“Ominous News for AIDS Victims,” warned the headline at CBS.com, reflecting its TV coverage. “Alarmed doctors [fear that] the epidemic might soon take a deadly turn,” led The Boston Globe, while helpfully noting that even though combo therapy had given new hope to “thousands of once-doomed patients,” those same alarmed doctors now “realized it was borrowed time.” Yes, tut-tutted WebMD, such drugs had been a “lifeline” for lucky HIVers -- who were now “reaching the end of that line” (how’s that for Pulitzer-level metaphor extension?).
Why all this gloom-mongering? New research indicating that three quarters of all HIVers on HAART have developed drug resistance [see “Buzz Back From ICAAC,” POZ, February/March 2002]. After five years of a dramatically reduced U.S. death toll from AIDS -- and nothing more nihilistic than sunken cheekbones and a few too-late trips to the toilet -- the other Jimmy Choo was about to drop. And so the press began lining up behind ace reporter Laurie Garrett, whose March 1999 Esquire cover story debuted this doomsday scenario, for last call at the AIDS cocktail party.
The study, presented in December by veteran virus-sleuth Doug Richman, MD, looked at the blood samples of about 1,650 HIVers -- a pool weighted to reflect a demographic cross-section of the estimated 200,000 American HAART takers. Of the roughly 1,000 with a detectable viral load, 78 percent showed resistance to at least one of the three major classes of HIV meds. Extrapolating from these data, Richman estimated that 49 percent of HAART takers had such resistance by early 1999, when the blood was drawn. All this boom-lowering sent treatment advocates into high dudgeon. TAG’s Mark Harrington slammed the media coverage as “appalling.” In “Data and Spin,” in the venerable AIDS Treatment News, John James worried that the reports “could have future consequences for society’s political will to deal with the HIV epidemic, both in the U.S. and abroad.” In other words, would the average post-9/11 American sit up and say, "Why should I get tested for HIV, or go on those nasty drugs, or see my taxes pay for them, when they don’t even work?"
Still, data are data, and no one is accusing Richman of cooking the books. Rather, the hue-and-cry was over the press’ sin of omission -- essential info that would have put the study’s stark, scary numbers into context. The most glaring oversight was the time-period factor: The blood was from patients who had started HAART before 1996, so many were likely on a mere nuke or two -- a wimpy offensive compared to a protease triple-combo onslaught. Three other telling details most press left untold:
First, “virologic failure” doesn’t equal treatment failure -- HIVers with resistant, detectable virus can still benefit from partially suppressive therapy. Second, resistant HIV is less fit and thought to be less harmful than nonresistant, “wild type” virus. Third, brand-new meds such as the double-protease, Kaletra, and the NtRTI, Viread, pack a punch against resistant virus -- as do many pipeline drugs, especially the class of entry inhibitors, like T-20.
But the media’s most loaded message was the finding that patients with the best care (read: gay white men) have the most resistance. This apparent paradox makes clinical sense once you understand that the “best” HIV care prior to 1996 was double nukes -- a fast track to resistance to the whole class. “But the emotional subtext that sold the newspapers,” wrote James, “was that gay white men, despite all their advantages, were not doing their part to control the epidemic.” Now that is a tune the media can whistle backward: Dizzy queens missing pricey doses because they were up all night boogying to Cher and having bareback sex!
If the media is the message, does Doug Richman want to kill the messenger? “I’ve been dealing with the press for 15-plus years now,” Richman says, “and I’ve gotten philosophical. I knew everyone would put their own spin on it. Overall, though, I wouldn’t call the coverage ’hysterical.’ I think people are too defensive, too worried [about resistance].” Richman took pains to explain why gay white men had the highest resistance rates, “because I knew if I didn’t, it would be seen as an attack on a risk group” -- which he was accused of a year ago when he announced findings that transmission of resistant virus was up 20 percent due to unprotected sex. “We got attacked for accusing gay men of being promiscuous. I got vicious e-mails.” Richman sighs. “But the number of people willing to not go around just giving p.c. talks is diminishing.”
Suffice it to say, rumors of HAART’s death are greatly exaggerated. “Sensationalizing the resistance data is ludicrous,” says UCSF advocate Jeff McDonnell. “The HAART honeymoon is over -- but the marriage is far from done.”