Two years ago a UCSF news release about drug-resistant staph infection mischaracterized the results of a study, leading the city's largest daily paper to print a headline describing the San Francisco gay community as "an epicenter" for a new strain of virulent staph.
No such epidemic happened.
Now, the prestigious journal Science has published a paper by researchers at UCSF and UCLA, including James Kahn and Sally Blower, that predicts a "wave" of HIV drug resistant strains "will emerge over the next five years in San Francisco due to transmission from untreated individuals."
The results of the paper are based on modeling and calculations looking at the transmission of drug resistant strains of HIV involving just one class or type of antiretroviral drug �" non-nucleoside reverse transcriptase inhibitors (NNRTIs). It was not a study examining the actual levels of drug resistant HIV and rates of its transmission in San Francisco. Other studies that have been done looked at actual levels of transmission of drug resistant strains of HIV and found rates declining, not rising. Today at CROI, an HIV/AIDS science conference held this year in San Francisco, a poster is being presented titled, "Decreasing Prevalence of Drug Resistant Mutations over a 7 Year Period in the CFAR Network of Integrated Clinical Systems." In addition, there are currently six classes of antiretrovirals and newer versions of NNRTIs that are effective against NNRTI resistant strains. You do not need to include an old NNRTI to put together an effective regimen.
Ultimately, models are opinions. The country's current economic mess, for example, stems from the faulty assumptions built into economic models that failed to predict a decline in real estate prices. Just last month, Blower modeled the spread of H1N1, or swine flu, through air travel. Her conclusion, from a UCLA press release: "We found that many infections could occur if the infected individual was traveling in economy class but relatively few if the individual was traveling in first class." Really? How did that work out?
But the claim of a wave of drug-resistant strains is false, and the last sentence of the paper concerns us greatly: "Consequently, currently circulating NNRTI-resistant strains in San Francisco pose a great and immediate threat to global public health."
Once again, gay men in San Francisco are being stigmatized using code words. There are no caveats in the final sentence of the paper. And note that it states "currently," which should mean that right now in San Francisco we should be seeing this "immediate threat" from drug resistant strains of HIV.
The implication of that last sentence is that somehow the resistant virus is being created only in San Francisco, which is not true. HIV experts have long held that people living with HIV here are treated similarly to those living elsewhere throughout the United States and in the developing world. Blower et al. had no basis to single out San Francisco. The paper also infers, through that final sentence, that somehow this resistant virus will be widely transmitted to folks in the developing world. How, when, and where will that happen? NNRTI resistant virus is being transmitted at this moment through heterosexual sex in Johannesburg and other Sub-Saharan locations where NNRTIs are widely prescribed. What may or may not be happening in San Francisco has nothing to do with HIV transmission there. This is sloppy reasoning at best, especially in light of the fact that lawmakers in Uganda are debating that hideous "kill the gays" bill. Surely, the Science article adds fuel to that fire.
When we reported on this study in mid-January, Dr. Grant Colfax, the city's HIV prevention chief, was emphatic that HIV drug resistance is not a public health crisis. He noted that while drug resistance is always a concern, health officials were clear that "the benefits of treatment are high and that the new guidelines regarding treatment have swung toward recommending treatment earlier."
But the paper could hamper efforts for the "test and treat" model in the developing world where many people with HIV are not offered treatment until T-cells hit around 200 �" a point at which life expectancy lessens even with successful treatment than if treatment was started at 350 or 400 T-cells or even earlier.
If the Blower and Kahn paper is correct, why aren't we seeing any real-time red flag problems in treating people? We're not seeing that here in San Francisco, or Los Angeles, or New York City, or in any city where these medications have been prescribed widely for at least 10 years and where there has been ample opportunity to transmit resistant virus and then face the problems associated with treating patients infected with the resistant virus. This supports Colfax, who is at ground zero here in San Francisco and has been steadfast in downplaying the Science paper. "The sky is not falling," he told us.
A real concern is that Science, a widely respected peer-reviewed journal, would even publish a report such as this, especially that final sentence. There is no evidence presented in the paper for that stigmatizing sentence and reviewers and editors should have demanded its removal. The authors themselves show a callous disregard for the HIV individuals who are patients, study participants, and donors (it's the David Geffen School of Medicine at UCLA) at their respective institutions.
Science should re-review the paper and consider retracting it. The authors at UCSF and UCLA should apologize for this shoddy research that can inflame homophobia and AIDSphobia.