchers, who suggested
that the rapid progression of the disease might have more to do with the
man's immune system than the aggressiveness of the virus.

Given the heated reaction and the complexity of the scientific questions
involved, it is not surprising that the department has been cautious in
releasing details about the inquiry.

Still, yesterday's update by the department failed to answer a central
question regarding the case: Did the man transmit this new strain to his
sexual partners?

"As of today, no other cases of multi-drug-class resistant, rapidly
progressive H.I.V. have been identified," health officials said. But that
does not mean that no other cases exist.

The case that set off the alarm involves a man who tested positive for
H.I.V. in December and developed AIDS by January. Investigators say they
believe that he has been infected for as long as 20 months or as little as 4
months. On average, it takes 10 years to develop AIDS after infection, but
the curve is wide, with some people developing AIDS after about 20 years
while others have it progress within a year or so.

The man's virus also showed signs of being resistant to nearly all of the
roughly 20 licensed drug treatments.

Health officials, however, said yesterday that they were encouraged that the
patient seemed to be responding to treatment that includes two licensed
drugs.

"It is probably the most encouraging thing there is about this
investigation," Dr. Frieden said. Still, the man remains seriously ill.

The update by the department comes after researchers at the Aaron Diamond
Center, which alerted the city to the man's case, published a genetic study
of the strain that they said showed it to be unusually aggressive.

But it is the ongoing investigation by the health department in conjunction
with the work being done in laboratories that will ultimately reveal the
strain's significance. It could be months before any definitive conclusions
can be reached, officials said.

In an interview, Dr. Frieden said he remained convinced that the department
made the right decision in issuing an alert.

"It is certainly the case that because we did go public we are more likely
to find future cases as they occur," he said. He also pointed to some
disturbing behavior patterns the investigation revealed.

"The social network surrounding this case indicates that unsafe, anonymous
sex, along with the use of illicit drugs including crystal methamphetamine,
remains common," the department said in its statement.

NEW YORK CITY DEPARTMENT OF HEALTH AND

MENTAL HYGIENE

Thomas R. Frieden, MD, MPH

Commissioner

FOR IMMEDIATE RELEASE

Tuesday, March 29, 2005

UPDATE ONTHE INVESTIGATION OF A RARE STRAIN OF HIV IN A NEW YORK CITY
RESIDENT

NEW YORK CITY - March 29, 2005 - The New York City Department of Health and
Mental Hygiene is continuing its investigation of a multi-drug-class
resistant strain of HIV that appears to have rapidly progressed to AIDS in a
New York City man. This is an update on the status of the investigation.

The source of the New York City man's infection is still unknown and remains
under investigation. Although the patient's strain of HIV is highly drug
resistant, the patient is responding to treatment thus far that includes the
two drugs to which his strain appears to be susceptible, as well as other
drugs which may be effective. The extent to which this strain has spread
remains under investigation. As of today, no other cases of multi-drug-class
resistant, rapidly progressive HIV have been identified. We have reached
most of the named contacts of the patient. Many were previously
HIV-infected. Obtaining blood samples for resistance testing, and testing of
these samples to determine the genetic relatedness of strains is continuing
and may take weeks to months to complete.

Laboratories have identified several patients whose strains may be related
to this patient's strains. However, database matching and laboratory
analysis of these strains is complex and we do not expect to have results of
genetic analyses of these strains for weeks or months. No patients with
identical strains have been identified.The Aaron Diamond AIDS Research
Center recently presented findings from a study of a group of men who have
sex with men who were tested for HIV between 1999 and 2004, which indicated
that more than one quarter of those with recent infection have resistance to
one or more drugs. Resistance to any 2 classes of antiretroviral drugs
increased from 2.6% in 2000 to 9.4% in 2004. In summary, there is good news
and bad news, and there are many things that we still don't know.

The good news:

The patient is responding to treatment thus far. This indicates that the
strain, while difficult to treat, appears to be treatable at this point.
However, the patient remains critically ill and must continue to be
monitored closely. To date, no other patients have been identified with the
same strain . Through efforts of the Health Department, physicians,
laboratories, and others, there is now a monitoring system in place to
identify similar cases if they occur. The Health Department has learned from
physicians that they are testing patients for this strain of HIV. This means
that we have a better chance of identifying additional cases in the coming
months and years if they occur. Community organizations and physicians
report an increased discussion of the need for safer sex and HIV prevention

The bad news:

Many of the patient's partners were anonymous and the Health Department will
not be able to reach them. Therefore, they may not be tested for HIV and, if
infected, may not be diagnosed for months or years.

Investigation of the social network surrounding this case indicates that
unsafe, anonymous sex along with the use of drugs including crystal
methamphetamine remains common. Many of the patient's partners already knew
they were HIV-positive, some for many years. Nevertheless, they had unsafe
sex and used drugs. Many had a recent history of other sexually transmitted
diseases, such as syphilis and gonorrhea. Many unsafe sexual encounters
occurred in public sex venues and through Internet contacts.

What we don't know (a partial list)

The precise time of this patient's infection, which occurred sometime
between 4-20 months prior to his first positive HIV test. How many other
people have similar strains of HIV Whether there have been additional
patients with this strain who remain undiagnosed; Whether there will be such
cases in the future. This is a complex investigation and can take months. We
will continue to provide periodic updates throughout this process.

Public Health Messages

Whether one is HIV negative or HIV positive, safe sex is critical.
Medications can lose their effectiveness if resistance occurs. . All New
Yorkers should practice safe sex. There are several indications that unsafe
sexual behavior, especially among men who have sex with men, may be
increasing. Nationally and in New York City, syphilis, LGV, and gonorrhea
among this population have increased over the past few years.

Doctors caring for HIV-infected people should promote adherence by
simplifying regimens and ensuring access to mental health and substance
abuse services and housing. People being treated for HIV should adhere to
their medication regimen to reduce their viral load and to prevent the
development of resistance. . Doctors should routinely offer HIV counseling
and voluntary testing, and should consider the diagnosis of acute retroviral
syndrome among people who have risk factors for HIV and present with
flu-like symptoms, fever, swollen glands, sore throat, rash, muscle aches,
diarrhea, headache, nausea and vomiting. People with acute HIV can be very
infectious because they are not aware that they are positive and the viral
load (amount of HIV in the blood and body fluids) can be very high during
acute retroviral syndrome.

People at risk for HIV should learn their status so that they can access
treatment if they are infected and take steps to prevent transmission of the
virus to others.

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#026

CONTACT: (212) 788-5290; (212) 788-3058 (After Hours)

Sandra Mullin (smullin@health.nyc.gov)