Measles
America's HIV Outbreak Started In This City, 10 Years Before Anyone Noticed
HIV arrived in New York City precisely 10 years before doctors first noticed the disease, a conclusion that's based on new research published today in Nature. The finding solves a 35-year-old mystery surrounding the origins of America's outbreak, the first in the world to be noticed by doctors.
It indicates the virus passed from the Caribbean to New York in the early 1970s, where the disease gained a foothold for at least half a decade, before triggering outbreaks in places like San Francisco. The study also clears the name of Gaëtan Dugas, so-called "Patient Zero," who had been wrongly blamed for bringing the virus to U.S. Shores.
"This is the clearest scientific debunking of the myth around 'Patient Zero,'" said Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases at the NIH, who wasn't involved with the new study. "It's definitely clear that when 'Patient Zero' got infected, it was after already spreading throughout.'
New York's earliest strains most resemble those from the Caribbean, where researchers believe the disease first landed in the Western Hemisphere.
An international team of geneticists, microbiologists and medical historians solved this case through detective work. In 1981, UCLA physician Michael Gottlieb reported the first cases of HIV/AIDS — initially described as an infectious cancer — among gay men living in Los Angeles. But based on what's now known about HIV, these couldn't have been the first cases. For instance, research found eventually it takes 10 years, on average, for an infected person to show symptoms.
So Michael Worobey, an evolutionary biologist at the University of Arizona, stepped back into the past. They spent years tracking down blood samples taken prior to 1981 that contain signs of the virus. He and his colleagues stumbled upon two Hepatitis B virus studies from 1978-1979 — one in New York, the other in San Francisco — that had collected blood samples from gay men. Back then, though no one knew it, people with a high-risk of catching Hepatitis B turned out be high-risk for HIV, Worobey said during a press conference on Tuesday.
They whittled 11,000 blood specimens down to a set of 33 New York samples and 83 samples with signs that those patients had mounted an immune response against HIV. But to trace the history of the outbreak, the team needed genetic material, whereupon they encountered a big problem. The archived specimens hadn't been stored using the best practices for preserving genetic material, leaving major holes in the genetic codes of the HIV virus from each patient.
The early patterns of HIV-1 spread in the Americas as outlined in Worobey et al., Nature, 2016. The map summarizes the main patterns of spread inferred from the comparison of HIV genomes collected in different location. The map inset shows the initial introduction of HIV-1 subtype B lineage into the Caribbean from Africa. From there, the virus spreads first to NY and subsequently to different locations in the United States. Photo by Worobey et al., Nature, 2016
Imagine your friend gifts 10 storage bins to you, each with a shredded copy of the Declaration of Independence inside of it. Then your friend grabs one handful of shreds from each bin and says, "Piece together the document, please!" This task is hard even with all the pieces.
To surpass this barrier, the researchers developed a "jackhammer" gene sequencing approach. It amplifies the signal from each cut up piece of genetic code, making it easier to notice the fragments that might overlap. Over the course of years, they found enough overlapping fragments to build the complete genomes of HIV viruses from eight patients — three from San Francisco and five from New York.
"It is true, it's not a huge number," Worobey said. "But it tells you a whole lot, if you're looking at the geographical patterns."
That's true thanks to genetic diversity.
Genetic diversity — or different mutations among a set of genomes — can pinpoint when a population arrived in a certain place. Put one person on an deserted island, and the genomic diversity is low and defined just by them. Add a second person, and you've doubled the diversity. If you know when the two arrived — and of course you do since you put them there — then you can chart how genetic diversity changed over time. But if you can also work backwards, with just the people — or in this case, different patients' copy of the HIV — if you know how common mutations are in the genomes.
"This is, in my mind, the last piece of the puzzle."
Worobey and his colleagues found genetic diversity was higher in the New York samples, suggesting the virus landed there first.
"We can date the jump into the U.S. At about 1970, or 1971, and you see a very telltale pattern of extensive genetic diversity in New York City, suggesting that New York City was the key hub of diversification for the virus," Worobey said. "Restricted genetic diversity in San Francisco, suggesting San Francisco was a later dispersal out of this New York City hub."
Their analysis traced the bulk of HIV infections in San Francisco to a single introduction from New York by around 1976, before the virus quickly spread across the country.
No blame left to give
Gaëtan Dugas, who died March 30, 1984 due to complications with HIV/AIDS, was mistakenly branded as "patient zero" or the first cases in America's HIV outbreak. Photo via Wikimedia
"This is, in my mind, the last piece of the puzzle," said Beatrice Hahn, a virologist at the University of Pennsylvania, who first discovered that HIV originated in chimpanzees and other primates before infecting humans.
"We now have a very detailed understanding where HIV came from, the number of times it got introduced into the human population, the location where that occurred, how the virus then moved around within Africa, and started to spread, and then how the virus was then transferred to other places around the world, including the United States," she said.
Based on genetic heritage analysis conducted in the new study, New York's earliest strains most resemble those from the Caribbean, where researchers believe the disease first landed in the Western Hemisphere. But HIV, as we know it, started sometime in the early 20th century in Africa, Worobey said, and it wasn't a one-time event.
"This pandemic strain that we call the main group of HIV-1 is one of several non-human primate viruses that have crossed over," Worobey said. "It's not the only one, it's just the most successful one."
He said one of these HIV variants — HIV-1 subtype B — successfully emerged out of Africa, sometime in the mid- to late-1960s, and took hold in the Caribbean by 1967. A Haitian HIV strain from 1969 is the closest relative to those that first dropped into New York, suggesting it may have been the source of America's outbreak. However, this virus had been circulating among Haiti, Dominican Republic, Jamaica, Trinidad and Tobago and Haitian immigrants, making it difficult to pin to a single Caribbean nation.
"How the virus moved from the Caribbean to the U.S., and New York City in the 1970s is an open question," Worobey said. "It could have been a person of any nationality."
Plus, it's also important to distinguish between tracing the origins of a virus and placing blame, he said, because no one should be blamed for spreading a virus that no one even knew about.
This advice could also apply to Gaëtan Dugas. Dugas was a flight attendant for Air Canada and an early AIDS patient who, in the mid-1980s, the Centers for Disease Control and Prevention linked to a network of HIV transmission between 10 American cities. In the case report on the network, investigators initially labeled Dugas as "Patient O" to indicate he lived "Out(side)-of-California." However, when disease detectives later transcribed his entry into a separate report, they used "patient 0," i.E. Zero.
"Patient zero" is a term typically used by epidemiologists to denote the first-known case of an outbreak. Popular media, such as the 1987 best-selling book "And The Band Played On" by journalist Randy Shilts, spread this inaccurate information — even going as far as to suggest Dugas brought HIV to America.
"Yes, Randy's book clearly promoted the idea [of 'Patient Zero']," director Fauci said. "And since it was so popular, it became folklore."
An annotated clipping of a People Magazine article about Gaëtan Dugas sent to San Francisco AIDS Foundation circa 1988. Photo via NIH
Today's study clears Dugas' name, once and for all, by comparing his HIV sample with those collected from San Francisco and New York in 1978-1979.
"That's really a spectacular part of the story. It removes the sense of blame and shame from him [Dugas]," said Paul Volberding, head of the Center for Aids Research at the University of California San Francisco, who saw some of the first HIV patients in America, including Dugas. "Dugas was having sex and spreading the virus. But this study makes the point that a number of the people that he was having sex with were already symptomatic when he first had contact."
Volberding said the hyperbolic confusion over Dugas is representative of what can happen during the early days of modern outbreaks. The early days of any outbreak are hectic for doctors and public health officials on the best days, and a total garbage fire on the worst. Remember the fervor over Thomas Eric Duncan in Dallas during the Ebola outbreak?
You can't tell an outbreak is happening until people get sick, so doctors are inherently one step behind. Yet even without the internet, Volberding recalled that the first reports of AIDS in 1981 quickly passed between U.S. Physicians' letters to medical journals, as they recognized the symptoms in their patients.
"The day that I saw my first patient on July 1, 1981, I was making rounds in the hospital with a new trainee, who had just arrived in New York," Volberding said. "He said, 'I think we saw some of those patients there.' News spread from New York to San Francisco kind of instantaneously."
Volberding wrapped up by explaining that studies like Worobey's are a marker of the future, because they pair epidemiology with new-age technology to solve outbreaks.
"Epidemics will continue to happen, and the better we can understand them in real-time, the better we can possibly respond," Volberding said.
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Give NowThree Women Contract HIV From Dirty "vampire Facials" At Unlicensed Spa
The spa was quickly shut down, and the owner Maria de Lourdes Ramos De Ruiz, 62, was charged with practicing medicine without a license. In 2022, she pleaded guilty to five counts and is serving a three-and-a-half-year prison sentence.
A second spa client, another woman between the ages of 40 and 50, tested positive for HIV in a screen in the fall of 2018 and received a diagnosis in early 2019. She has received a vampire facial in the summer of 2018. Her HIV infection was also at stage 1. Investigators scrambled to track down dozens of other clients, who mostly spoke Spanish as their first language. The next two identified cases weren't diagnosed until the fall of 2021.
The two cases diagnosed in 2021 were sexual partners: a woman who received three vampire facials in the spring and summer of 2018 from the spa and her male partner. Both had a stage 3 HIV infection, which is when the infection has developed into Acquired Immunodeficiency Syndrome (AIDS). The severity of the infections suggested the two had been infected prior to the woman's 2018 spa treatments. Health officials uncovered that the woman had tested positive in an HIV screen in 2016, though she did not report being notified of the result.
The health officials reopened their outbreak investigation in 2023 and found a fifth case that was diagnosed in the spring of 2023, which was also in a woman aged 40 to 50 who had received a vampire facial in the summer of 2018. She had a stage 3 infection and was hospitalized with an AIDS-defining illness.
Viral genetic sequencing from the five cases shows that the infections are all closely related. But, given the extent of the unsanitary and contaminated conditions at the facility, investigators were unable to determine precisely how the infections spread in the spa. In all, 198 spa clients were tested for HIV between 2018 and 2023, the investigators report.
"Incomplete spa client records posed a substantial challenge during this investigation, necessitating a large-scale outreach approach to identify potential cases," the authors acknowledge. However, the investigation's finding "underscores the importance of determining possible novel sources of HIV transmission among persons with no known HIV risk factors."
HIV Outbreak Persists As Officials Push Back Against Containment Efforts
CHARLESTON, W.Va. — Brooke Parker has spent the past two years combing riverside homeless encampments, abandoned houses, and less traveled roads to help contain a lingering HIV outbreak that has disproportionately affected those who live on society's margins.
She shows up to build trust with those she encounters and offers water, condoms, referrals to services, and opportunities to be tested for HIV — anything she can muster that might be useful to someone in need.
She has seen firsthand how being proactive can combat an HIV outbreak that has persisted in the city and nearby areas since 2018. She also has witnessed the cost of political pullback on the effort.
Parker, 38, is a care coordinator for the Ryan White HIV/AIDS Program, a federal initiative that provides HIV-related services nationwide. Her work has helped build pathways into a difficult-to-reach community for which times have been particularly hard. It's getting increasingly difficult to find a place to sleep for the night without being rousted by police. And many in this close-knit group of unhoused individuals and families remain shaken by the recent death, from complications of AIDS, of a woman Parker knew well.
The woman was barely in her 30s. Parker had encouraged her to seek medical care, but she was living in an alley; each day brought new challenges. If she could have gotten basic needs met, a few nights' decent sleep to clear her head, Parker said, she would have more likely been open to receiving care.
Such losses, Parker and a cadre of experts believe, will continue, and maybe worsen, as political winds in the state blow against efforts to control an expanding HIV outbreak.
EMAIL SIGN-UpIn August 2021, the Centers for Disease Control and Prevention concluded its investigation of an HIV outbreak in Kanawha County, home to Charleston, where people who inject opioids and methamphetamine are at highest risk. The CDC's HIV prevention chief had called it "the most concerning HIV outbreak in the United States" and warned that the number of reported diagnoses could be just "the tip of the iceberg."
HIV spreads easily through contaminated needles; the CDC reports the virus can survive in a used syringe for up to 42 days. Research shows offering clean syringes to people who use IV drugs is effective in combating the spread of HIV.
Following its probe, the CDC issued recommendations to expand and improve access to sterile syringes, testing, and treatment. It urged officials to co-locate services for easier access.
But amid this crisis, state and local government officials have enacted laws and ordinances that make clean syringes harder to get. In April 2021, the state legislature passed a bill limiting the number of syringes people could exchange and required that they present an ID. Charleston's City Council added an ordinance imposing criminal charges for violations.
As a result, advocates say, a substantial number of those at highest risk of contracting HIV remain vulnerable and untested.
Public health experts also worry that HIV infections are gaining a foothold in nearby rural areas, where sterile syringes and testing are harder to come by.
Joe Solomon is co-director of Solutions Oriented Addiction Response, an organization that previously offered clean syringes in exchange for contaminated ones in Kanawha County. Solomon said the CDC's recommendations were precisely what SOAR once provided: co-location of essential services. But SOAR has ceased exchanging syringes in the face of the efforts to criminalize such work.
Solomon, who was recently elected to the Charleston City Council on a platform that includes measures to counter the region's drug crisis, said the backlash against what's known as harm reduction is "a public attack on public health."
Epidemiologists agree: They contend sidelining syringe exchanges and the HIV testing they help catalyze may be exacerbating the HIV outbreak.
Fifty-six new cases of HIV were reported in 2021 in Kanawha County — which has a population of just under 180,000 — with 46 of those cases attributed to injection drug use. By the end of November, 27 new cases had been reported this year, 20 related to drug injection.
But the CDC's "tip of the iceberg" assessment resonates with researchers and advocates. Robin Pollini, a West Virginia epidemiologist, has interviewed people in the county with injection-related HIV. "All of them are saying that syringe sharing is rampant," she said. She believes it's reasonable to infer there are far more than 20 people in the county who've contracted HIV this year from contaminated needles.
Pollini is among those concerned that testing initiatives aren't reaching the people most at risk: those who use illicit drugs, many of whom are transient, and who may have reason to be wary of authority figures.
"I think that you can't really know how many cases there are unless you have a very savvy testing strategy and very strong outreach," she said.
Research shows sustained, well-targeted testing paired with access to clean syringes can effectively slow or stop an HIV outbreak.
In late 2015, the Kanawha-Charleston Health Department launched a syringe exchange, but in 2018 shuttered it after the city imposed restrictions on the number of syringes that could be exchanged and who could receive them. Then-Mayor Danny Jones called it a "mini-mall for junkies and drug dealers."
When officials abandoned the effort, SOAR began hosting health fairs where it exchanged clean syringes for used ones. It also distributed the opioid overdose-reversing drug naloxone; offered treatment, referrals, and fellowship; and provided HIV testing.
But when the new state restrictions and local criminal ordinance took effect, SOAR ceased exchanging syringes, and attendance at its fairs plummeted.
"It's indisputable and well established. It's comprehensive; it's inclusive," Pollini said of research supporting syringe exchange. "You can't even get funding to study the effectiveness of syringe service programs anymore because it's established science that they work."
Joe Solomon, co-director of Solutions Oriented Addiction Response, was recently elected to the Charleston City Council on a platform that includes measures to counter the region's drug crisis. Solomon says the backlash against what's known as harm reduction is "a public attack on public health." (Taylor Sisk for KHN) Syringe exchanges are credited with tamping down an HIV outbreak in Scott County, Indiana, in 2015, after infections spread to more than 200 intravenous drug users. At that time, then-Gov. Mike Pence — after initially being resistant — approved the state's first syringe service.
A team of epidemiologists worked with the Scott County Health Department on a study that determined that discontinuing the program would result in an increase in HIV infections of nearly 60%. But in June 2021, local officials voted to shut it down.
In Kanawha County, SOAR was making inroads. Interviews with numerous clients underscore that people felt safe at its health fairs. They could seek services anonymously. But most acknowledge that the promise of clean syringes was what brought them in.
Charleston-based West Virginia Health Right operates a syringe exchange that Dr. Steven Eshenaur, executive director of the Kanawha-Charleston Health Department, credits with helping reduce the number of new HIV diagnoses. But advocates say the imposed constraints — particularly the requirement to present an ID, which many potential clients don't have — inhibit its success.
HIV diagnoses are up this year in nearby Cabell County and Pollini worries that without more aggressive action, an HIV epidemic could take root statewide. As of Dec. 1, 24 of West Virginia's 55 counties had reported at least one positive diagnosis this year.
HIV is preventable. It's also treatable, but treatment is expensive. The average cost of an antiretroviral regimen ranges from $36,000 to $48,000 a year. "If you're 20 years old, you could live to be 70 or 80," said Christine Teague, director of the Ryan White program in Charleston. That's a cost of more than $2 million.
Saving lives and money, Pollini said, requires being both proactive — ongoing, comprehensive testing — and reactive — ramping up efforts when cases rise.
It also requires "meeting people where they are," as it's commonly put — building trust, which opens the door to education about what HIV is, how it's spread, and how to combat it.
Teague said it also requires something more: addressing the fundamental needs of those on the margins; foremost, housing.
Parker agrees: "Low-barrier and transitional housing would be a godsend."
But Teague questions whether the political will exists to confront HIV full force among those most at risk in West Virginia.
"I hate to say it, but it's like people think that this is a group of people that are beyond help," she said.
This story was produced by KHN (Kaiser Health News), a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.
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