AIDS Experts Awaken to a False Alarm
The announcement from New York health officials in early February was chilling: A single patient had progressed from HIV infection to AIDS in months rather than years, and his strain of the HIV virus seemed impervious to normally effective medicines.
The patient, a gay man in his 40s, had unprotected anal intercourse with scores of partners. Headlines of a potential new killer spread around the world.
“This case is a wake-up call,” Dr. Thomas R. Frieden, New York City’s health commissioner, said at a news conference where he issued a warning for physicians to prepare for a possible new phase in the epidemic.
Yet several AIDS experts immediately questioned the importance of the case and the strategy of publicizing it so widely.
Months later, those doubts seem to have been confirmed.
No super-strain has emerged. The patient, whose name has been withheld, has responded to drug therapy. No one -- not even the man’s known sexual partners -- was found to be infected with the same HIV strain.
Some AIDS specialists now say the New York announcement was scientifically naive and needlessly alarmist -- risking the effectiveness of future prevention efforts.
“Does it do good to [mislead] people and exaggerate?” asked Dr. Robert Gallo, co-discoverer of the virus that causes AIDS. He condemned Frieden’s far-reaching conclusions as “scientifically, completely invalid, without a shred of evidence.”
Frieden and Dr. David Ho, director of the Aaron Diamond AIDS Research Center in Manhattan, where much of the patient’s lab work was done, declined interview requests.
But Frieden recently defended his decision in a letter to the journal Annals of Internal Medicine.
“We did not issue an alert to cause fear, nor do we think this was the primary result of our announcement,” Frieden wrote. “It would not have been appropriate to await additional cases before making an announcement. The goal of public health is to prevent, not describe, outbreaks.”
The patient’s condition did seem to encompass a frightening confluence of factors.
The presence of HIV in the patient’s blood reached high levels, and essential immune system cells were severely depleted within 20 months after he was infected, rather than the typical several years. Three of the four major classes of antiretroviral drugs proved ineffective.
The patient was a user of crystal methamphetamine, an illegal drug that loosens inhibitions and might suppress immune response.
The seriousness of the alert was bolstered by the stature of the doctors behind it, some of whom were among the most respected in AIDS research. Ho, Time magazine’s 1996 Man of the Year for his AIDS work, lent a stamp of scientific certainty.
The February announcement included caveats about assuming too much from a single case. But scientific uncertainty can be a hard sell to the media, and the event seemed suffused with the subtext that this could be a turning point in the epidemic.
Hundreds of articles and broadcasts followed. Some took a hysterical tone -- perhaps an overreaction by media outlets that were criticized for ignoring early cases of AIDS more than 20 years ago.
“New AIDS Super Bug -- Nightmare Strain Shows Up in City,” trumpeted the New York Post. “New AIDS Peril Puts America on High Alert” was how the Hindu, one of India’s large national newspapers, played the story. The New York Times headlined one of its several stories: “Chilled by Findings, Investigators Dreaded the Mounting Evidence.”
The problem, however, was that for many experienced AIDS workers, none of the conditions was new or particularly rare.
Dr. Douglas Richman, director of the Center for AIDS Research at UC San Diego, said resistance to three classes of AIDS drugs was relatively common.
“Rapid progression occurs in a subset of people,” said Richman, lead author of a study that showed widespread drug resistance similar to that of the New York patient’s. “High rates of promiscuity among men who have sex with men, especially those who abuse methamphetamines, is frighteningly high.”
“I didn’t see this as a new, master virus that posed a threat of a new epidemic,” Richman said.
Gallo, director of the Institute of Human Virology at the University of Maryland, said the New York officials might have jumped to the conclusion that a single virulent infection would be easily transmitted.
The infection might say more about the individual’s susceptibility to the virus than about the virus’ ability to spread easily.
Canadian researchers Dr. Julio Montaner and Richard Harrigan at the British Columbia Centre for Excellence in HIV/AIDS detected two similar cases in 2001, and those patients apparently did not pass along the virus.
“It wasn’t clear that there was a real public health benefit from the way the announcement was made, as opposed to investigating more details in advance,” said Dr. Paul Volberding, director of the Center for AIDS Research at UC San Francisco.
The New York case has reflected the fractured perspectives about how to combat AIDS in an era when the epidemic has lost some of its urgency.
Once AIDS was a virtual death sentence. Today, with appropriate care and drug treatments, most people in this country with HIV or AIDS live relatively long lives. But the improvement has fed a growing complacency among high-risk populations and the general public.
At the same time, widespread use of crystal meth and its tendency to promote unsafe sex has undermined recent progress -- a message that advocacy groups and health officials have tried to convey with limited success.
The New York case offered a rare megaphone to wake people up. Several health officials and AIDS support groups agreed with the high alert.
“The time to issue a warning is when something bad might take place,” said Dr. Ronald Valdiserri, AIDS prevention director for the Centers for Disease Control and Prevention. “I don’t think it was counterproductive.”
Gay Men’s Health Crisis, a major New York service and advocacy group that receives health department funding, was a key participant in the New York announcement.
Frieden “handled the announcement prudently,” said George Ayala, who directs an AIDS prevention program for the Gay Men’s Health Crisis and AIDS Project Los Angeles.
“We want to be mindful of where the epidemic is going, and use these situations to remind ourselves about the seriousness of HIV and AIDS,” Ayala said.
But Matt Foreman, executive director of the National Gay and Lesbian Task Force, said the announcement was irresponsible and had damaged the credibility of the effort to combat AIDS.
“It had a very salacious overtone,” Foreman said. “What it did was feed stereotypes about gay men and their sexual behavior.... Another two weeks or three weeks to really understand the science and the implications of these findings would have been appropriate -- not this rush to judgment.”
Arthur Caplan, director of the Center for Bioethics at the University of Pennsylvania, faulted the news media for blowing the story out of proportion but said New York officials should not have been surprised by the response and might have squandered their credibility.
“When it comes to HIV, it’s fair to say there will be no moderation,” Caplan said. “People are poised to panic.”
Dr. Jonathan Fielding, L.A. County public health director, agreed but added that it was easy to second-guess the New York researchers.
“It’s difficult either way,” Fielding said. “You’re likely to be criticized if you didn’t announce it and there were more cases. People would ask, ‘Why did you keep it a secret?’ ”
