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The Invention of Patient Zero

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The Blue triple-X video and buddy-booth parlor. (Photo Credit: Edward Keating)

Some wonder if he didn’t see potential in the mysteries of this new case. “David Ho has a huge shop that he has to maintain,” says Dr. Cecil Fox, an AIDS pathologist and veteran of many skirmishes, who owns a biotech company in Arkansas. “If he finds a new phenomenon, naturally he’s going to jump on it with all four feet.”

Ho denies he was under any particular pressure when the patient arrived at the center. “Think about this: We’re doctors, scientists, doing research,” he says. “Our mission is research.”

On January 17, the patient was seen by Marty Markowitz, Ho’s longtime research collaborator. Markowitz ordered more tests, which confirmed the dire clinical picture. The patient continued his precipitous decline, losing nine pounds in the next three weeks. His viral load rose to 650,000. Viral samples were sent to a San Francisco lab for resistance sequencing, tests that help determine which drugs are most likely to be effective.

Although Markowitz did not respond to interview requests, he has spoken often about the case in public. “Let me tell you, this guy told me he had four partners and no drug use,” Markowitz said at a meeting of AIDS doctors at the Strata restaurant in New York on February 15. “And I am a very difficult guy to fool. But he’s very charming, very handsome, very successful. You’d invite him to Christmas. You’d want your mother to meet him. He is not a demon. He’s a great guy. But he has . . . he has a dark side.”

Ultimately, he confided in Markowitz about how meth propelled him through the sexual underground. “This man,” Markowitz told the meeting of doctors, “has had thousands of sexual contacts over the past three years. I said it right. Thousands.”

In the weeks between his presumed exposure in late October and his diagnosis after Christmas, Markowitz learned, the man had swapped fluids with about ten other partners, unknowingly exposing them to his virus. This is one of the biggest problems with sero-sorting. People who don’t know they’re infected are responsible for more than 50 percent of all new infections.

This is why, despite all the internecine conflict, there’s unanimity among doctors on the issue of safe sex. Still, some people have proposed population-based sero-sorting as a way to slow the epidemic. And one study has led researchers to speculate that if men born before 1980 never had sex with men born afterward, the epidemic would eventually die out in the gay community.

“The way I look at it,” says AIDS specialist Paul Bellman about the influence of crystal meth, “Chelsea is like Iraq; every day, somebody gets blown up.”

While the rate of HIV transmission seems to have dropped in each of the past three years, case reports of syphilis and drug-resistant gonorrhea are soaring among gay men, suggesting more people are having unprotected sex.

Though he felt ill, the New York patient assumed he was still negative and no risk to anybody else, his longtime physician says. Still, he’s been vilified. “This guy is a total and utter asshole,” Larry Kramer told the New York Observer. “What happens is, this is what people think gay people are like. Now we can’t move forward, we can’t get to our place in the sun, because of stupid assholes like this.”

Michael Mullen emphatically defended his patient, who he says never engaged in unsafe sex after his diagnosis. “He’s so beat up about this, he would never, ever do something like that. That’s a total lie, a fabrication—it’s just not true.”

On January 22, a Saturday, e-mail arrived on Markowitz’s computer from the lab with resistance-test results showing the man’s virus was extremely mutated, rendering it less likely to respond to 19 of the 21 approved AIDS drugs. Markowitz had never seen a more resistant strain. The only thing that causes HIV to acquire resistance is sporadic exposure to anti-AIDS drugs—the virus, a clever foe, can seize the opportunity of poor drug adherence to change attributes and evade medication.

But that alone didn’t cause Markowitz great concern. What worried him was the fact that this mutated virus seemed to cause disease so rapidly. On average, HIV needs about ten years to bring on full-blown AIDS, though in a small percentage of infected people—perhaps 45 in 10,000—it progresses in under a year. Ordinarily, rapid progression is more likely associated with viruses that have few or no mutations; the more changes a viral strain undergoes to evade medications, the less potent it becomes. But here was a mutated and fast-progressing virus, a frightening combination. In addition, when Markowitz cultured the virus, he found it was at least as contagious as non-mutated viruses. Markowitz has said he ordered the standard tests, which look for the nine markers that make some people genetically disposed to progress quickly to AIDS—all that came back were negative. Markowitz came to the frightening conclusion that he was looking at a deadly new viral subspecies. “If you can’t see the horse and you want to see a zebra, that’s your prerogative. But the data here is incontrovertible,” Markowitz said.

Most leading researchers, however, were not so quickly convinced. Many viewed Markowitz’s analysis as overly influenced by the Aaron Diamond Center’s preconceptions. “It is fairly agreed upon that what produces rapid outcome is the host, not necessarily the virus,” says Dr. Michael Ascher, an immunologist now working for the federal government. “We just don’t know what all the factors might be yet.”

Markowitz and Ho had some indication of resistance and doubt among their colleagues when they submitted their findings to the Retrovirus Conference in Boston. When it was decided, after a peer-review process, that the results were not significant enough to be discussed on a panel, but instead should be displayed on a large poster board in a room with other research posters, Markowitz reportedly became furious. “He began to argue with the organizers, saying the poster would present a danger to the public health—because so many people were going to crowd around it, someone would be injured,” one attendee said. “People were scratching their heads.”

Markowitz also began work on an emotional op-ed piece he hoped the Times would publish—and when the paper chose not to, he began to circulate it himself: “As I write, the extent of this potential, silent tsunami is being defined,” he warned. “This untreatable virus with an aggressive clinical course can bring us back to the eighties and early nineties—the truly darkest years.”

“It was of course a stressful, emotional moment for him,” David Ho told me. “Marty saw that the man had a virus that was resistant to nearly all the drugs and he had a very aggressive course of disease, and that was sufficiently alarming to us to say, ‘Wait a minute: Because of his active sexual history, are there more such cases out there?’” This was difficult to ascertain, because many of the patient’s sexual contacts had been anonymous. Even those whose names he knew hesitated to come forward.


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