Petrelis Files

NYC HIV Expert:
Public Debate Needed on Swiss Study

Dear Michael,

I applaud you for your reporting and commentary on the recent release of the Swiss study and the way it has been handled so far by public health officials. I also greatly appreciate Walter Armstrong's insightful commentary that's posted on your blog. I would like to highlight some of the points that each of you has made and perhaps add a few of my own.

My gut reaction was that this study was one of the most important study done since the beginning of the AIDS epidemic. The Swiss Study both has the potentially enormously positive public health implications to reduce new infections and as Walter so poignantly points out to "acknowledge what it means to sexually, emotionally and even spiritually to people who have been living with the shame and fear of sex as infectious-all the while longing for the day when natural sex could return."

While it is understandable that the public health implications of the Swiss Study are carefully examined by public health authorities and the public at large before any formal changes in safe sex guidelines are made regarding risks for HIV transmission, I agree with Michael and Walter that the kind closed door deliberations that are going on in the SF Department of health seem inadequate.

The question of why there are 40,000 new HIV infections in America well into the era of HAART undoubtedly has a multifacted answer but at the bottom line reflects a failure of public health. Stigmatization, discrimination, disempowerment, poverty, and lack of access to real information about HIV infection risks are in my opinion responsible for many of these 40,000 new infections. In addition a real commitment by public health officials to reducing these new infections appears to be lacking given the institutionalization of discriminatory policies of the Bush administration by the public health service.

To my knowledge there is no publicly funded NIH study examining whether or not in men who have sex with men what the risk of HIV transmission is in monogamous serodiscordant couples if the positive partner has an undetectable viral load. It seems that this study should have been done long ago and if not urgently needs to be done now.

In my own practice, I am seeing about one newly HIV infected patient every 1-2 months. Approximately, 4/5 had been carefully following safe sex practices as such as advised by the SF department of health regarding condom use and had tested negative for many years. Whether as a result of a condom break, an unprotected oral sex encounter or some unidentifiable risk factor each of these individuals seroconverted. In no situation to my knowledge, extending back over many years did the negative partner in a serodiscordant monogamous relationship similarly seroconvert.

In fact I regard it of great public health importance that in each patient of mine who has recently seroconverted they generally had no knowledge of their partners HIV status or if they knew or considered that there partner might be positive they had no knowledge of their viral load. Each of my patients was relying on adhering to their own understanding of safe sex practices which had served them well, well until it didn't. Current safe sex recommendations do not include trying to obtain specific info regarding a partners viral load status.

I appreciated David Wilton's comment on Michael's blog about the focus of AIDS public health officials on male circumcision as prevention but all but ignoring the Swiss Study.

Michaels analysis of the SF Health Dept's communique about the Swiss study goes point by point over problems with that communique and should be the focus of a vigorous discussion and debate by public health officials, clinicians and researchers, the community of HIV infected individulas and the public at large.

One last point.

"HIV patients who carefully follow there treatment regimens may develop resistance." Certainly, if a patient who is undetectable is nonadherent then viral rebound and viral resistance can and usually will occur and change the status of that patient from undetectable and increase their infectivity.

However, it is rare for viral rebound and resistance to occur on a predictably excellent suppressive regimen such as those in the DHHS Guidelines in an adherent patient. I haven't seen it!

Patients including adherent patients do have viral blips as they must have had in the Swiss Study. Apparently in the Swiss Study blips didn't lead to infections.

It seems important to establish whether in men who have sex with men blips in well suppressed patients could result in new infections in unprotected sexual encounters. While this is of theoretic concern and should be aggressively investigated I again want to reinforce the importance of what I am observing in my practice.

The newly infected MSM patients in my clinical practice generally have been adhering to safe sex guidelines but have not been aware of the viral load status of their contacts. No serodiscordant MSM's have seroconverted in my practice who are in monogamous relationships.

I hope this note stimulates more discussion and debate and in particular an opening up of the dialogue between public health officials, clinicians, the HIV infected community gay community and public at large.

Sincerely,
Dr. Paul Bellman
New York, NY