Friday, March 25, 2005

Methamphetaimine and Unprotected Sex = HIV Superstrain

The Guardian Unlimited has a story about a New York Club which may have facilitated the spread of a new strain of HIV:

West Side story: a tale of unprotected sex which could be link to new HIV superbug

New fears for gay men after doctor breaks silence

Mark Honigsbaum in New York
Saturday March 26, 2005
The Guardian

From street level it looks like the entrance to any other New York office block. But mount the stairs to the second floor and you suddenly find yourself standing in front of a glass booth from behind which an attendant is busy dispensing locker keys and towels to a line of eager young men. No Drugs or Poppers, reads a notice beside the fogged glass. No Sleeping in Public Areas.

This is the West Side Club, a Manhattan bathhouse where both HIV-positive and HIV-negative men come to enjoy the steam and engage in anonymous and often unprotected sex with other men. According to an HIV/Aids practitioner whose clients are frequent visitors, it may also be where the so-called Aids superbug, whose existence was revealed last month, was first transmitted.

The extraordinary claim is made by Gary Blick, a Connecticut-based physician who heads a regional taskforce aimed at educating gay men about rising HIV and syphilis infections. Last week he decided to break his silence about the bathhouse and his clients' possible role in the transmission of the supposed new superstrain of HIV because of his mounting concerns about what he views as the continued unsafe sex practices in the gay community.

In particular, Dr Blick, who runs an HIV treatment centre in Norwalk, a sedate commuter town to the north of Manhattan, wanted to warn men to be vigilant ahead of last weekend's Black Party, a three-day shindig at New York's Roseland Ballroom where gay men engage in anonymous sex, fuelled by crystal meth, a highly addictive amphetamine that lowers sexual inhibitions and which many doctors blame for the recent increase in HIV transmissions.

Genetic match

"Most patients who abuse crystal meth do not care whether or not they are practising safer sex," said Dr Blick. "Here in Norwalk we're only 45 minutes out of the city. I felt I had to get my message out."

He chose to do so by issuing a press release revealing that a California laboratory had found a partial genetic match between the middle-aged New York man who is at the centre of the superbug alert and one of his clients. His announcement infuriated public health officials who have been at pains to counter accusations of scaremongering about the virus.

The existence of a possible new superstrain of HIV first surfaced on February 11 when the New York health commissioner, Thomas Frieden, gave details of the New York man, who remains anonymous, citing an unprecedented combination in his case of multi-drug resistance and the rapid onset of Aids. Mr Frieden too has faced criticism for going public.

Further scientific backing to the thesis that the New York man could be infected with a new strain of HIV that could be much more difficult to treat and contain was provided last week in the medical journal the Lancet which suggested that he might have gone from being infected with the strain of HIV to developing full-blown Aids in the space of just four months - something not seen since the advent of the epidemic in the early 1980s.

The study, co-authored by Martin Markowitz and David Ho, researchers at New York's Aaron Diamond Aids Research Centre, also found that the new strain contained an extra key for latching on to human receptor cells and evading the body's immune response.

For many gay activists and scientists specialising in Aids, such findings are premature. "One man does not make an epidemic," said John Moore, an Aids expert at Cornell University. "If they'd reported a cluster of cases I would be much more concerned."

But what of the claims of Dr Blick of a connection between the New York case and his client in Connecticut? Although Steve Wolinsky, a specialist in HIV genetics at Northwestern University, points out that without wider studies Dr Blick's claims are meaningless, the California lab's findings are being taken sufficiently seriously for the health department to request that Dr Blick forward further cell samples to the Aaron centre.

And on Tuesday Dr Blick spoke directly to Dr Markowitz to inform him that another lab had turned up a match for their New York patient. Intriguingly, this time the match was the partner of Dr Blick's Connecticut patient - a gay man also in his 40s whom Dr Blick has simultaneously been treating for multi-drug resistant HIV.

Both men have given accounts to Dr Blick of how they may have passed the infection to the New York patient - a story which leads straight to the door of the West Side Club and shines an uncomfortable light on the crystal meth sex scene and the widespread ignorance among gay men about the risks associated with HIV transmission.

Unlike other venues where men meet for anonymous sex, West Side has a reputation for being a friendly and pressure-free environment. Many men undoubtedly visit the bathhouse simply to unwind after a hard day at the office. Others go there in the hope of finding sympathetic partners - or, in the phraseology favoured by crystal meths users, to "party and play".

According to one regular attendee who asked to remain anonymous, the West Side Club is attractive to many HIV positive men precisely because "no one questions you about your HIV status" there. The result is "everyone assumes everyone is positive".

He says that when he has offered to use condoms in the past he has been told by the men he has partnered not to bother. Instead, like many of the bathhouse's clientele, he goes "bareback" oblivious to the fact that even HIV positive men need to protect themselves during anal sex because of the risk of cross-infection with different strains of the virus.

According to Dr Blick this appears to be precisely what happened one weekend last autumn when his clients travelled to the club from Connecticut. Not surprisingly, neither of the men was willing to speak directly to a journalist - like the New York man they have only agreed to cooperate with public health officials on the basis of anonymity.

However, the men told Dr Blick that the New York patient had already identified them to public health officials who have been working with him to trace his contacts. "He remembered key details about my clients' occupations. He also recalled particular markings on their bodies," said Dr Blick.

The officials believe that until November, when he started complaining of a febrile illness, the New York man was probably HIV negative (when he had last been tested in May 2003 he was clear). However, in the autumn of 2004, fuelled by his addiction to crystal meth, he had begun trawling the internet for new partners. By October, the period when he met the Connecticut couple at the West Side Club, he was having scores of casual encounters. It was only in December, when his health began to deteriorate and he was diagnosed with HIV, that he ceased his sexual activity.

Unlike the New York man, Dr Blick says his clients were not addicted to crystal meth. However they liked to binge on the drug and told Dr Blick that tragically on this particular weekend in October the New York man did not volunteer his HIV status and neither did they.

This week Dr Blick informed his clients that they might have inadvertently been responsible for infecting the New York patient and hence triggering the emergence of the possible new strain of HIV. He said the pair were devastated by the news. "They said that if they had know the guy was HIV negative they wouldn't have had sex with him," said Dr Blick.

However, Dr Blick's link between his patients and the New York case are far from certain. He has stressed himself that the lab report was preliminary, did not prove there had been direct transmission from his patients, and that the Aaron centre would need to do further screening of the gene "envelope" to be certain.

But whatever the truth, there is little doubt that Blick's tale is a further wake-up call for New Yorkers who, after the anxious chatter that followed Mr Frieden's announcement six weeks ago, had once again slipped into complacency about the risks of transmission.

It has added to anxieties that a degree of complacency about the risks of transmission of HIV may have entered the New York gay scene, encouraged by the use of crystal meth. "People have safe-sex fatigue - they are fed up of having to be afraid of HIV," explained Peter Staley, the founder of Aids Med, an internet-based treatment site for people living with HIV, and himself an HIV positive recovering crystal addict. "In those circumstances, crystal is the perfect Petri dish for disease transmission."

The most worrying aspect of the New York case is how rapidly the man progressed to Aids and how difficult his infection has proved to treat. When the man was first diagnosed with Aids in January his T-cell count - the measure of his ability to mount an immune response - was negligible and by February he had lost 20 lb (9kg). Although he has since put on weight, according to the latest medical reports he is responding to only one of the 21 anti-retroviral drugs.


Does that mean that his virus is a unique superstrain, one that could spark a new epidemic? And is Dr Blick right to say that recombination between his clients' strains of HIV may be the reason the New York man developed Aids so quickly?

According to most scientists it is simply too early to say. Treatment specialists at Gay Men's Health Crisis, New York's leading advocacy group for men with HIV, point out that rapid progression on its own is hardly news. In a trawl of the medical literature GMHC turned up several recent cases where individuals infected with HIV had developed Aids and died within six months.

Neither is there anything new about multidrug resistance. Studies have found resistance to at least one drug in up to 15% of new infections and multiple resistance in 1.3% of new infections.

What GMHC concedes is worrying is the possibility that the New York patient may have been infected with one or more multidrug resistant strains at the same time - not just from the Connecticut men but other men he may have had unsafe sex with. It is also concerned about the widespread perception in gay circles that it is safe to have condom-free anal sex with other positive men because one strain of HIV is somehow protective against another.

"That's where we need to do more work to educate people," admitted George Ayala, the director of GMHC's Institute of Gay's Men's Health. "There is no doubt that the safe-sex message - use condoms - is not considered as relevant today as it used to be." But there is also a risk of crying wolf, Mr Ayala warns. In a clear swipe at Mr Frieden he says officials should take care "not to make announcements that demonise gay men and the choices they make around sex and drugs".

In an editorial accompanying the Aaron research study last week, the Lancet agreed that alarm about any so-called superbug was premature, pointing out that the rapid progression of the disease in the New York man could be due to an "as yet undetermined host susceptibility". But the journal praised Mr Frieden's decision to go public, arguing that it could speed up the investigation by encouraging the man's sexual contacts to come forward.

According to a public health official quoted last week by the New York Times, that strategy is already paying dividends. The department has heard from more than a dozen men believed to have had sex with the patient and is now testing their blood to see if he passed on the virus.

Scientists say we will have to wait and see whether newspapers were right to brand the new strain a superbug. But the case is already a timely reminder that, for all the advances in anti-retroviral therapy, HIV remains a formidable foe.

Special reports
Medicine and health

Special investigation
February 2003: Saving Grace - why 30m people with Aids can't get the drugs they need

Full text
UN Aids report, November 2002
UN report into Aids, July 2002

Useful links
NHS Direct: HIV/Aids
British HIV Association
Eldis HIV/Aids guide
National Aids Trust
Terrence Higgins Trust
Elton John Aids Foundation
Children with Aids
Médecins Sans Frontières

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