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Reply to Volberding: The Role of Public Health
Submit responseTo the Editor:
Volberding raises concerns about the handling of a case of highly drug resistant, rapidly progressive HIV infection in a man who had many anonymous high-risk sexual contacts (1,2). Several issues should be clarified.
We agree with Volberding that the patient’s infection was “extremely rare” and that we do not know if it has or will spread. Contact investigation began weeks before our public announcement, but was of limited value because of the anonymous nature of the great majority of contacts (3).
Public health has a duty to warn the public. Our announcement was intended to, and we believe likely did, increase the odds of identifying if this strain has or will spread. This is because the announcement likely increased demand for testing among people at risk for HIV, increased testing for HIV infection in general and primary HIV infection in particular by doctors, increased testing for drug resistance, and because we initiated public health surveillance for drug resistance (which had not been done prior to this case).
Furthermore, we believe our announcement reduced the likelihood of spread of this and other strains of HIV by emphasizing the risks of unsafe sexual behavior, providing the facts about this very concerning strain, and encouraging physicians to redouble efforts to diagnose, provide ongoing risk-reduction counseling, and improve treatment efficacy of people living with HIV/AIDS (3).
Although the future epidemiology of this strain cannot be predicted, we believe that this individual case represents a critical public health event, warning about ongoing unsafe sexual behavior, often in the context of substance abuse, in the community of men who have sex with men, and of the increase in primary drug resistance among HIV-infected people (4,5).
We share Volberding’s perspective that important public health concerns include continued risky behavior and our failure to reduce barriers to HIV diagnosis and to diagnose primary HIV infection. We would add to that the lack of population-wide monitoring of treatment efficacy and the assumption that the HIV epidemic can be described and analyzed but not controlled.
We did not issue an alert to cause fear, nor do we think this was the primary result of our announcement. 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.
Thomas R. Frieden, MD, MPH Commissioner of Health and Mental Hygiene City of New York
1. Volberding PA. The New York case: lessons being learned. Ann Intern Med. April 21, 2005; [Epub ahead of print].
2. Markowitz M, Mohri H, Mehandru S, et al. Infection with multidrug resistant, dual-tropic HIV-1 and rapid progression to AIDS: a case report. Lancet. 2005;365:1031-8.
3. DOHMH alert #7: primary 3-drug-class-resistant HIV-1 infection with rapid CD4+ T cell depletion and progression to AIDS in a New York City man who has sex with men. New York City Department of Health and Mental Hygiene. February 11, 2005. (Accessed at http://www.nyc.gov/html/doh/downloads/pdf/cd/05md07.pdf on May 3, 2005.)
4. Little SJ, Holte S, Routy JP, et al. Antiretroviral-drug resistance among patients recently infected with HIV. N Engl J Med. 2002; 347:385-94.
5. Shet A, Mohri H, Berry L, et al. Transmission of drug resistant HIV-1 in patients with acute and early HIV-1 infection in 2003 to 2004. Proceedings of the 12th Conference on Retroviruses and Opportunistic Infections; February 24, 2005; Boston, Mass.
Conflict of Interest:
No financial conflict of interest. The author is Health Commissioner of New York City and made the decision addressed in Dr. Volberding's article.