Johnson Aziga
Photograph by: Handout, CNS

1.  Guilty verdict in first ever murder trial for sexual HIV transmission.

April 7, 2009

A Canadian man who is thought to have recklessly transmitted HIV to seven women, two of whom subsequently died, has made legal history by becoming the first person ever to be convicted of first-degree murder for sexual HIV transmission. The case has reignited the criminalisation debate in Canada, which has prosecuted more HIV-positive individuals per capita for sexual HIV exposure or transmission than any other country in the world.

The trial, which lasted six months, concluded last Saturday, when a nine-man, three-woman jury found Johnson Aziga, 52, guilty of two counts of first-degree murder, ten counts of aggravated sexual assault and one of attempted aggravated sexual assault after deliberating for three days.

Mr Aziga, who was born in Uganda, came to Canada as a refugee in 1990 and was diagnosed HIV-positive in 1996. After the dissolution of his ten-year marriage in 1998, Mr Aziga dated several women that he met through his work as a research analyst with the Ontario government, and others that he met in bars in Hamilton, a suburb of Toronto.

In October 2002, a newly diagnosed woman named Mr Aziga as a recent sexual contact. Since 1998, Canadian law has required individuals diagnosed with HIV to disclose their HIV status to their sexual partners prior to sexual contact that may risk transmission, and Mr Aziga was ordered to practice safer sex under Section 22 of Ontario’s Health Protection and Promotion Act. He was also required to provide a list of his previous sexual partners.

In March 2003, another newly diagnosed woman also named Mr Aziga as a recent sexual contact. The Hamilton health department issued Mr Aziga with a second public health order and informed the police, who put Mr Aziga under surveillance. He was arrested at his home in August 2003 whilst having unprotected sex with a woman who has since tested HIV-positive and identified in court as Ms C. She had been dating Mr Aziga since February 2003 and last year, she filed a C$6m (£3.3m) civil suit against Hamilton’s police and public health departments for allegedly being used as “bait.”.

Following a widespread media appeal from the police for more sexual contacts, and, in late 2003 and early 2004, the death of two of the women who had also named Mr Aziga as a previous sexual partner, Mr Aziga was eventually charged with two counts of first-degree murder and eleven counts of aggravated sexual assault. Canadian law mandates that if someone dies following aggravated sexual assault, then this automatically results in first-degree murder charges.

Mr Aziga, who has been in prison since his arrest in August 2003, went through six defence teams delaying his trial, which finally began in October 2008. The court heard evidence from all eleven complainants, seven of whom believed that Mr Aziga had infected them with HIV, including pre-recorded video and audio testimony from the two women who had died. Both claimed that Mr Aziga had not disclosed his HIV status to them before having unprotected sex, and that they would not have had sex with him had he done so.

One of the women, known as ‘S.B.’, died in December 2003 at the age of 51 as a result of non-Hodgkin's lymphoma that was diagnosed in 2001. However, she was not tested for HIV until July 2002. She claimed that Mr Aziga infected her with HIV during the summer of 2000.

The second former sexual partner of Mr Aziga to die, known as ‘H.C.’, dated Mr Aziga for a year from October 2001. She was diagnosed HIV-positive in November 2002, began antiretroviral therapy a year later, but in April 2004 was diagnosed with Burkitt's lymphoma and died in May 2004.

Several expert witnesses testified that although such rapid progression is rare, it is not unheard of.

Although Mr Aziga’s defence team raised doubts about the provenance of HIV in these women and several others who had other sexual partners in the same sexual network and who may also have shared a similar strain of subtype A, the jury believed the testimony of Dr Paul Sandstrom, director of the Public Health Agency of Canada's national HIV and retrovirology laboratories, who concluded that only Mr Aziga could have infected the seven complainants who were HIV-positive.

Testimony from Dr Julian Gojer, a forensic psychiatrist hired by Mr Aziga's defence team to assess Mr Aziga's mental state and offer explanations for his behaviour appeared to backfire during cross-examination by the prosecution. Although Dr Gojer had found that Mr Aziga’s traumatic experiences as a younger man in Uganda and Kenya had resulted in a cognitive impairment that may have been exacerbated by his HIV infection, he also admitted that Mr Aziga was still capable of knowing that it was wrong to have unprotected sex without disclosing his HIV status.

During his summing up last Wednesday, Superior Court Justice Thomas Lofchik told the jury that if they found that the following nine elements were proven beyond a reasonable doubt, then they could find Mr Aziga guilty of murder:

• 1. That Mr Aziga had unprotected, penetrative sex with both of the deceased women.

• 2. That he was aware he was HIV-positive at the time of having sex with each woman.

• 3. That prior to sex, Mr Aziga was aware that he was required by law to inform all prospective sexual partners of his HIV status.

• 4. That he failed to disclose his HIV status to the two women.

• 5. That the women would not have consented to unprotected sex had he disclosed.

• 6. That both women were infected with Mr Aziga’s virus.

• 7. That Mr Aziga caused the women's deaths by infecting them with HIV during sex.

• 8. That Mr Aziga meant to cause the women's deaths or meant to cause them bodily harm that he knew was likely to cause their deaths, and was reckless whether death ensued or not.

• 9. That the aggravated sexual assault, the HIV infection, and the death of the two women were part of one continuous sequence of events forming a single transaction.

The jury found Mr Aziga guilty of both murder charges and ten of the eleven aggravated sexual assault charges, primarily because Canadian law essentially defines consensual sex without prior disclosure of HIV status as fraud. Mr Aziga will be sentenced on May 7th. A first-degree murder conviction leads to an automatic life sentence with no eligibility of parole for 25 years; each aggravated sexual assault conviction carries a maximum prison sentence of 14 years. Mr Aziga has already instructed his lawyer to ask legal aid for more funding for an appeal.

Although Mr Aziga’s double-murder trial is unique, almost 90 HIV-positive people have been prosecuted, and almost 70 convicted, of criminal HIV exposure or transmission in Canada since 1989. Some of Canada’s most prominent HIV clinicians, including Dr. Mark Wainberg and Professor Julio Montaner, have recently spoken out against such prosecutions, primarily on public health grounds.

Reference
Daily trial reports from The Hamilton Spectator, available here.

Knowingly exposing others to HIV ought to be a serious crime.

Or should it?

That is the furious argument unleashed by the trial of Johnson Aziga, a man who was found guilty last week of first-degree murder. The murder weapon was unsafe sex. The thoroughly repugnant Mr. Aziga was found to have infected seven women with HIV, even though he knew he was infected, and even though he knew he had a legal obligation to inform his sex partners. Two of his victims died of AIDS-related cancers.

Peter Troyer, a 37-year-old Toronto man who is himself HIV-positive, has no doubt about where he stands. “It is absolutely reasonable to have a law,” he says. “He exposed people to a potentially dangerous virus without their consent. I wouldn't want to live in a society that didn't punish this behaviour at the highest level.”






But Canada's gay and HIV-AIDS activist groups overwhelmingly disagree. They believe the law will further stigmatize people who are HIV-positive. It could lead to serious violations of people's human rights. It will remove the onus from uninfected people to protect themselves, and may even give them a false sense of security. Perversely, it may even lead to higher rates of HIV.

“It is important to understand that there may be negative consequences if these cases are brought to trial,” argues Mark Wainberg, a leading AIDS researcher and activist based at McGill University.

The logic is that if you don't know you are HIV-positive, you can't be accused of its transmission.

That fear may make you more reluctant to get tested – and also more likely to infect others. People who don't know their HIV status are the main source of new infections.

There are cultural and political arguments too.

“For gay men, the most compelling argument against the criminalization of HIV is the propensity of those who hate us to use AIDS fear as a weapon against our civil liberties,” insists Sky Gilbert, a well-known gay-rights firebrand. He thinks the activist establishment should have demanded that Mr. Aziga be acquitted.

Like several similar high-profile prosecutions, the Aziga case involved heterosexual, not homosexual, sex. But in Canada, the politics of HIV-AIDS is primarily a gay issue. And the most passionate argument over criminalization and HIV is not between the activist groups and the general public. It's the one within the gay community itself. At root, the argument is not about what's best for public health. It's about morality, and responsibility, and the legacy of the gay-rights movement.

Phillip Berger, one of Canada's best-known AIDS doctors, has worked tirelessly both here and in Africa for more than 30 years. He's fed up – fed up with the efforts of the HIV-AIDS establishment to evade the issue of personal responsibility.

“I think people who deliberately, deceitfully and maliciously mislead people are no different from someone taking a gun and shooting them,” he says. “They should be held accountable, not go to therapy somewhere.” He points out that the law does not criminalize HIV. It criminalizes irresponsible behaviour. “My own belief is that leaders of the AIDS establishment, who have a lot of bona fide, legitimate concerns, should acknowledge that this type of conduct is completely unacceptable.”

Dr. Berger has seen plenty of tragic stories – people whose lives and health were ruined by somebody else. He flatly rejects the argument that the law will further stigmatize people with HIV. “The landscape of struggle with HIV has been transformed in 20 years,” he says. People with HIV used to be kicked out of apartment buildings, kicked out of the Y, and lose their jobs. Today, people with HIV are represented on every AIDS committee, in every scientific body, at every hospital.

In fact, a current ad campaign, now running in public spaces throughout Toronto, suggests that the worst stigma faced by HIV-positive men is being rejected for sex by HIV-negative men. “If you were rejected every time you disclosed, would you?” says the line over a photo of two young men embracing. The clear message is: How can you blame people who are HIV-positive for not telling?

One major fault line that divides the two camps is the question of whether curbing HIV-AIDS is a personal or a collective responsibility. Of course it's both. But the AIDS establishment has long expressed the view that it is overwhelmingly a social problem, and therefore must be addressed collectively – through better education, better access to testing, more instruction about safe-injection needle use, and more attention to “root causes” such as homophobia, sexism, racism, HIV stigma and discrimination. “Criminalization disproportionately places the responsibility for preventing HIV transmission on PHAs [people with HIV or AIDS],” asserts one influential legal group.

Not everybody thinks that's so very wrong. Brian Cornelson, a primary care physician at St. Michael's Hospital in Toronto, has been treating HIV-AIDS patients for 17 years. “What I tell my patients is that people who are positive have 100-per-cent responsibility to not infect others, and people who are negative have 100-per-cent responsibility not to infect themselves. If everybody took that stance, we wouldn't have any HIV transmission.”

He too believes the position of the activist establishment is flat-out irresponsible. “They've put the stigmatization issue in front of the transmission issue,” he says. “For me, as a gay man and a physician, this is particularly dismaying.”

Another subtext in the dispute is the legitimacy of discussing a certain subculture of high-risk gay sex practices – one that involves lots of drugs and promiscuity. The activist establishment never brings this up, even though it plays a big role in the vector of the disease. Mr. Troyer, for one, figures the issue deserves a lot more candour. He got in trouble a while back when he publicly questioned whether offering bathhouse tours to new kids in the city was an effective prevention strategy.

The irony is that most people with HIV do behave responsibly. AIDS doctors say the vast majority are horrified at the thought of infecting someone else. But the idea of giving anyone a pass because they're victims makes many people deeply angry.

Michael Leshner is one of them. Mr. Leshner, a long-time activist, and his partner were the first gay couple in Canada to be legally married. “The ads give people with HIV-AIDS a moral pass to infect,” he says. “Whenever you define a person or a group as victims, the danger is that you excuse away their conduct. It's as if they have no responsibility to themselves or others.”

For him, the historic fight for gay rights was all about dignity, agency, and the right to be recognized as fully human. “You had to break the cycle of victimization,” he says. “And that meant to stand up and say, ‘Here I am.'”

In his view, even people who bear the heavy burden of HIV deserve the dignity of being treated like anybody else. “They have the right to make moral choices,” he says. “The true victimization is by people who say that gay men with HIV do not have an absolute obligation to disclose. It's putting us back in time.”

But what about activists' fear that the Aziga case is the start of the slippery slope? What about Sky Gilbert's dire warning that gay men will be harassed and hounded and dragged through the courts by self-righteous agents of the justice system and vengeful former lovers? “I have more faith in the system than that,” Mr. Leshner says.

Partly because HIV is not the terrible stigma – or the death sentence – that it used to be, infection rates in Canada have been creeping back up in recent years. In Toronto, the infection rate among gay men is 24 per cent; in Ottawa it's 11 per cent. The disagreement over how to get those numbers down has turned into something very like a schism – one that divides gay men and casts people like Peter Troyer, who was diagnosed seven years ago, in the role of an apostate.

“I think it needs to be said that if you choose not to disclose, you will not only be letting yourself down, but your community and society as a whole,” he says. “You did the wrong thing, and most importantly, wrong for you.” He doesn't see himself as anybody's victim. He sees himself as a fully empowered, HIV-positive adult.

By Margaret Wente, http://www.theglobeandmail.com

April 5, 2009

Giving patients taking tenofovir supplements of vitamin D helped reduces levels of a hormone – parathyroid hormone or PTH - that causes loss of calcium from the bones, a joint London/New York study has found.

Although osteopenia and osteoporosis (loss of calcium from the bones) are common in people with HIV, both on and off therapy, tenofovir, one of the most widely used drugs, has also been associated in some studies with higher levels of bone mineral loss. However the mechanism for this is unclear, or even whether tenofovir is a direct cause of osteopenia at all.

Vitamin D is essential for bone metabolism too and in both this study and another one also presented at the BHIVA Conference this year, appears to be almost universally deficient in people with HIV too.

The researchers, from King’s College Hospital in London and Mount Sinai Hospital in New York, theorised that the ‘missing link’ between HIV, tenofovir, vitamin D and calcium loss is parathyroid hormone (PTH). This hormone causes calcium to be released from the bones into the bloodstream, where it is needed for regulation of the nervous system; in turn high calcium levels stop the release of PTH, in a feedback loop. However if parathyroid hormone levels become set at too high a level, too much calcium is released from the bones.

The hypothesis investigated by the researchers is that HIV somehow causes low vitamin D levels, which cause the blood to be low in calcium. This pushes up PTH levels, which cause some of the bone mineral loss seen in HIV infection. PTH levels are then are further increased by tenofovir, and thus make the bone mineral loss worse.

The team therefore measured vitamin D and PTH levels in 45 men who were taking HIV drugs. They found sub-optimal vitamin D levels (defined as below 30 nanograms per millilitre) in the majority of the men – 71% - and 41% had higher-than normal levels of PTH.

All the patients with high PTH were taking tenofovir, and no subject whose levels of vitamin D were normal or above had high PTH.

Seventeen of the 45 patients were advised to take vitamin D supplements because they had very low levels; of these, 14 reported good adherence to the supplement. Vitamin D levels increased in all 14 and PTH levels decreased in nine of the 14. The higher the patients’ original PTH values were, the greater the fall in PTH they experienced on vitamin D. The five patients with the highest baseline levels of PTH had the greatest decreases in PTH; these were in the order of a threefold decline, and went down to normal values. All of these patients were taking tenofovir. In contrast in the six patients with the lowest baseline PTH, levels stayed exactly the same.

This is a small preliminary study and the results need to be treated with caution. In the first place, the study is too small to eliminate possible confounders - other reasons people might have low vitamin D or high PTH. Secondly, given that vitamin D deficiency appears nearly universal in patients with HIV (another study looking at over 1000 patients at King’s College Hospital found below-normal vitamin D levels in 91% of patients) it is uncertain what the clinical significance of this is or whether vitamin D supplementation, for patients taking tenofovir or otherwise, will help to improve bone mineral loss.

References
Childs K et al. Vitamin D and calcium supplements reverse the secondary hyperparathyroidism that commonly occurs in HIV patients on TDF-containing HAART. Fifteenth BHIVA Conference, Liverpool. Poster P89. 2009.

Welz T et al. Risk factors for vitamin D in an ethnically diverse urban HIV cohort: which antiretrovirals are implicated? Fifteenth BHIVA Conference, Liverpool. Oral presentation O6. 2009.

April 6, 2009

Infection with a second strain of HIV (superinfection) may have medical consequences, according to a presentation at the 15^th British HIV Association (BHIVA) conference.

A small study of eight gay men with HIV who were not on treatment and had increases in their viral load found two whose viral load increases were clearly due to infections with a second strain of HIV.

In one case the patient‘s second strain of HIV was drug-resistant. He also experienced a recurrence of acute HIV symptoms which required hospitalisation for suspected meningitis and a large, though temporary decrease in CD4 count. In the other case the patient’s original strain of HIV, which was drug-resistant, was replaced by an apparently stronger non-resistant strain and his viral load increased from around 3000 to half a million. However he maintained a CD4 count over 1000 and his viral load had returned to 3000 a year later.

In this prospective study at the Royal Free and Royal London Hospitals, gay men who were diagnosed with HIV, did not start HIV treatment, and continued to have unprotected anal sex after diagnosis were monitored for cases where their viral load increased more than threefold (0.5 logs) during routine follow-up appointments. The eight men who met these criteria were diagnosed between 2004 and 2008 and their average age was 30, younger than the average age for diagnosis in gay men. For the study, all diagnosed gay men not starting treatment had their HIV’s genetic make-up analysed in detail.

An increase in the men’s viral load was noted an average of 19 months after diagnosis in these eight cases. When this was detected, the genetic make-up of the men’s HIV was re-analysed. In six cases there was no difference in the viral sequences, but in two cases the researchers found a completely different strain of virus which had ‘taken over’ from the first one. There was no overlap between the genetic sequences of the two viruses, indicating that this was not a case of recombination (two viruses combining to make a new one) but of two populations of viruses, a stronger and a weaker, co-existing.

In the first case the superinfection happened five months after the initial one. The patient was diagnosed during the acute phase of his initial infection. He had HIV seroconversion symptoms (a flu-like illness and severe headache) and a viral load of a million which subsequently declined to 40,000 copies/ml.

However five months after infection he experienced a return of the same symptoms, requiring hospitalisation and an MRI scan for suspected meningitis.

His viral load went back to 160,000 and subsequently increased further to nearly a million. His CD4 count fell temporarily from 430 to 240 cells/mm³ though it subsequently rebounded to about 390 cells/mm³. He continued to have high-risk sex and over the next six months also acquired first infections of syphilis and herpes. His second virus had two resistance mutations to nucleoside drugs.

In the second case the patient acquired a second strain three years after the first. In this case his original virus had two drug resistance mutations. When his viral load increased he was given another resistance test 3.5 years after diagnosis which showed no evidence of the mutations. Analysing previous samples showed he had acquired a superinfection six months previously.

The researchers conclude that HIV-infected patients who continue risk behaviour are at risk of superinfection “both in the early and established phases of the disease”. They recommend that all patients not on treatment who experience unexpected viral load increases should be screened for superinfection (though the kind of intensive phylogenetic screening used in this study is purely a research tool, costing £10,000 per patient).

They argue that this study adds to the case for starting HIV treatment early in patients who continue risk behaviour, both because it may cause illness and pass on drug resistance, and also because it may make people considerably more infectious.

Reference
T Doyle at al. High risk sexual behaviour and HIV-superinfection: An indication for early initiation of antiretroviral therapy? Fifteenth British HIV Association Conference, Liverpool, Poster presentation P150, 2009.

April 8, 2009