New 3-DCR HIV strain does not respond to three classes of anti-retroviral medication

A highly resistant strain of rapidly progressive human immunodeficiency virus (HIV) has been diagnosed for the first time in a New York City resident who had not previously undergone antiviral drug treatment, according to the Department of Health and Mental Hygiene (DOHMH). The strain of three-class antiretroviral-resistant HIV - or 3-DCR HIV - does not respond to three classes of anti-retroviral medication, and also appears to greatly shorten the interval between HIV infection and the onset of AIDS.

The patient is a male in his mid-40s who reported multiple male sex partners and unprotected anal intercourse, often while using crystal methamphetamine (crystal meth). He was first diagnosed with HIV in December 2004 and appears to have been recently infected. The diagnosis of 3-DCR HIV was made shortly thereafter at the Aaron Diamond AIDS Research Center. Since then, the patient has developed AIDS. DOHMH is counseling and offering HIV testing to those contacts of the patient who have been identified.

While drug resistance is increasingly common among patients who have been treated for HIV, cases of 3-DCR HIV in newly-diagnosed, previously untreated patients are extremely rare, and the combination of this pattern of drug resistance and rapid progression to AIDS may not have been diagnosed previously. Strains of 3-DCR HIV are resistant to three of the four available types of antiviral drugs that are most commonly prescribed: nucleoside reverse transcriptase inhibitors, non-nucleoside reverse transcriptase inhibitors, and protease inhibitors. This strain also caused a rapid onset of AIDS, which usually occurs more than ten years after initial infection with HIV. In this patient's case, onset of AIDS appears to have occurred within two to three months, and at most 20 months, after HIV infection.

Health Commissioner Thomas R. Frieden, MD, MPH said, "This case is a wake-up call. First, it's a wake up call to men who have sex with men, particularly those who may use crystal methamphetamine. Not only are we seeing syphilis and a rare sexually transmitted disease - lymphogranuloma venereum - among these men, now we've identified this strain of HIV that is difficult or impossible to treat and which appears to progress rapidly to AIDS. This community successfully reduced its risk of HIV in the 1980s, and it must do so again to stop the devastation of HIV/AIDS and the spread of drug-resistant strains. Second, doctors in New York City must increase HIV prevention counseling, increase HIV testing, obtain drug susceptibility testing for patients testing HIV-positive who have not yet been treated, improve adherence to antiretroviral treatment, and improve notification of partners of HIV-infected patients. Third, the public health community has to improve our monitoring of both HIV treatment and of HIV drug resistance, and we have to implement prevention strategies that work."

The Health Department recently issued a Health Alert to physicians, hospitals and other medical providers asking them to test all previously untreated patients newly diagnosed cases for anti-HIV drug susceptibility. The Department is monitoring laboratories for additional cases of 3-DCR HIV in newly diagnosed persons. DOHMH is also working with New York State to establish a long-term system for monitoring drug resistance in HIV-positive patients who have not yet undergone treatment.

Dr. Frieden added, "Patients who are on treatment for HIV/AIDS and are doing well do not need susceptibility testing unless advised to by their physician."

Dr. David Ho, CEO and Director of the Aaron Diamond AIDS Research Center, said "This patient's infection with an HIV-1 strain that is not amenable to standard antiretroviral therapy, along with his rapid clinical and immunological deterioration, is alarming. While this remains a single case, it is prudent to closely watch for any additional possible cases while continuing to emphasize the importance of reducing HIV risk behavior."

"The rapidly growing crystal meth epidemic in New York city continues to play a significant role in facilitating the transmission of HIV. In light of the emergence of this virulent new strain, health care providers must be especially vigilant in not only recognizing and diagnosing HIV infection, but also in recognizing the signs and symptoms of crystal methamphetamine use in their patients," said Dr. Antonio Urbina, Medical Director of HIV education and training, at St. Vincent's Catholic Medical Center.

"Callen-Lorde is deeply concerned about this newly identified case of multiple drug resistant HIV," said Jay Laudato, Executive Director of the Callen-Lorde Community Health Center. "We urge all persons, both HIV negative and positive, to only engage in safer sex practices in order to prevent new infections or re-infection. For those persons who don't know their status, we urge HIV testing and obtaining the information and support necessary to reduce their risk for HIV infection. We also ask all gay and bisexual men to become knowledgeable about the dangers of crystal methamphetamine and in particular its relationship to sexual risk taking."

Dr. James Braun, President of the Physicians Research Network, said "We believe that the transmission of treatment-resistant HIV was a disaster waiting to happen, particularly in communities where safer sex is not practiced regularly and in light of people using drugs like crystal meth. All primary care providers in acute care settings need to know how to diagnose HIV in its earliest stages and where to refer people so that new infections are properly worked up and treated."

"HIV prevention is an ongoing process," said Ana Oliveira, Executive Director of Gay Men's Health Crisis. We have to double our efforts and resources to maintain treatment and prevention education for people who are infected as well as for those who are not. New Yorkers must be vigilant and know that infection with resistant strains of HIV can be avoided. People living with HIV can live healthy and satisfying lives by protecting themselves and their partners, regardless of HIV status."

Tokes M. Osubu, Executive Director of Gay Men of African Descent, said, "This is the news we have all been fearing. While the recent advances in HIV treatment have led to the improvement of countless lives, we have always known that many people respond poorly to these therapies and for many others, the side effects are devastating. Continued education about staying safe and avoiding HIV remains our most potent weapon."

Dr. Jay Dobkin, Director of the AIDS Program at Columbia University Medical Center, said, "This case is a striking reminder that the risk of getting infected with HIV has not gone away. In fact, risky behavior may be even more dangerous now since there is a chance of infection with a virus we may not be able to treat."

"This case should drive home the point that substance use can lead to unsafe sex, and unsafe sex can lead to infection with a highly drug-resistant strain of HIV that can be extraordinarily difficult to treat and may cause rapid progression to AIDS," said Roy M. Gulick, MD, Associate Professor of Medicine at Weill Cornell Medical College in Manhattan.

Dr. Jack DeHovitz, Professor at SUNY-Downstate Medical Center said, "This finding supports the need for enhanced availability of HIV testing, as well as preventive interventions, which are effective in reducing subsequent HIV transmission."

There is an epidemic of HIV and AIDS in New York City: more than 88,000 New Yorkers are known to be living with HIV/AIDS, and an estimated 20,000 more are believed to be living with HIV/AIDS and don't know it.

By knowing your HIV status, you can protect yourself, anyone you are having sex with, and, if you are pregnant or planning pregnancy, your baby. Free and fully confidential STD exams and treatment, as well as confidential or anonymous HIV testing, are available at Health Department clinics throughout New York City. Health insurance, proof of citizenship and/or parental consent are not required to receive these services. Please call 311 or visit http://www.nyc.gov/health for a list of clinics and hours of operation.

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