The "Bareback" Lie

It was unfortunate that much of the reporting by the mainstream media from the recent XIV International AIDS Conference in Barcelona gave short shrift to one of the most important, and apparently most gasp-inducing, findings presented: that the notion that it is harmless and inconsequential for HIV-positive individuals to have unprotected sex with one another?"bareback" sex, in the parlance of its hucksters?appears to be a tragic myth, one that may be fueling the epidemic among gay men in the United States and promoting the transmission of drug-resistant strains of HIV. Both The New York Times and The Washington Post largely overlooked this news of "superinfection," as it is called, amid many other stories from the conference that the papers dutifully reported. The Wall Street Journal gave strong play to it, but focused more on the study's crushing implications regarding the development of an AIDS vaccine. (That is an equally important conclusion of the study, so I'm not going to beat them up about it.)

As far as I could tell, only the Pulitzer Prize-winning AIDS reporter Laurie Garrett, in a piece in Newsday headlined "Hope for AIDS Vaccine Fades; News of Superinfection Case," captured and conveyed the gravity of the finding: "Harvard Medical School's Dr. Bruce Walker startled scientists with word of an unusual case of a patient who, despite building up an immune response to HIV, then acquired a second HIV infection from a closely related virus and suffered a major setback. Scientists could be heard cursing and gasping as Walker presented his data? [Walker said that] 'The public health implication of this is that it is possible to become infected with a second strain of HIV, even a very closely related one.'"

Garrett, author of 1995's The Coming Plague, has been out front on AIDS for more than 15 years, and in recent years her reporting has taken on an almost prophetic quality. She has also written articles about the implications of the failure of protease inhibitors in some people and the emergence and spread of drug-resistant strains of HIV?as we are now seeing?back in the mid-90s. She also was among those who foresaw the increases in rates of infection among gay men as many would give up safer sex practices believing AIDS was less of a threat.

According to Garrett, Walker told the scientists in Barcelona that he'd treated a gay Boston man with anti-HIV drugs immediately after infection for several weeks, as he'd done with more than a dozen other patients. The man seemed to do very well, beating back HIV. But after a month, he was surging with virus, which turned out to be a different strain of HIV?a strain that was, genetically, 12 percent different from the strain with which he'd originally been infected. His "immune system was helpless in the face of the apparently new HIV," Garrett reported. The man told Walker that he'd engaged in unprotected sex with another man within 30 days of his original infection.

What this, tragically, means for a vaccine is that even a strain of HIV close to one that you might be vaccinated against can still cripple your immune system, rendering the vaccination useless. (And there are at least seven classes of HIV, each including many strains.) Cornell University AIDS vaccine researcher John Moore told Garrett: "This case, albeit anecdotal, has shattering implications for the development of a prophylactic vaccine." And what it means for HIV-positive gay men who have unprotected sex with one another is that they can be infected with other, perhaps more powerful strains of HIV, and, chillingly, may be passing on drug-resistant strains, helping to promulgate a super-HIV.

"While it's true Walker's patient is 'only one case,'" Garrett tells me, "it would be disingenuous to suggest there is no other evidence of superinfection, or immune system failure, to recognize secondary HIV infection. In fact, [at the conference] three other superinfection cases were described, and by my count at least 10 others have been cited in recent years. What made Walker's case stand out is the extraordinary caliber of his work on the case. Nobody has previously tracked so many aspects of the virology and immunology of a case, almost from the moment of infection."

Though he believes further studies should be done, Walker explained to the Washington Blade last week that "the detail available on this particular patient allowed us to conduct laboratory studies that make this a very solid study with measurable, reliable conclusions."

Garrett, who has been to these conferences year after year since they began in 1988, is someone you would imagine to be quite jaded when it comes to alarming reports. That's why it's significant that she was blown away by Walker's finding.

"On a personal level?which we journalists don't like to mention?I was stunned by both the quality of the work and its results," she says. "I just couldn't scribble notes fast enough?I felt every single word out of Bruce Walker's mouth that morning mattered deeply, in an historical sense, for this epidemic."

Garrett is careful to say that it is not known how common superinfection is, as there's been very little study of the phenomenon. We do now know with considerable certainty, however, that it does occur, and it may be more common than some would like to believe. Garrett notes that, with current data showing a quarter of new infections in San Francisco involving "clinically significant drug-resistant viruses," HIV-positive people on protease inhibitors who have unprotected sex are not only at risk of being infected with another strain of HIV but with one that won't respond to drug regimens.

Even those HIV-positive gay men who say they only have unprotected sex with other HIV-positive men and who claim they are scrupulous about asking their partners' HIV status?something that's not always so easy to do in the heat of the moment?thus may be infecting one another with new and more powerful strains of HIV.

You'd think that since the issue of "bareback" sex has been a flashpoint in the gay community in recent years media organizations would have focused more attention on the remarkable and ominous findings out of Barcelona. Twenty years ago much of the media stuck their heads in the sand on AIDS, in part because of a squeamishness about discussing gay sex. With successive waves of the epidemic now under way among younger generations of gay men, let's hope that squeamishness is not keeping reporters from now exposing the "bareback" lie.