AIDS activist Stephen Gendin took years to become resistant to most HIV drugs, using them one after another as they came on the market, desperate to save his life. But now his partner, Kyle McDowell, is starting out with Gendin's resistant strain. "This eliminates most treatment," says McDowell.
Such cases re-emphasize the importance of prevention. But they also point to the implacable logic of HIV, which has killed almost 12 million people, infects another person every five seconds, and now is mutating under the pressure of powerful but not curative drugs.
"It's not surprising at all" that resistant strains have begun to circulate, says Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases. Indeed, given the astonishing vigor of this virus, many of the conference's scientific findings were sobering but not surprising. Among the most important are that HIV continues to replicate even when patients are taking potent medication, and that in the very first days after the virus enters the body, it infiltrates certain long-lived cells that then harbor it for many years. So even if a patient has an ordinary strain of HIV that is vulnerable to the drugs - and even if that patient is among the lucky 10 percent of infected people who live in a First World country, where the expensive drugs are available - still, says Fauci, "it will be very difficult to eradicate this virus" from the body.
Yet the AIDS death rate continues to drop all across the developed world, and "I don't think deaths will go back up," maintains Bernard Hirschel, the doctor who chaired the conference. Like many researchers, Hirschel and Fauci believe it might not be necessary to eradicate every last virus from a patient's body. They point to growing evidence that suggests the immune system can control HIV under the right circumstances, and that an AIDS-ravaged immune system can be regenerated with therapy. As David Ho, director of New York's Aaron Diamond AIDS Research Center, puts it, "Control without eradication is something we might call remission."
Whether the goal is eradication or remission, the lynchpin of therapy is a cocktail of three or more drugs, often involving a protease inhibitor, that patients must take every day to suppress the virus. But McDowell and Gendin are resistant to at least nine of the 11 currently approved drugs - and possibly to all of them.
Gendin has known for more than a year that he carries a multi-drug-resistant strain of HIV. He and McDowell never engaged in the riskiest behavior - having Gendin ejaculate into McDowell during anal intercourse - but sometimes Gendin would enter McDowell without a condom, withdrawing before climax. (In a case documented by San Francisco researchers, the source partner also withdrew before ejaculation; HIV is known to be present in preseminal fluid.) In addition, McDowell was often the insertive partner, and he didn't use a condom either. This, too, could have led to his infection.
Several studies presented at the conference suggested that some people are relaxing their safer-sex standards because they believe the new treatments have made AIDS manageable. Prevention workers will undoubtedly have to combat this misconception, but McDowell's story makes it clear that people engage in unprotected sex for reasons that are tangled and personal.
"For 10 years I was so safe," McDowell explains. His riskiest activity was to fellate without a condom, a practice generally considered low risk, and which he would do only once or twice a year. His friends, he says, considered his standards "maddeningly tight." Then McDowell turned 30, which, he says, "had a lot to do" with why he's now infected. He remembers thinking, "Oh my god, I let my twenties go." So he let himself enjoy "a few stolen insertions" with Gendin. Those gave him morning-after anxiety, but twice over a one-year period he tested HIV-negative, which bolstered what turned out to be a false sense of security.
Having sex without a condom "really made me feel profoundly erotically close," McDowell recalls. "When Stephen was not feeling well, it seemed the only way to be intimate." And when problems arose in the relationship, McDowell says, "I wanted to fix it with something highly symbolic." So they would have "makeup sex" that sometimes became "really intense." There was, he says, "something profoundly rich about risking my life for Stephen."
"This notion of sharing everything is being romanticized, and that's dangerous," warns Martin Delaney, a leading AIDS activist. Indeed, many activists believe Gendin had already romanticized "barebacking," as unprotected sex is called, when he wrote an article in the AIDS magazine POZ last summer about having skin-to-skin intercourse with another man who was also HIV-positive. That article sparked a heated controversy, because even between two infected people, a drug-resistant strain might be transmitted, unleashing a secondary infection that could sabotage a drug regimen. But many people with HIV consider that possibility theoretical.