Is having HIV ‘like a death sentence’?

This is an amended version of a blog entry originally entitled ‘Canada: Expert doctor defends his statements on HIV life expectancy’. I was forced to remove the original posting to which this entry refers due to a threat of legal action.

I have now included the news article from the original posting (about the Owen Antoine case in St. Thomas, Ontario, Canada) in this fuller entry on Mr Antoine’s trial.

The offending post dealt with the reported statements of Dr Anurag Markanday, the expert witness for the Crown in an article on the case from the St Thomas Times Journal, with which I strongly disagree.

Dr Anurag Markanday told the jury there’s no cure for HIV, but drugs do slow the process of the disease. “It’s like a death sentence … while we can keep the virus suppressed, we are going to run out of options.” Once diagnosed, the average lifespan of a person is eight to 10 years, he testified.

For someone with access to HIV treatment – as is the case in Canada – HIV is now a chronic, manageable condition.

In subsequent email correspondence, Dr Markanday again asserted his opinion that, “in the absence of a cure, I would still label it as “death sentence” for someone not on therapy (when clinically indicted) [sic] or in heavily treatment experienced patients with multiple drug mutations and limited options.”

Of course if someone is not on treatment when they should be (in most cases when they have a CD4 count below 350 cells/mm3) then they are more likely to get sick and die. But that is focusing on the exception and not the rule.

And yes, if someone was diagnosed in the 80s or 90s and burned through every class of drug they may well have multiple drug mutations, but there are now many options for what used to be known as ‘salvage therapy’, including the amazing new drugs and new drug classes that Dr Markanday says he is working with.

Consequently, I really must question his focus on worse-case scenarios and his use of the emotive phrase, ‘death sentence’.

Dr Markanday then points out “the effects from other co-morbidities such as hepatitis co-infection with early cirrhosis and mortality, hyperlipidemia/CV events have also increased. (In terms of number of years one could safely say at least ten years since the diagnosis).”

Again, I wonder why Dr Markanday focuses on hepatitis coinfection – which certainly does increase the likelihood of illness and death in someone with HIV? I have no idea whether the complainant was already infected with viral hepatitis before she was allegedly infected with HIV, but if this is not the case, how is it relevant?

As for lipid increase and cardiovascular events, the latest word from the D:A:D study, which looks at these events, is that “there does not seem to be an epidemic on the horizon – simply a risk that needs to be managed.”

So, yes, remaining on suppressive anti-HIV treatment, giving up smoking, exercising and eating well, and taking lipid-lowering drugs if indicated, may be necessary to reduce the risk of an HIV-positive person succumbing to a heart attack, but the increased risk of treated HIV infection itself is not considered something that dramatically alters life-expectancy.

Why could Dr Markanday not have said that with treatment, someone diagnosed with HIV infection today is expected to have, more or less, a normal lifespan? That is what Italy’s Dr Stefano Vella – one of the most respected HIV clinicians in the world – said at the 2006 International AIDS Conference in Toronto, and many expert HIV clinicians agree.

Solid data backs up Dr Vella’s assertion. In 2006, researchers from the United States calculated that someone who was provided with anti-HIV drug combinations according to 2004’s US treatment guidelines would benefit from these treatments for between 21 and 25 years before they finally stopped working. Their estimate included four separate attempts at suppressing HIV to ‘undetectable’ levels, from first-line therapy to ‘salvage’ therapy. (Schackman BR et al. The lifetime cost of current HIV care in the United States. Medical Care 44(11); 990=997, 2006.)

Last year, a large Danish study concluded that a 25 year-old diagnosed with HIV and treated with the anti-HIV drugs available then could expect to live well into their mid-sixties . The Danish study found that the average 25 year-old who remained HIV-negative could expect to live until they were in their mid-seventies. Consequently, successfully treated HIV infection appears to reduce life-expectancy by about ten years. (Lohse N et al. Survival of persons with and without HIV infection in Denmark, 1995-2005. Annals of Internal Medicine:146: 87-95, 2007.)

However, anti-HIV treatments – and knowledge about how to best use them – continue to advance at a rapid pace. As time goes on, experts believe that is very likely that other ways of treating HIV will be discovered that will mean that successful outcomes from the use of anti-HIV treatment could last even longer.

Certainly, HIV can lead to some serious illnesses if untreated. In 2006, around 100 out of the 400 deaths reported in HIV-positive people in the UK were due to their being diagnosed with HIV too late for effective anti-HIV treatment, highlighting the importance of HIV testing in order to make the most of the latest advances in anti-HIV therapy.

Another third of these 400 deaths were not considered related to HIV at all. Consequently, most HIV-related deaths are preventable if HIV is diagnosed early enough and treated succesfully. (Johnson M et al. BHIVA Mortality Audit. BHIVA Autumn Conference, London, 2006.)

Ultimately, anti-HIV treatments have greatly improved the life expectancy of people with HIV, as long as they:

• Know their HIV status early enough to get timely and effective treatment
• Have access to good quality HIV treatment and care
• And take anti-HIV drugs regularly and on time.

Finally, as for life expectancy for someone not on treatment, there are new data from UNAIDS and WHO which finds that, as a result of a better understanding of the natural history of untreated HIV infection, the average number of years that people living with HIV are estimated to survive without treatment has been increased from nine to eleven years.

Swiss statement on sexual HIV transmission has major legal implications

On Wednesday, I reported on aidsmap.com that four Swiss HIV experts have produced the first-ever consensus statement to say that HIV-positive individuals on effective antiretroviral therapy and without sexually transmitted infections (STIs) are sexually non-infectious.

This has major implications for criminal HIV exposure law, and possibly also for criminal HIV transmission defence strategies.

In their statement, originally in French, the experts say that:

unprotected sex between a positive person on antiretroviral treatment and without an STI, and an HIV-negative person, does not comply with the criteria for an “attempt at propagation of a dangerous disease” according to section 231 of the Swiss penal code nor for “an attempt to engender grievous bodily harm” according to section 122, 123 or 125.

This suggests that all jurisdictions that have HIV exposure laws need to rethink their definitions of HIV exposure. In the meantime, it provides an excellent defence for people who are accused of exposure when on a stable regimen with an undetectable viral load.

Since this statement is now in the public domain it could be used as a mens rea defence in reckless HIV transmission cases – the accused honestly believed that he or she was not being reckless (absent disclosure and condom use).

It also suggests that it should be easier for the police to figure out that the complainant is barking up the wrong tree when accusing a particular individual of being responsible for their HIV infection, if that individual can prove they were on a suppressive anti-HIV regimen at the time.

The statement is remarkable, but no surprise. Doctors and other informed people have been thinking this for several years, but because of the concern that the evidence may be misinterpreted, the data have not been so publicly discussed before.

I have previously written on this for AIDS Treatment Update, reviewing much of the same data the Swiss experts reviewed. To my chagrin, although I concluded at the time that ‘undetectable does not always equal uninfectious’, I didn’t focus on when undetectable might well equal uninfectious. That will be the subject of a future article in HIV Treatment Update.

As you will see, knowing when you are likely to be uninfectious is not easy, and the Swiss statement sidesteps the practical issues that many people are likely to face when making decisions. How can you be sure you, or your partner, doesn’t have an STI, which are often asymptomatic?

I thought readers of this blog might find the article illuminating, anyway, so I include the revelant sections below. The complete newsletter can downloaded here; and a previous article in ATU 118 on the link between treatment and prevention which reviews earlier studies, can downloaded here.

‘

Undetectable’ but infectious?
What the difference between HIV levels in blood and sexual fluids means for infectiousness, by Edwin J Bernard
From AIDS Treatment Update 141, November 2004

Why HAART doesn’t eliminate infectiousness
The idea that taking Highly Active Antiretroviral Therapy (HAART) can reduce infectiousness is not new, and was the subject of an ATU article two years ago (Issue 118, October 2002 ).

In the past few years, scientists have discovered that levels of HIV measured in the blood – which is what we know as viral load testing – are not always the same as levels of HIV measured in sexual fluids. These include cum and pre-cum (semen) in men, sex fluids produced by women, both as lubrication for sex and as ‘ejaculation’ at orgasm, and the coating (mucous membrane) that lines the arse (rectum).

Although many people on HAART with ‘undetectable’ viral loads in their blood also have an ‘undetectable’ viral load in their sexual fluids, and therefore seem less likely to transmit HIV, this is not always the case. Some people with ‘undetectable’ viral loads in their blood have quite high viral load in their sexual fluids, which could be high enough to infect somebody else.
The relationship between levels of HIV in the blood and in sexual fluids is quite complex, and it is thought to be governed by two major issues: the levels of anti-HIV drugs that penetrate into the genital tract, and the presence of inflammation, including, but not limited to, STIs in the genitals.

Defining ‘undetectable’
‘Undetectable’ viral load is one of the aims of anti-HIV therapy. However, the definition of ‘undetectable’ viral load is constantly changing as the technology used to measure viral load improves.

An undetectable viral load result indicates that a specific viral load test cannot find any HIV in a given blood sample. An undetectable result does not mean that the blood is free of HIV. In fact, most people with ‘undetectable’ viral load have HIV in their blood, as well as in blood cells, tissue and bodily fluids.

For each viral load test, there is a lower limit of detection – a limit below which it is not possible to measure the amount of HIV present. Samples with very low levels of HIV, for example below 40 copies/ml, are described as having a viral load that is ‘undetectable’, or ‘below the level of detection’.

This lower threshold depends on the sensitivity of the test. The older, standard tests, which may still be in use in some UK clinics, measure down to 400 or 500 copies/ml. Consequently, an ‘undetectable’ result with a standard test may not mean an ‘undetectable’ result using an ultra-sensitive test, which can measure down to 40 or fewer copies/ml.

Genital tracts, semen and HIV
Genital tracts are the tubes inside the male and female sex organs. The male genital tract is generally considered to a ‘sanctuary site’ for HIV (a place separate from the rest of the body where HIV can hide). This is due to the presence of something called the ‘blood-testis barrier’, which is a layer of cells connected by specialised ‘tight junctions’ that prevent drugs from passing between the blood and areas of the testicles where sperm develops and matures. It is currently thought that HIV found in semen comes from the blood or the lining of the genital tract.

Viral loads in the genital tracts of men
Although most studies show that the majority of men treated with antiretroviral drugs experience parallel declines in viral load in both the blood and semen, all studies have shown considerable individual variation in responses. This means that some men may still have infectious HIV in their semen after their viral load tests indicate that HIV is undetectable in the blood. The following patterns have been observed:

• Viral load becomes undetectable in blood weeks, months or even years before doing so in semen
• Viral load becomes undetectable in blood but not in semen.
• Viral load becomes undetectable in semen but not in blood
• Blood viral load rebounds after a period of undetectability but viral load in semen remains undetectable

In the first case, prolonged HIV production in the genital tract may be explained by the fact that long-lived cells that have been infected by HIV continue to pump out virus copies because anti-HIV drugs cannot adequately penetrate these particular cells.

Another explanation might be that virus production continues because latently infected cells are triggered into virus production by the presence of infections or inflammation.

Dr Tariq Sadiq, Senior Lecturer and Honorary Consultant in HIV and genitourinary medicine at St. George’s Hospital Medical School, offers this explanation: “Many studies have shown that patients on protease inhibitor- or efavirenz-containing regimes have suppressed semen viral loads although there is poor penetration of these drugs into semen. This is probably because penetration [of these drugs] into the tissues of the genital tract, where it is likely to matter most, is not poor,” he continued. “However, another explanation is that the nucleoside analogue components of the regimens, which are often at high levels in the semen, may be adequate to suppress genital tract virus.”

Drug levels are different in the blood and semen

A very recent study has found that many anti-HIV drugs are not reaching high enough levels in semen to prevent HIV from replicating. This, many experts argue, increases the chances that an ‘undetectable’ viral load in the blood many not be providing a full picture of how well the drugs are controlling HIV in the genitals. This could result in higher levels of HIV in sexual fluids than in the blood, even when the viral load is ‘undetectable’ in the blood.

This particular study found that levels of the two most commonly-prescribed drugs in the UK – the non-nucleoside, efavirenz (Sustiva), and the boosted protease inhibitor, lopinavir (Kaletra) – do not reach high enough concentrations to reduce viral load in the male genital tract to ‘undetectable’ levels. The same was found for the ritonavir-boosted protease inhibitors amprenavir (Agenerase), and saquinavir (Invirase, Fortovase), as well as the recently-approved fusion inhibitor, T-20 (enfuvirtide, Fuzeon).

With the exception of indinavir, protease inhibitors (PIs) appear to have poor penetration into the genital tract. This is probably due to the protein binding of protease inhibitors and the high protein content of semen, or to the low levels of polyglycoprotein (Pgp), a substance which pumps protease inhibitor molecules out of cells. Pgp is present at very low levels in cells of the brain and testes.

Viral loads in the genital tracts of women
Several large studies have found a strong association between the level of viral load in blood and the level of viral load in women’s sex fluids. However, there is some evidence that antiretroviral therapy may not always result in an undetectable viral load in both blood and vaginal fluid, especially when a genital infection, like urethritis, is present.

In addition, viral load in the female genital tract varies during the course of a menstrual cycle, even among women on anti-HIV treatment. A recent study of viral load changes during the menstrual cycle found that viral load levels in vaginal fluid tended to peak at the time of menstruation and fell to the lowest level just prior to ovulation

Men with ‘undetectable’ viral loads who are the receptive partner in unprotected anal intercourse may have a much higher risk of transmitting HIV than previously thought

HIV in the rectum
Several studies have shown that detectable levels of HIV may persist in the tissue that lines the rectum even after HIV becomes undetectable in the blood. A very recent study that compared levels of viral load in the blood, semen and the coating of the rectal lining (mucous membrane) in men taking HAART found that viral load was, on average, five times higher in semen and 20 times higher in the rectal lining than in the blood.

These findings imply that men who believe themselves to have an ‘undetectable’ viral load and who are the receptive partner in unprotected anal intercourse may have a much higher risk of transmitting HIV than previously thought.

Sexually transmitted infections
Sexually transmitted infections (STIs) are important co-factors in the transmission of HIV. Not only can STIs enhance the sexual transmission of HIV by increasing the rate of viral shedding, but HIV infection can also increase susceptibility to STIs.

Dr Sadiq and his colleagues have shown that even where viral load in semen is ‘undetectable’ on HAART, sexually transmitted infections can cause viral load rebound in semen . Conversely, even when viral load is rising in blood, viral load in semen can be brought under control if a sexually transmitted infection is treated, reinforcing the view that the blood and the genital tract are largely independent compartments.

However, Dr Sadiq points out that “the role of genital inflammation may not necessarily be critical. In the work we have done in the UK , a minority of men negative for urethritis and sexually transmitted infections had viral loads considerably higher in semen compared to blood.

“Although it is true that the role of the genital tract as a separate compartment is often exaggerated, more work needs to be done to investigate non-inflammatory factors associated with apparent ‘independent’ genital HIV-1 replication.”

It is important to remember that ‘lower risk’ is a relative term, and does not mean low risk or no risk at all.

Is it sensible to make choices about safer sex based on viral load results?
A recent health education campaign by GMFA (a London-based, volunteer-led gay men’s health organisation), which was aimed at gay men who choose to have anal sex without condoms, included information that suggested that a lower viral load could reduce the risk of HIV transmission.

Although studies in heterosexuals have shown that there is a link between higher viral loads and greater sexual infectiousness, and it does seem logical to assume that a lower viral load would mean a lower risk, the reality is much more complicated.

One the one hand, more information is appearing that suggests many anti-HIV drugs don’t reach high enough levels in sexual fluids to suppress HIV levels in the same way that they do in the blood.

On the other, there is still uncertainty regarding how important anti-HIV drug levels are in sexual fluids, and other experts point the finger at sexually transmitted infections (STIs) as the cause of higher HIV levels in sexual fluids.

What is certain is that a viral load test is simply a ‘snapshot’ of levels of HIV in the blood at the time the test was taken, and that since your viral load can rise and fall at any moment, it could have changed since your last blood sample was taken.

Of course, if you are not taking HAART then you are likely to be more infectious than someone taking HAART.

It is also important to remember that ‘lower risk’ is a relative term, and does not mean low risk or no risk at all.

Given the uncertainties surrounding the effects of HAART on sexual infectiousness, is it really sensible to make choices about safer sex based on viral load results?

KEY CONCLUSIONS

  • A significant proportion of people are now making safer sex decisions based on their – or their partner’s – viral load.
  • The link between viral load in the blood and viral load in sexual fluids is complicated.
  • Levels of some anti-HIV drugs are lower in sexual fluids, and this could mean that there is higher chance of HIV transmission even when viral load is ‘undetectable’ in the blood.
  • Levels of HIV in women’s sexual fluids are also affected by their periods.
  • Levels of HIV are thought to be twenty times higher in the lining of the arse than in the blood, even in those taking anti-HIV drugs.
  • Sexually transmitted infections can increase levels of HIV in sexual fluids, whether you are on anti-HIV drugs or not.
  • Making informed choices about safer sex requires taking on board a lot of information, which can change over time.
  • The best way to protect your partners from HIV and yourself from STIs is to use condoms for anal and vaginal sex, gloves for fisting, and latex barriers like dental dams for sexual contact that is oral-genital (oral sex) and oral-anal (rimming) sex.

US: Kansas man’s 32 month sentence for HIV exposure doubled

A man already convicted to 32 months’ prison in one Kansas county has been sentenced to another 32 months for the same ‘crimes’. I previously reported his guilty verdict in December, and erroneously had him from Missouri, rather than neighbouring Kansas (I have now corrected the original story). Both trials took place in different counties in Kansas. Since the sentences will run consecutively, his punishment has essentially been doubled.

Update: I originally read the judge’s quote – “I was not aware that those prior convictions involved the same young women.” – as meaning that his prior conviction DID involve the same women; when, actually, it may mean the opposite. So this may not be ‘double jeopardy’.

However, this case is very interesting because his prior conviction is being appealed because, according to the man’s lawyer, “the current Kansas law is unconstitutional…[because] the law essentially made sexual relations illegal for people who have tested positive for HIV.”

This is current Kansas law (taken from The Body.com)

Kans. Stat. Ann. § 65-6005

Class C Misdemeanor

Any person violating, refusing or neglecting to obey any provision of the rules and regulations adopted by the Secretary of Health for the prevention and control of AIDS shall be guilty of a class C misdemeanor.

This case is also interesting because the man’s defence – and remember this is for HIV exposure, not transmission – was that he had an undetectable viral load, and therefore did not believe there was a significant risk of transmission. This was rejected by the judge; however, many informed people with HIV are concluding what many experts privately believe – that an undetectable viral load in the blood almost always means that transmission is at best unlikely, and potentially impossible.

See this very interesting (orginally private) online discussion between Swiss HIV expert, Dr Bernard Hirschl and a group of very informed patient advocates, which highlights the tension between private and public statements.

The full report, from The Emporia Gazette, is below.

Robert Richardson sentenced in HIV-exposure case

Originally published 01:23 p.m., January 17, 2008
Updated 01:23 p.m., January 17, 2008

Robert Richardson was sentenced Wednesday to serve 32 months in prison on each of two cases of exposing people to the HIV virus he carries.

The sentences were handed down by Judge Jeffery J. Larson Wednesday afternoon in Lyon County District Court, after hearing a prepared statement from one of the victims as well as a statement from Richardson.

The sentences are to run consecutively to earlier sentences imposed on those charges in Douglas County. The Douglas County sentences already have been appealed to the Kansas Court of Appeals and have not been heard yet.

Defense attorney Stephen Atherton handed Larson paperwork to initiate an appeal of the sentences at the close of the hearing.

Atherton said after the sentencing that the appeal is based on a belief that the current Kansas law is unconstitutional. He said that the law essentially made sexual relations illegal for people who have tested positive for HIV.

Richardson’s trial had been to the judge, rather than to a jury. Defense and prosecution witnesses stipulated to certain facts in the case, and testimony was given by medical personnel. As part of the agreement, the prosecution had agreed not to oppose concurrent sentencing if the defendant were convicted.

“Mr. Richardson was advised at that time that the court does not have to abide by that agreement,” Larson said.

Neither of the women are from Lyon County, but came to Emporia on several occasions to meet Richardson at a motel while he was here on work-related travel in the fall of 2005, according to testimony presented at Richardson’s preliminary hearing last year.

One of the victims attended the hearing to present a statement about how Richardson’s actions affected her.

She cited the trauma she underwent after learning that she had been exposed to HIV. She had difficulty sleeping and, when she could sleep, she suffered from nightmares, she said; she also was shocked, devastated, frightened, missed work and had difficulty eating.

She said that she had asked Richardson about sexually transmitted diseases and he said that he carried none.

The risk of “losing my life for the mistake of trusting a friend seems like too high a price to pay,” she said. “… It’s taking something that should have been private and intimate in my life and opening it to … ridicule.”

Results have been negative in two tests for HIV “but this experience has made me closed and withdrawn from others,” she said.

She asked the judge to order consecutive prison sentences, rather than concurrent terms.

“There is absolutely no reason to think Mr. Richardson will not endanger the lives of others when he is released,” the victim said.

In a statement to the court, Richardson said that he believed he posed no risk to the women when they had sexual intercourse because his HIV is under control with medications.

“I have a lot more knowledge of this disease myself than the general public,” he said. “I’ve been shown time and again … people will not hear me when I tell about it.”

He said that he cared about the women who later accused him.

“I would have never, never done something I believed would have hurt somebody else,” he said. “ … This disease is not spread by people like me.”

It is spread, he said, by people who do not get tested for HIV and continue to have sexual relations without treatment for the virus.

During the preliminary hearing, evidence was presented that showed Richardson had been diagnosed as HIV positive in 1998.

In his statement on Wednesday, Richardson also asked for visiting privileges with his 20-month-old son, whom he has never seen.

“He has 12 teeth now, and I’ve never held him, or sung him to sleep or kissed his cheek,” he said. “ … I just ask that I can have 10 minutes’ visitation time with my son.”

Larson prefaced the sentencing with remarks to the defendant, saying that he had been impressed by Richardson’s conduct during court proceedings.

“You have proven yourself to be an eloquent speaker in the courtroom, which is not something we see frequently,” Larson said.

He reminded the defendant, however, that while Richardson was aware that the likelihood of transmitting the disease was slight, it did exist and he did not tell the victims of that possibility.

“You made a decision to expose these young women no matter how slight,” Larson said.

When one of them asked if he had an STD, Richardson told her that he did not.

“And (you) were not truthful about it,” Larson said.

He told Richardson that criminal history was one of several factors that needed to be considered in sentencing, including the prior convictions in Douglas County.

“I was not aware that those prior convictions involved the same young women,” Larson said.

After the sentencing, Larson said he would take the visitation request under advisement and discuss risks with jail personnel before making a ruling.

Larson set Richardson’s appeal bond at $50,000 in each case.

UK: Leicester and Manchester cases update

A brief update to ongoing cases in Leicester and Manchester.

The Leicester trial will begin on January 29th at Leicester Crown Court.

A hearing called by the defence to dismiss charges against a Manchester man, due to lack of scientific evidence, will be held on February 5th at Manchester Crown Court.

Editorial: HIV forensics in the BMJ

http://www.newscientist.com/article/mg19526213.900-hiv-sequences-cannot-prove-guilt-in-court.html

HIV sequences cannot prove guilt

19 September 2007

People infected with HIV might well want to know who gave it to them – but the genetic sequence of their virus won’t tell them.

The virus is now routinely sequenced in each infected person to uncover drug-resistance genes, but virus sequences have also been used in several high-profile court cases by lawyers seeking to show who infected whom. This has led some HIV carriers to wonder if they might be able to do the same.

“The data won’t work for that,” warns Deenan Pillay of University College London – because HIV evolves too fast. This means that even though the viruses from two people may look similar, other local viruses may even be more alike. Analysing them can’t show whether A infected B or vice versa, whether it went through a third person or whether both were infected by another person (BMJ, DOI: 10.1136/bmj.39315.398843.BE).

However, the British database – now the world’s largest collection of viral sequences from a national epidemic – could answer other important questions. For example, it could tell us whether certain strains tend to spread among certain risk groups, or where the super-spreaders of HIV are.

From issue 2621 of New Scientist magazine, 19 September 2007, page 5

Africa’s HIV transmission laws based on questionable science

Africa’s HIV transmission laws based on questionable science
by Cassandra Willyard, New York
Nature Medicine 13, 890 (2007)
Published online: 31 August 2007

Faced with an AIDS epidemic that kills millions every year, countries in sub-Saharan Africa are contemplating a new prevention strategy: criminal charges.

Uganda, touted as the rare success story in the region, is the latest nation to propose a law that would criminalize knowingly transmitting HIV to another person, the country’s health minister announced in June. Since 2001, Zimbabwe, Lesotho and Swaziland have also adopted similar laws.

Few say the laws do what they’re intended to: reduce the spread of HIV. “They make lawmakers feel good, but they have very limited positive benefits for the public,” says Jonathan Berger, head of policy and research at the Johannesburg-based AIDS Law Project.

Apart from stigmatizing the disease more than it already is, critics warn, the laws ignore the fact that these countries may not have the resources to perform the careful genetic analysis required to distinguish the innocent from the guilty.

Phylogenetic analysis helps pinpoint how closely related two isolates of HIV are. In a criminal case, a virologist would obtain genetic sequences of the virus from both parties involved and compare them to sequences in a database, such as the US National Institutes of Health’s GenBank, or from other infected individuals in the community.

If the viruses appear more closely related to each other than they are to samples taken from the larger population, it increases the likelihood that one person infected the other.

The procedure has its limitations, however. “It doesn’t say anything about the direction of movement. It doesn’t say anything about timing. It doesn’t even really say that the transmission took place between the two people,” says Yusef Azad, director of policy and campaigns at the National AIDS Trust, a UK-based advocacy group. “They both could have been infected by a third party.”

Still, phylogenetics can exonerate the innocent. If the two HIV samples aren’t closely related, it’s unlikely one person could have infected the other. “The greatest power of it is exculpatory,” says Gerald Learn, a microbiologist at the University of Washington. “If I was a defense lawyer, I would insist on it.”

But the procedure is complicated and costly. “Scientists who are not trained in this field couldn’t just read published reports and try to do this on their own without having the proper tools,” says Michael Metzker, assistant professor of molecular genetics at the Baylor College of Medicine in Houston.

Genetic analysis of each HIV sample can require more than 100 sequences, with a price tag between $1 and $5 per sequence—no small sum in a developing country.

A few labs in Uganda are equipped to do the analyses, says Maria Wawer, a professor of population, family and reproductive health at Johns Hopkins University who conducts research in Uganda. “But it is likely to remain too expensive for the foreseeable future,” she says.

Courts in these countries may instead rely on circumstantial evidence, raising the risk of wrongful convictions.

“In the absence of really clear scientific evidence as to who infected whom,” says Azad, “there will too often be an assumption that those categorized as undesirable by society are guilty of infecting other people.”

In 2002, UNAIDS argued against laws that penalize HIV transmission, recommending instead that responsible individuals be prosecuted using standard criminal laws, notes Azad. “Any legislation which singles out HIV for this kind of criminal sanction is breaching international human rights guidelines.”

Australia: Editorial argues epidemiological information should be used to prosecute ‘reckless’ individuals

An editorial in The Age argues that Australia’s HIV Epidemiology Project should be used to track down individuals who are ‘reckless’ so that they can be prosecuted.

This is not only unethical, it is also not scientifically possible given the uncertainties inherent in phylogenetic analysis – the scientific method used when assessing the relationship between HIV genotypes.

A suitable case for treatment. Unsuitable for restriction.
Editorial, The Age
May 14, 2007

The battle against HIV/AIDS in Australia is being waged on shifting territory. In one area there is solid ground: the promise of scientific vigilance to find factors contributing to the rise in infection rates, particularly in Victoria. Elsewhere is a darker, more treacherous landscape: the threat of politically initiated assessments of HIV-positive visitors to Australia and the possibility they could be banned altogether. Both initiatives originate from the Federal Government.

As The Age reports today, the Government’s Health Protection Committee has chosen a team of Victorian scientists to analyse HIV infections over the past three years to determine who or what is responsible for the rise in national infection rates from 656 cases in 2000 to 930 in 2005, an increase of 41 per cent; in this state HIV infection is at its highest level for 20 years: in 2006, 334 cases of HIV were reported to the Department of Human Services, an increase of 17 per cent on the previous year. As part of its investigation, the HIV Epidemiology Project will examine whether genotyping HIV infections – developing a genetic profile of the virus in patients – could help identify groups of individuals transmitting the virus. Three men, including a Melbourne man, Michael John Neal, are before Australian courts on charges of recklessly or deliberately infecting others with HIV.

Although civil-rights groups representing people living with HIV and AIDS have raised ethical concerns over genotyping – previously used only in criminal cases or to determine a virus’ resistance to drugs – the Health Minister, Tony Abbott, who approved the project last month, has said the research is aimed at gathering information on risk groups and not tracking down individuals. This has been supported by the head of the Infectious Disease and Epidemiology Unit at Monash University, Dr Karin Leder, who says risk groups are the focus of the first phase of the project, with any future investigation of individuals dependent on the data received. If, however, this leads to the identification of HIV-positive individuals who, through indiscriminate recklessness are endangering the lives of others, then surely public safety must take precedence over rights to privacy.

The HIV Epidemiology Project should be welcomed. At the very least, it represents a national approach to what is really a national problem, as well as a significant step towards proper research into a condition that knows no boundaries. Any sensible measure that can lead to a reduction in the HIV infection rate cannot be discounted, especially when news of the project comes at the same time as Government funding of almost $10 million over four years for a national HIV-prevention program, including a new media campaign. The project should also, by default, begin to restore confidence in a health system beleaguered by last month’s breakdown in bureaucratic communication at Victoria’s Department of Human Services; this led to the sacking of the state’s chief health officer, Dr Robert Hall, by his minister, Bronwyn Pike, over alleged non-disclosure of three HIV-positive people under police investigation.

A far more sensitive issue, one that stigmatises rather than helps HIV sufferers, is the intention of the Prime Minister, John Howard, to restrict or perhaps ban such infected people from entering the country. Mr Howard has written to his immigration and health ministers seeking advice on the public-health implications of letting HIV-positive people into Australia. This follows Mr Howard’s response last month, when asked about allowing in HIV-positive immigrants, “My initial reaction is no”. Mr Howard also said there could be “humanitarian considerations”.

Some countries, including the United States, Russia and the United Arab Emirates, have absolute bans on HIV sufferers; others, such as Britain and France, are more tolerant. It is difficult to see how Australia could benefit from becoming an HIV exclusion zone without being seen to be unnecessarily discriminatory or alarmist. It would be better for the Government to concentrate on the more effective methods of control through scientific research and public awareness.

Australia: Federal goverment plans HIV genotype database to ‘trace reckless infections’

‘The Age’ reports on the HIV Epidemiology Project which may be used to trace people who criminally transmit HIV.

Full report below:

Plan to genetically trace reckless HIV infections
Julia Medew
April 28, 2007

People who have recklessly or deliberately infected others with HIV could be genetically traced under a project approved by the Federal Government.

Documents obtained by The Age reveal the project will investigate whether genotyping HIV infections — developing a genetic profile of the virus in patients — could identify groups of people or individuals responsible for transmitting the virus.

The approach, believed to be a world first, was approved by Health Minister Tony Abbott earlier this month after several high-profile cases raised concern about how HIV positive people were being managed by health authorities.

Three men, including Melbourne man Michael John Neal, are before Australian courts on charges of recklessly or deliberately infecting others with HIV.

Under the plan, titled HIV Epidemiology Project, a team of scientists will be asked to examine the epidemiology of current HIV infection in Australia, including infections in high-risk groups such as homosexual men, injecting drug users and migrants and refugees gaining entry to the country.

They will also look at the movement of HIV positive people across the nation and behaviour that could be contributing to rising infection rates. HIV infections have surged 41 per cent across Australia from 656 cases in 2000 to 930 in 2005.

Associate Professor Andrew Grulich, head of the HIV Epidemiology and Prevention Program run by the National Centre in HIV Epidemiology and Clinical Research, welcomed news of the project but said any effort to map the transmission of HIV across the nation in recent years would be controversial and extremely difficult.

“(Genotyping) may be of use for investigating particular individuals who are alleged to be behaving irresponsibly but at a population level there is more doubt about whether it would be useful,” he said.

Dr Grulich believed a national approach to genotyping HIV infections would be a world first. It is only used in criminal cases or to determine a virus’ resistance to drugs, he said.

Health Minister Tony Abbott said the project was not designed to target individuals for criminal prosecution, but to help public health education campaigns. “If AIDS is still very much a disease of gays and drug users, there is not much point running a campaign pitched to the general public,” he said.

Jamie Gardiner, a vice-president of Liberty Victoria, said any project designed to point the finger at particular people would undermine the public health approach to HIV that Australia had used since the 1980s.

“It’s hard to imagine that ethics approval would be granted for a project like this. This is a project whose purpose is not about the curing or prevention of illness but one that is being perverted for the pursuit of inappropriate criminal justice objectives,” he said.

Brett Hayhoe, president of People Living with HIV/AIDS Victoria, said “The last thing we need is for an already marginalised community to be marginalised and victimised more.”