Mon, Oct 31, 2016 page7

• Mythology of ‘Patient Zero’ still haunts HIV/AIDS prevention

  The strain of HIV responsible for almost all early AIDS cases in the US arrived in the county in about 1967, long before the 1980s epidemic, a new analysis found

  • By Donald McNeil Jr / NY Times News Service
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  In the tortuous mythology of the AIDS epidemic, one legend never seems to die: Patient Zero, also known as Gaetan Dugas, a globe-trotting, sexually insatiable French Canadian flight attendant who supposedly picked up HIV in Haiti or Africa and spread it to dozens, even hundreds, of other men before his death in 1984.

  Dugas was once blamed for setting off the entire US AIDS epidemic, which traumatized the nation in the 1980s and has since killed more than 500,000 Americans. The New York Post even described him with the headline “The Man Who Gave Us AIDS.”

  However, after a new genetic analysis of stored blood samples, bolstered by some intriguing historical detective work, scientists on Wednesday declared him innocent.

  The strain of HIV responsible for almost all AIDS cases in the US, which was carried from Zaire to Haiti about 1967, spread from there to New York City around 1971, researchers concluded in the journal Nature. From New York, it spread to San Francisco around 1976.

  The new analysis shows that Dugas’ own blood, sampled in 1983, contained a viral strain already infecting men in New York before he began visiting gay bars there after being hired by Air Canada in 1974.

  The researchers also reported that originally Dugas was not even called Patient Zero — in an early epidemiological study of cases, he was designated Patient O, for “outside Southern California,” where the study began. The ambiguous circular symbol on a chart was later read as a zero, stoking the notion that blame for the epidemic could be placed on one man.

  Myths like that of Patient Zero echo in prevention efforts even today, experts said. Many vulnerable groups, including young gay men and African women, fail to use protective drugs or avoid testing because they fear being stigmatized or accused of being carriers.

  Reflecting on the epidemic’s early days, Anthony Fauci, then a doctor treating AIDS patients and now the director of the US National Institute of Allergy and Infectious Diseases, said he remembered it seeming plausible at the time that one person was responsible.

  In hindsight, he added, the idea now seems absurd.

  “We were unaware of how widespread it was in Africa,” Fauci said. “Also, we thought, based on very little data, that it was only about two years from infection to death.”

  The new data are consistent with the scenario described in 2011 in The Origins of AIDS, by Jacques Pepin, an infectious disease specialist at the University of Sherbrooke in Quebec.

  Relying on previous genetic research and African colonial records, Pepin showed that HIV was carried from Kinshasa to Haiti in the 1960s — most likely by one of the thousands of Haitian civil servants recruited by the UN to work in the former Belgian Congo after colonial rule collapsed.

  In Haiti, he theorized, a few cases were multiplied by unsterile conditions at a private blood collecting company, Hemo-Caribbean, that opened in 1971 and exported 6,057 liters of plasma to the US monthly. Plasma clotting factors were used by US hemophiliacs, many of whom died of AIDS.

  Haiti was also a sex-tourism destination for gay men, another route the virus could have taken to New York.

  The blood samples analyzed in the new study were collected in 1978 and 1979 in New York and San Francisco as part of an effort to make a hepatitis B vaccine. Researchers stored almost 16,000 blood samples; nearly 7 percent of those from New York and 4 percent of those from California later turned out to be infected with HIV.

  A team led by Michael Worobey, an evolutionary biologist at the University of Arizona in Tucson and lead author of the Nature paper, sequenced the genomes of the HIV found in some of those samples and compared them with viral DNA in samples collected in the early 1980s from Haitians, Dominicans and others treated in US hospitals.

  Because decades spent in freezers had degraded many samples, Worobey said, his lab developed an “RNA jackhammering” technique similar to that used to reconstruct the ancient Neanderthal genome.

  Counting mutations allowed the researchers to “wind back the molecular clock” and see when each strain of HIV diverged from its ancestors.

  Africa has a dozen HIV groups, and Haiti’s epidemic came from one of those. The New York samples all derive from one Haitian strain, and those from San Francisco are all so closely related that they probably all resulted from one person introducing one New York strain, Worobey said.

  The symptoms that were later called AIDS were first recognized in 1981, and the legend of Patient Zero began with a 1984 study that traced the sexual contacts of 40 gay men with Kaposi’s sarcoma or other indicators of late-stage AIDS. Eight of them, half in New York and half in Southern California, had sex with an unidentified flight attendant.

  Initially described as “Case 057” and then as Patient O, he reported having about 250 sexual partners a year.

  That study incorrectly assumed that most patients developed AIDS symptoms within about 10 months of infection. In reality, it takes years — so some participants might have been infected long before meeting Dugas.

  Also, Dugas might have become the cluster’s focal point partly because he kept a diary. Men in the study reported an average of 227 partners a year, often quick, anonymous encounters in bars and bathhouses, but Dugas gave investigators 72 names.

  Harold Jaffe, who was one of the original investigators and is now the associate director for science at the US Centers for Disease Control and Prevention (CDC), said the text of the original article referred to a “patient outside California.”

  However, the chart, of which he had an early copy, was admittedly ambiguous. At the center is the “O” or “0,” identified as the “index patient.” The other cases are numbered: “LA3” and “NY15,” for example.

  The legend itself sprang from the publicity campaign for a best-selling 1987 book, And the Band Played On, by Randy Shilts, a gay San Francisco journalist who himself died of AIDS in 1994.

  In a 1993 interview, Shilts said he had heard CDC investigators use the term Patient Zero and thought “Oooh, that’s catchy.”

  By hunting down former boyfriends of men in the 1984 study, Shilts established that the flight attendant was Dugas, who was born in Quebec, but lived his last years in Vancouver, British Columbia.

  Shilts said he was initially horrified that his publisher, St Martin’s Press, focused his book tour on Patient Zero instead of the government’s slow response to the epidemic, but he went along.

  Although Shilts did not accuse Dugas of starting the US epidemic, he demonized him as a deliberate spreader of the virus who ignored a doctor’s demand that he stop having unprotected sex, and coldbloodedly told some sex partners that he had “gay cancer” and now they might get it.

  Back in 1984, the term Patient Zero was not normally used to describe an outbreak’s first case, said Jaffe, a coauthor of the new Nature paper.

  “I don’t remember who first used it,” he said. “But after Randy Shilts did, we started saying it ourselves.”

  Later, he said, when reporters asked if Dugas had brought AIDS to North America, “We said no, that he wasn’t the first. But I think they went with it anyway. The idea of Patient Zero was very attractive. Letter O would not be a story.”

  Richard McKay, a Cambridge historian and another coauthor of the Nature paper, has long fought for Dugas’ reputation, saying his friends in Vancouver’s gay community had painted a sympathetic portrait of him for Shilts, who ignored it.

  Humanizing Dugas could help in the fight to end the epidemic, said Robert Grant, an AIDS researcher at the University of California, San Francisco.

  Even though the disease can now be both prevented and controlled, many people — both in San Francisco and in Africa, he said — resist getting tested for HIV and fool themselves into believing they are not at risk, because they fear being blamed by their social circle.

  “No one wants to be the Patient Zero of their village,” he said. “But this may be helpful because it says, ‘Just because you are the first to be diagnosed doesn’t mean you started the epidemic.’”
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