"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,

The strain of three-class antiretroviral-resistant HIV -- or 3-DCR HIV -- does not respond to three classes of anti-retroviral medication. It 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.

"This is the news we have all been fearing," says Tokes M. Osubu, Executive Director of Gay Men of African Descent. "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."

Rapid Onset of AIDS

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.

Wake-Up Call

"This case is a wake-up call," says Health Commissioner Thomas R. Frieden, MD, MPH. "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," Dr. Frieden warns.

"Second," he continues, "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," says Dr. Frieden, "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."

Testing for Drug Susceptibility

The Health Department recently issued a Health Alert to physicians, hospitals and other medical providers asking them to test all previously untreated patients with 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.

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

Reducing Risk Behavior Critical

"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," says Dr. David Ho, CEO and Director of the Aaron Diamond AIDS Research Center. "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," he recommends.

"The rapidly growing crystal meth epidemic in New York city continues to play a significant role in facilitating the transmission of HIV," says Dr. Antonio Urbina, Medical Director of HIV education and training at St. Vincent's Catholic Medical Center. "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," he notes.

Substance Use and Unsafe Sex

"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," says Jay Laudato, Executive Director of the Callen-Lorde Community Health Center. "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," adds Laudato.

"This case is a striking reminder that the risk of getting infected with HIV has not gone away," says Dr. Jay Dobkin, Director of the AIDS Program at Columbia University Medical Center. "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," Dr. Dobkin notes.

"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," adds Roy M. Gulick, MD, Associate Professor of Medicine at Weill Cornell Medical College in Manhattan.

Know Your HIV Status

There is an epidemic of HIV and AIDS in New York City, says DOHMH. 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, the Health Department emphasizes.

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, DOHMH urges.