Sweden: Health agency criticised for not co-operating with police

The Swedish Institute for Infectious Disease Control has revealed in an article in a medical journal that they have refused to co-operate with police in tracking down individuals who may have broken Sweden’s draconian public health and criminal HIV exposure and transmission laws. Following a public furore, they have now backtracked somewhat.

Articles from the Associated Press and The Local.se below.

Swedish health agency blasted for HIV stance

STOCKHOLM, Sweden (AP) — A Swedish health agency revealed in an article published Wednesday that it had refused to help police track down people who knowingly infect others with HIV.

The revelation triggered harsh criticism and the government agency, the Swedish Institute for Infectious Disease Control, agreed later in the day to resume helping police.

Officials for the agency were quoted in a medical newspaper as saying they had declined to cooperate with police because they disagreed with current legislation that criminalizes the willful spread of the AIDS virus.

The report in the Dagens Medicin weekly sparked anger among prosecutors, police and government officials, who accused the institute of placing itself above the law.

The institute backtracked and its officials also clarified their position, saying they had no problem with the law itself, but believed the penalties for spreading HIV were too severe. The willful transmission of the virus is punishable by a maximum 10 years in prison.

Jan Albert, an expert at the agency, said the threat of imprisonment harms prevention efforts because some people who suspect they may have the virus refrain from getting tested for fear of prosecution.

Albert said the agency had declined to help police on many occasions, “but we’ve come to the understanding that we’ll resume work with the police.”

‘Decriminalize spread of HIV’: agency
Published: 22 Oct 08 11:38 CET

A Swedish government agency is refusing to assist the police in an ongoing investigation concerning a person suspected of infecting a woman with HIV.

Under current legislation, a person with HIV risks spending one to ten years in jail on assault charges if he or she knowingly has unprotected sex with another person.

“The criminalization of HIV makes preventive work more difficult. Also, sentences are very tough,” Ragnar Norrby, director-general of the Swedish Institute for Infectious Disease Control (SMI), told newspaper Dagens Medicin.

In a reversal of its previous policy, the disease control institute has recently refused to cooperate with prosecutors who requested information on a person suspected of spreading HIV.

“It is now our view that spreading HIV should not be classified as an offence,” Jan Albert, SMI head physician and regional manager, told Dagens Medicin.

“It is at least as much the responsibility of the individual person to understand that unprotected sex involves risks,” he added.

According to Ragnar Norrby, the threat of prosecution leads many people infected with HIV to remain anonymous, making it more difficult to trace the spread of the virus.

SMI also notes that the development of antiretroviral drugs has meant that HIV can no longer be equated to a death sentence.

Canada: Swiss statement on infectiousness fails to impress judge in Mabior case

The trial of Clato Mabior, the Sudanese migrant found guilty on six counts of criminal HIV exposure in Winnipeg earlier this month, was exceptional in a country where trials for criminal HIV exposure and transmission take place on an almost weekly basis.

First, the Mabior case is difficult for those of us who want to challenge criminal prosecutions for HIV exposure or transmission due to the nature of Mr Mabior’s other offences. It has resulted in a strong-worded editorial in the Winnipeg Free Press (see below) which suggests that the Canadian public cares little about understanding important issues such as the effect of treatment on transmission risk, or why disclosure is not necessarily the best way of protecting oneself and others from HIV.

All HIV infected persons are told of their obligations to sex partners. If they break the rules, they should be subject to a health order and police intervention — second chances merely put innocent persons at risk. Mabior’s warped sense of obligation and desperate attempt to rationalize his depraved conduct indicate a need to balance risk with the swift and heavy hammer of police action when trust is breached.

Second, and even more important, the transcript of the verdict by Queen’s Bench Justice Joan McKelvey, who presided over the trial is the first I’ve seen to seriously consider up-to-date science on the effect of HIV treatment on the risks of HIV exposure, as well as deal with the vexing issue of residual risks with condom use.

The defence argued that Mabior’s state of mind was that he did not believe he was infectious, and submitted the recent Swiss statement on the effect of treatment on infectiousness. However, expert testimony from Dr John Smith, who concluded that Mr Mabior may have been uninfectious for some of the time, also stressed that condoms were only 80% reliable. (An excellent review of condom effectiveness by Michael Carter of NAM, can be found here).

The Crown argued that the CDC and WHO disagreed with the Swiss, and this had the effect of persuading Justice McKelvey that the Swiss were probably wrong, that the Swiss statement only applied to monogamous couples with disclosure.

[81] The evidence of the accused’s undetectable viral load and its relationship to HIV transmission was also considered by the Crown. The Crown submitted that there was no evidence to suggest that a significant risk of serious bodily harm did not exist when viral loads were undetectable. There was argued to be a continuing risk that HIV could be passed through sexual intercourse in such circumstances. The issue was not related to a percentage of risk, but instead concerned the potential consequences of transmission, which were described as lethal. If there was any chance of transmission, there was an intolerable risk. The Thornton case was argued to evidence such a finding.

Justice McKelvey concluded the following:

[101] The statements of the CDC and WHO express very well the continuing risks of the transmission of this disease.

[104] I am also persuaded that endangerment of life has been proven in those circumstances where protection was utilized. This finding is supported by the evidence of Dr. Smith that condoms are considered to be only 80% reliable.

[105] This finding of endangerment of life includes those complainants who were exposed while the accused’s viral load was considered to be low, suppressed or undetectable. I have found the medical and scientific evidence to be very persuasive that even with an undetectable viral load, there remains a risk of transmission of HIV with resultant endangerment of life. This is particularly so given the medical evidence that other influences or factors such as STDs or the use of female contraception can affect or “spike” a viral load.

[106] There was a continuing risk that HIV could be passed upon sexual intercourse in all of the circumstances. I find from the evidence that there was endangerment to life for each of the complainants in this case.

She also noted that the Swiss statement – and the publicity about it – happened three years after the events for which Mr Mabior was on trial.

Worryingly, she also found that since that there is residual risk even when condoms are used, due to their 20% ‘failure’ rate, a “significant risk of serious bodily harm existed”.

[116] I am not prepared to follow the decision in Edwards with respect to the issue of protected intercourse based upon the medical evidence which was presented in this case and the “reliability” factor related to condom use. In this context, it is important to recall the evidence of Dr. Smith which stated that condoms are only 80% reliable and constitute an 80% reduction in HIV incidence. (Report, p. 6). Further, cases such as Thornton have demonstrated that a 99.3% screening safety rate was still considered to be too significant a risk in those circumstances. I am persuaded that in those circumstances where protection was used and the accused was regarded as infectious by the medical evidence, that a significant risk of serious bodily harm existed.

However, she did accept that “the combination of an undetectable viral load and the use of a condom would serve to reduce the risk below what would be considered a significant risk of serious bodily harm.”

I have made the 65 page transcript of Justice McKelvey’s ruling available to download as a pdf document (484 KB) in full from my website: here.

(Click here for a page refresh with all postings on the Clabior case)

HIV precedent
Winnipeg Free Press
July 17, 2008

There is a telling element in the case of an HIV-infected Winnipegger convicted this week of having unprotected sex with six young women. His defence rested on his contention that medical science shows the risk of passing on HIV during sex was so low that he had no responsibility to tell his partners he was carrying the AIDS virus.

Clato Lual Mabior, a man who preyed upon vulnerable young women and girls, is an unlikely authority on the relative risks of transmitting HIV. One victim testified that she was raped and that intercourse had been anal and unprotected, much riskier than protected vaginal sex. As well, the health status of the sex partner can change those odds dramatically: A woman with a sexually transmitted disease is much more susceptible to HIV. Mabior had multiple sex partners, increasing risk further.

None of this, however, is germane to the charges he faced. Anyone who does not inform a sex partner he or she has HIV can be found guilty of aggravated sexual assault. Mabior is facing deportation to his native Sudan, after he serves his sentence here. But that can be little solace to his victims, who faced or face years of uncertainty over their own health. It is little comfort to the general public to know that although Mabior was in contact with public health officials who repeatedly warned him of his obligations to his sex partners, he abandoned any sense of responsibility and decency for his own pleasure. He was not served with a public health order, under which he could have been detained, until police charged him with sexual assault. At that point, the Winnipeg Regional Health Authority took the unprecedented step of issuing a public notice, identifying the fact he was HIV-positive.

Mabior, like another man before the courts on similar charges, was given the benefit of doubt by public health authorities, tasked with counselling and monitoring those with HIV and AIDS. The latter man was given repeated warnings, despite officials learning he was having unprotected sex. Understandably, a public health worker treads a fine line as health practitioner and public watchdog, but the cases indicate the pendulum must swing further into the realm of public interest.

All HIV infected persons are told of their obligations to sex partners. If they break the rules, they should be subject to a health order and police intervention — second chances merely put innocent persons at risk. Mabior’s warped sense of obligation and desperate attempt to rationalize his depraved conduct indicate a need to balance risk with the swift and heavy hammer of police action when trust is breached.

Singapore: Man gets a year in prison for HIV exposure via oral sex

The first person to be convicted of HIV exposure in Singapore has been sentenced to a year in prison. Incredibly, the HIV-positive man performed oral sex in a public toilet, which, as I had noted in my previous blog posting on this case, results in no risk to the person being sucked.

In a report from Bloomberg, Dr Andrew Grulich, professor of epidemiology at the University of New South Wales in Australia, commented, “In a case like this where the risk is miniscule, it seems ludicrous to be prosecuting a person.”

There are two reports below: the first from Singapore’s Straits Times reporting the story ‘straight’, and the second, from Bloomberg, with commentary.

Man jailed for not telling boy of risk in first HIV case
Elena Chong
July 14, 2008

IN THE first case of its kind, a 43-year-old HIV sufferer was jailed for 12 months on Monday for having sex with a boy without telling him of the risk of contracting the infection and getting him to agree to accept that risk.

Chan Mun Chiong, a former chef, pleaded guilty to performing oral sex on the 16-year-old boy at the third level male toilet of Northpoint Shopping Centre in Yishun last year.

Deputy Public Prosecutor Royce Wee said that Chan had been diagnosed to have human immunodeficiency virus infection (HIV) since March 1999.

On Sept 15 2007, he was at the mall’s toilet cubicle when he initiated some hand signals under the partition to the victim in the adjacent cubicle, indicating that he was interested to engage in sex.

The duo went one floor up to a cubicle for the disabled. He then performed oral sex on the boy for two to three minutes.

The DPP said Chan did not inform the victim of the risk of contracting HIV infection from him and did not get the boy’s voluntary agreement to accept that risk before the sexual intercourse.

After that Chan asked the victim to turn around, but he refused. Chan persisted but the boy again refused. The victim told him to get out of the cubicle.

Angry, Chan left but followed the victim around the shopping centre. The victim became worried and approached a security officer for help.

The court heard that the boy regretted what Chan did to him and his parents no longer speak to him. The DPP said fortunately, he was not infected.

He asked Principal District Judge Bala Reddy to impose an appropriate sentence on Chan, who could have been fined up to $10,000 and/or jailed for up two years.

Under the new laws passed last month, the penalties have been upped to $50,000 or a jail term of up to 10 years or both.

Singapore Jails Man With HIV for Performing Oral Sex on Youth
by Simeon Bennett

July 15 (Bloomberg) — Singapore jailed a man with HIV for performing oral sex on a teenage boy, the first time the city- state has used its laws to prosecute someone with the virus that causes AIDS, the Straits Times reported.

The 43-year-old chef was sentenced to one year in jail after pleading guilty to a charge he exposed the 16-year-old to HIV without informing him of the risks first, according to the report. The teenager didn’t contract the virus, the report said.

“The risk of transmission of HIV through oral sex is so low that it hasn’t been able to be measured in epidemiological studies,” Andrew Grulich, a professor of epidemiology at the University of New South Wales in Australia, said in a telephone interview from Sydney. “In a case like this where the risk is miniscule, it seems ludicrous to be prosecuting a person.”

Singapore is seeking to curb its HIV infection rate, which has doubled in the past decade. In April, lawmakers passed amendments to laws that make it a crime for a person who doesn’t know their HIV status and has “reason to believe” they may have the virus to have sex without informing a sexual partner or taking “reasonable precautions” to protect them.

The man performed oral sex on the teenager in a shopping mall toilet cubicle in September, the Straits Times reported. After the teenager refused his request for anal sex, he followed him around the mall until the boy asked a security guard for help, the newspaper said.

A spokesman for Action for AIDS, Singapore’s HIV advocacy group, said he needed the approval of a committee to comment.

In the April amendments to the law, Parliament also increased the penalties to a maximum 10 years jail and S$50,000 ($37,000) fine. The man was charged before the amendments came into effect.

So far this year, 192 people have been diagnosed with HIV in Singapore, compared with 167 in the same period last year, according to data on the health ministry’s Web site.

Singapore’s legal age of sexual consent is 16. The city- state also outlaws any act of “gross indecency” between men.

US: Military court discusses viral load and HIV exposure

The issue of whether someone with an undetectable viral load can be guilty of HIV exposure has been discussed in a US court for the first time – the US Court of Appeals for the Armed Forces.

In this extremely interesting article from Gay City News (below) the five-member panel spent some time discussing whether an HIV-positive soldier who had previous pleaded guilty to HIV exposure (actually aggravated assault) could set aside his guilty plea following testimony from a military doctor that he was “highly unlikely” to be able to transmit HIV given his extremely low viral load.

At a sentencing hearing after his guilty plea, Captain Mark Wallace, a military doctor, testified that it was highly unlikely that X could have infected either woman because of his low viral load. Judge Charles Erdmann, writing for the court, noted Wallace’s testimony that “it was ‘unquestionably’ possible that X could transmit the virus but that the likelihood was ‘extremely low’ due to his low viral load.” Wallace acknowledged that there were documented cases of low viral load individuals who had sexually transmitted the virus, but emphasized that this was “very, very unlikely.”

When pushed to quantify his testimony, Wallace said the probability that Dacus could transmit HIV through unprotected sex with a woman was about 1 in 10,000, and that when he used a condom it was 1 in 50,000.

Although the majority did not agree, and did not allow his guilty plea to be set aside, two members of the panel found this expert testimony valid enough to question HIV exposure laws given evolving scientific knowledge of HIV transmission.

HIV Liability At Issue
By: ARTHUR S. LEONARD

A military appeals court ruling on aggravated assault charges against an HIV-positive male soldier who had sex with two women, one without a condom, without disclosing his serostatus provoked an interesting debate about what standard to apply given developing knowledge about transmission of the virus.

A five-judge panel of the US Court of Appeals for the Armed Forces was unanimous in its May 6 ruling rejecting the soldier’s effort to set aside his guilty plea, but two of the judges joined in a concurring opinion suggesting some reconsideration of the issue is in order.

Army Staff Sergeant X, a married man, learned that he was HIV-positive in 1996, and received the usual counseling about his responsibility to use a condom and also inform his partners of his status. Medical testimony in the case indicates that he is one of the rare individuals whose immune system suppresses the virus to an undetectable level without any medication. As a result, he remains asymptomatic and is unlikely to ever develop AIDS.

Military prosecutors charged him with two counts of attempted murder, arising from his adulterous sexual encounters with two women. He used a condom with the first woman, and claimed he barely penetrated her. With the second, however, he did not use a condom, and had an affair that included at least 11 occasions of sexual intercourse.

X did not deny the factual allegations, and in the face of the drastic penalties for attempted murder, agreed to plead guilty to lesser charges of aggravated assault and adultery, both violations of the Uniform Code of Military Justice (UCMJ).

At a sentencing hearing after his guilty plea, Captain Mark Wallace, a military doctor, testified that it was highly unlikely that X could have infected either woman because of his low viral load. Judge Charles Erdmann, writing for the court, noted Wallace’s testimony that “it was ‘unquestionably’ possible that X could transmit the virus but that the likelihood was ‘extremely low’ due to his low viral load.” Wallace acknowledged that there were documented cases of low viral load individuals who had sexually transmitted the virus, but emphasized that this was “very, very unlikely.”

When pushed to quantify his testimony, Wallace said the probability that X could transmit HIV through unprotected sex with a woman was about 1 in 10,000, and that when he used a condom it was 1 in 50,000.

In his appeal, X argued that his guilty plea was inconsistent with Wallace’s evidence introduced at the sentencing hearing. Under military law, conviction on aggravated assault requires that it be established that “the natural and probable cause of exposing” his sexual partner “to the HIV virus is death or grievous bodily harm,” or, put another way, that his conduct was “likely to produce death or grievous bodily harm.”

Applying this standard in prior HIV cases, military courts had taken into account both the probability that the virus could be transmitted and the harm that would be caused if it was transmitted. Erdmann first rejected X’s argument that even if he had infected his partners, they would not have been seriously harmed since he enjoys a very low viral load. That claim was not supported by medical evidence, since Wallace testified X’s low viral load was attributable to the strength of his immune system, not to a weak strain of HIV in his system.

The issue of X being unlikely to transmit the virus to a partner was a more complicated matter. In the past, military courts found that the statutory standard was met if the risk of HIV infection is “more than merely a fanciful, speculative, or remote possibility.” Erdmann wrote that “although the risk of transmitting the virus was low and therefore arguably ‘remote,’ the risk was certainly more than fanciful or speculative.”

This was enough to satisfy the court that X’s guilty plea should not be set aside, but two members of the court, Judges Margaret A. Ryan and James E. Baker, suggested that the issue of risk should be revisited in “an appropriate case.”

Ryan wrote that the standard being applied, though in line with other military rulings, “gives me pause,” and that a 1 in 50,000 chance seems at odds with the intent of the military code. She also noted the UCMJ does not state that “because the magnitude of the harm from AIDS is great, the risk of harm does not matter.” The standard in the statute is whether the conduct is “likely to produce death or grievous bodily harm,” which seems, according to Ryan, a higher standard than the risk being “so low as to approach being no ‘more than merely a fanciful, speculative, or remote possibility.'”

If the case had involved an appeal of a conviction at trial rather than a guilty plea, Ryan and Baker would have been inclined to reconsider it.

Ryan and Baker’s concerns deserve wider discussion in the civilian sphere as well, since many states prosecute HIV-positive individuals who have sex without disclosing their serostatus to partners. The severity of punishment is supposed to reflect the risk facing the uninfected party, yet the occasional appellate decisions that have emerged suggest that courts have been slow to adapt to the unfolding evidence about medical successes in reducing viral loads to undetectable levels and, consequently, lowering the risk of transmission.

Australia: Perth man stabbed with syringe unlikely to have HIV

So much of the reporting I see on HIV-related ‘crimes’ is shoddy and scare-mongering, so I was pleased to see this follow-up story from ABC News online that highlights how hard it is to be infected with HIV by being stabbed in the shoulder with a syringe.

The original story from ABC News online, entitled, ‘Stab victim fears HIV infection,’ had gaven a rather different impression. It’s a shame, though, that ABC News didn’t approach the Health Department before airing their first report.

The Health Department of [Western Australia] says there is a very slim chance a 55-year-old man stabbed with a syringe near the Midland train station has contracted HIV.

The victim was told ‘welcome to the world of HIV’ when he was stabbed in the shoulder by a man he refused to give money to.

The Department’s Director of Communicable Disease Control Paul Van Buynder says there has never been a case in WA of a person contracting the virus after being attacked by someone with a syringe.

“There was one health care worker in the last 25 years while we’ve been monitoring this that did sustain a needle stick injury with a known HIV positive patient and that patient did seroconvert despite taking medication at the time, but that’s the only case in the last 25 years in Western Australia,” he said.

Dr Van Buynder says even if the assailant had the virus there would only be a three in one thousand chance of the man contracting it.

“The risk of Hepatitis C and Hepatitis B, which are more infectious diseases, is higher than the risk of HIV, but again it relates to the possibility of the assailant themselves being infected.”

Swiss statement on sexual HIV transmission was inspired by HIV exposure prosecutions.

Very interesting interview on aidsmeds.com with Dr Bernard Hirschel, of the University of Geneva, the lead author of the controversial Swiss consensus statement which said that successful treated individuals with an undetectable viral load for at least six months and no concurrent sexually transmitted infection has a close to zero risk of transmitting HIV to an HIV-negative partner (who also has no STIs).

He says that one of the main reasons he and his colleagues were motivated to issue the statement was due to their frustration with Swiss courts not accepting a belief that undetectable viral load meant uninfectious as a defence during criminal HIV exposure trials.

The first[reason for the statement] is, a series of trials in Switzerland where people were accused of endangering others through sexual relations—they were HIV-positive, the partner was HIV-negative. The defense said, “well, there was little or no danger because my client was treated and he had undetectable viremia.” This defense was not admitted based on official statements saying that treatment had little influence on infectivity. And that’s just plain wrong. So there needs to be some official statement to the contrary.

The full interview, with Regan Hoffman, Editor of Poz magazine, is available in video form here, and the transcript can be found here.

I’m currently putting together an eight page article examining the statement, the global reactions (which have been wide-ranging), and the implications (which are even more wide-ranging), for the April issue of HIV Treatment Update.

US: HIV-positive man who forced wife to have oral sex arrested for HIV exposure, rape

An HIV-positive man was arrested in the New Orleans area last Saturday, after his wife complained to police investigating a disturbance that he had forced her to have oral sex with her, without a condom.

He is charged with aggravated rape, second-degree battery, intentional exposure of another person to HIV…and several outstanding traffic violations.

The full story, from The Times-Picayne, is below.

Husband held on rape, HIV charges
Police are called to Gretna hotel room
Tuesday, February 12, 2008
West Bank bureau

A Harvey man accused of raping his wife and intentionally exposing her to the HIV virus remained in the Jefferson Parish Correctional Center on Monday.

The 43-year-old man was booked Saturday with aggravated rape, second-degree battery, intentional exposure of another person to HIV and several outstanding traffic violations. His bond was set at $370,000. The Times-Picayune, which does not identify the victims of sex crimes, is not publishing the man’s name to protect his wife’s identity.

Gretna Deputy Police Chief Charles Whitmer said police were called to a disturbance at a hotel in the 1400 block of Claire Avenue on Saturday evening. When they arrived, they were directed to a hotel room occupied by the couple.

Whitmer said that as deputies approached the room, the man stuck his head outside and said that everything was fine. However, his wife began screaming for help from inside the room, Whitmer said.

When officers entered the room, the woman told them that her husband had come back to the hotel intoxicated and demanded that she have sex with him. When she refused, she said he beat her and forced her to perform oral sex on him without a condom. The woman was briefly able to escape the room, but her husband chased her down and dragged her back to the room by her hair, Whitmer said.

He said that police learned that the man has been HIV-positive for several years and that he and his wife are aware of his condition. The woman told officers the couple typically used protection during sexual relations.

Whitmer said that if someone who is HIV-positive knowingly engages in unprotected sex, particularly if the sex is nonconsensual, he or she can be booked with intentional exposure of the disease.

UK: Reckless HIV transmission case dismissed due to insufficient evidence

Some good news from the UK (actually, it’s the law of England and Wales that this case is relevant to). I reported this story today on NAM’s website, aidsmap.com.

Reckless HIV transmission case dismissed due to insufficient evidence

Edwin J. Bernard, Monday, February 11, 2008

The case against an HIV-positive man charged with grievous bodily harm for allegedly ‘recklessly’ sexually transmitting HIV was dismissed at Manchester Crown Court last Thursday following legal argument.

A 39 year-old man had been charged under Section 20 of the Offences against the Person Act 1861 (OAPA) – recklessly causing serious bodily harm – last September. An application for bail had been refused on the grounds that there was a risk other offences could be committed; consequently, the man had been in custody since his arrest.

The complainant was a 37-year-old woman who tested HIV-positive in September 2007, after the accused man had provided her name to clinic staff for contact tracing purposes.

In his application to dismiss the case, defence barrister, Alan Walmsley, noted that since this was her first-ever HIV antibody test, and since the complainant had admitted to at least five sexual partners in the twelve months before her diagnosis, the evidence was insufficient for a jury to be able to convict.

Judge Martin Rudland agreed, and said that this opened up the “possibility of the infection…being potentially from sources other than the defendant. The more the arguments have unfolded, the more I’ve become alive to the prospect of an injustice.”

“I suspect the defendant probably infected the complainant,” he noted, “but that is a long way short of what the prosecution need to prove.”

According to a report in today’s Manchester Evening News, Judge Rudland freed the defendant with these words: “You are still HIV-positive. You still have clear obligations [to those] with whom you have sexual relations. You are still likely to be a defendant in criminal proceedings if you do not behave. Do you understand?”

The man answered that he did, and then left the court a free man.

This is the third time that a lack of evidence in an English prosecution for HIV transmission has resulted in the defendant being cleared.

In August 2006, a gay man was acquitted of ‘reckless’ HIV transmission at Kingston Crown Court, following evidence that phylogenetic analysis could not definitely prove that the defendant infected the complainant.

In February 2007, in a case that went unreported at the time, a Preston Crown Court judge dismissed a ‘reckless’ HIV transmission charge against a gay man due to the fact that other sexual partners of the complainant – who may have been the source of his infection – did not agree to have blood samples taken for HIV testing or phylogenetic analysis.

The defence lawyer in all three of these cases, Khurram Arif, of London solicitors, Hodge Jones & Allen, tells aidsmap.com: “This case highlights the principle that the Crown Prosecution Service has the burden of proving the reckless transmission of HIV. Proving who caused whom to be infected without scientific and medical evidence is extremely difficult. The sexual history of complainants and medical records are material when considering the possible sources of infection and in my opinion should be made available to the defence very early when causation is in issue.”

Is having HIV ‘like a death sentence’?

This is an amended version of a blog entry originally entitled ‘Canada: Expert doctor defends his statements on HIV life expectancy’. I was forced to remove the original posting to which this entry refers due to a threat of legal action.

I have now included the news article from the original posting (about the Owen Antoine case in St. Thomas, Ontario, Canada) in this fuller entry on Mr Antoine’s trial.

The offending post dealt with the reported statements of Dr Anurag Markanday, the expert witness for the Crown in an article on the case from the St Thomas Times Journal, with which I strongly disagree.

Dr Anurag Markanday told the jury there’s no cure for HIV, but drugs do slow the process of the disease. “It’s like a death sentence … while we can keep the virus suppressed, we are going to run out of options.” Once diagnosed, the average lifespan of a person is eight to 10 years, he testified.

For someone with access to HIV treatment – as is the case in Canada – HIV is now a chronic, manageable condition.

In subsequent email correspondence, Dr Markanday again asserted his opinion that, “in the absence of a cure, I would still label it as “death sentence” for someone not on therapy (when clinically indicted) [sic] or in heavily treatment experienced patients with multiple drug mutations and limited options.”

Of course if someone is not on treatment when they should be (in most cases when they have a CD4 count below 350 cells/mm3) then they are more likely to get sick and die. But that is focusing on the exception and not the rule.

And yes, if someone was diagnosed in the 80s or 90s and burned through every class of drug they may well have multiple drug mutations, but there are now many options for what used to be known as ‘salvage therapy’, including the amazing new drugs and new drug classes that Dr Markanday says he is working with.

Consequently, I really must question his focus on worse-case scenarios and his use of the emotive phrase, ‘death sentence’.

Dr Markanday then points out “the effects from other co-morbidities such as hepatitis co-infection with early cirrhosis and mortality, hyperlipidemia/CV events have also increased. (In terms of number of years one could safely say at least ten years since the diagnosis).”

Again, I wonder why Dr Markanday focuses on hepatitis coinfection – which certainly does increase the likelihood of illness and death in someone with HIV? I have no idea whether the complainant was already infected with viral hepatitis before she was allegedly infected with HIV, but if this is not the case, how is it relevant?

As for lipid increase and cardiovascular events, the latest word from the D:A:D study, which looks at these events, is that “there does not seem to be an epidemic on the horizon – simply a risk that needs to be managed.”

So, yes, remaining on suppressive anti-HIV treatment, giving up smoking, exercising and eating well, and taking lipid-lowering drugs if indicated, may be necessary to reduce the risk of an HIV-positive person succumbing to a heart attack, but the increased risk of treated HIV infection itself is not considered something that dramatically alters life-expectancy.

Why could Dr Markanday not have said that with treatment, someone diagnosed with HIV infection today is expected to have, more or less, a normal lifespan? That is what Italy’s Dr Stefano Vella – one of the most respected HIV clinicians in the world – said at the 2006 International AIDS Conference in Toronto, and many expert HIV clinicians agree.

Solid data backs up Dr Vella’s assertion. In 2006, researchers from the United States calculated that someone who was provided with anti-HIV drug combinations according to 2004’s US treatment guidelines would benefit from these treatments for between 21 and 25 years before they finally stopped working. Their estimate included four separate attempts at suppressing HIV to ‘undetectable’ levels, from first-line therapy to ‘salvage’ therapy. (Schackman BR et al. The lifetime cost of current HIV care in the United States. Medical Care 44(11); 990=997, 2006.)

Last year, a large Danish study concluded that a 25 year-old diagnosed with HIV and treated with the anti-HIV drugs available then could expect to live well into their mid-sixties . The Danish study found that the average 25 year-old who remained HIV-negative could expect to live until they were in their mid-seventies. Consequently, successfully treated HIV infection appears to reduce life-expectancy by about ten years. (Lohse N et al. Survival of persons with and without HIV infection in Denmark, 1995-2005. Annals of Internal Medicine:146: 87-95, 2007.)

However, anti-HIV treatments – and knowledge about how to best use them – continue to advance at a rapid pace. As time goes on, experts believe that is very likely that other ways of treating HIV will be discovered that will mean that successful outcomes from the use of anti-HIV treatment could last even longer.

Certainly, HIV can lead to some serious illnesses if untreated. In 2006, around 100 out of the 400 deaths reported in HIV-positive people in the UK were due to their being diagnosed with HIV too late for effective anti-HIV treatment, highlighting the importance of HIV testing in order to make the most of the latest advances in anti-HIV therapy.

Another third of these 400 deaths were not considered related to HIV at all. Consequently, most HIV-related deaths are preventable if HIV is diagnosed early enough and treated succesfully. (Johnson M et al. BHIVA Mortality Audit. BHIVA Autumn Conference, London, 2006.)

Ultimately, anti-HIV treatments have greatly improved the life expectancy of people with HIV, as long as they:

• Know their HIV status early enough to get timely and effective treatment
• Have access to good quality HIV treatment and care
• And take anti-HIV drugs regularly and on time.

Finally, as for life expectancy for someone not on treatment, there are new data from UNAIDS and WHO which finds that, as a result of a better understanding of the natural history of untreated HIV infection, the average number of years that people living with HIV are estimated to survive without treatment has been increased from nine to eleven years.