HIV and Hepatitis C status - life expectancy prognosis
96 Various reports were provided in relation to the HIV status of the defendant, and to the complicating circumstance that he also has Hepatitis C. They show that he was first diagnosed as HIV positive in January 1998, and as Hepatitis C positive on 16 April 1997.
97 Dr Michelmore of the Albion Street Centre provided a report noting that recent blood tests "reveal some modest, but significant deterioration during the year 2002, both in regard to HIV infection and to the Hepatitis C infection". The HIV viral load was said to have stabilised at about 10,000 copies/Ml. That was described as a "low viral load". The CD4 count, however, was reported as having fallen from 868 on 9 November 2001, to 380 on 23 September 2002, indicating a significant deterioration. The ALT liver enzyme test was noted "to be mildly elevated", a finding which was said to be "significant".
98 With that background in mind, he expressed an opinion in regard to the defendant's life expectancy prognosis, with the caveat that an accurate prognosis was not possible, and with the advice that the Hepatitis C infection should be treated before he began HIV treatment.
99 He said that if the defendant elected to receive HIV treatment, his "long term prognosis should be excellent. With such a low viral load, the HIV would be easily controlled by antiretroviral drugs, and he should remain well indefinitely, perhaps even unaffected by HIV in the long term." He added that the management of this condition might also "ensure long term non-progression of hepatitis C".
100 He gave a caution that long term antiretroviral toxicities are a potential problem, and that the successful treatment of a patient does "very largely depend upon the patient's ability to take the treatment successfully". Missing doses, he explained "promotes the replication of virus in the presence of inadequate drug levels, and this eventually leads to viral mutation and drug resistance." He did not consider that the defendant required treatment at this time, but thought it likely that he would eventually require it, "perhaps as early as 2003".
101 If he elected not to receive treatment, then Dr Michelmore said, the long-term prognosis was "even more difficult to predict". His rough guess was that, in such circumstance, he would live for another 8 to 10 years approximately.
102 This report was supplemented by a report from Dr White of the Taylor Square Private Clinic, which was based solely upon a review of various documents provide to him, including the defendant's medical files, the pathology reports, and Dr Michelmore's report. Dr Taylor is a Sexual Health Physician in private practice at Taylor Square Private Clinic, and is also a staff specialist in sexual health medicine at Royal North Shore Hospital. He noted the reduction in the CD4 count, and stated that this brought the defendant into "the moderate class of immunodeficiency", the stage at which most HIV infected individuals will begin to notice symptoms. He also explained that people who delay their HIV specific therapy until their CD4 count is below 200, fare less well than those who commence above this level.
103 He said that the defendant's "exact risk of developing AIDS in the near future is difficult to quantitate, as it is dependant on many variables." By reference to the Mellors chart, which is used to calculate a percentage risk of the onset of AIDS, by reference to the patient's current CD4 and HIV viral load status, he said that, in the absence of HIV-specific therapy, the defendant had a 6.8%, 30.1 % and 53.5% risk of developing AIDS, in the next 3,6, and 9 years respectively.
104 If his CD4 count continued to decline, and his HIV viral load continued to rise, at the same rates as seen over the last 6 months, then, he said, the percentage risks mentioned would increase to 36.4%, 72.2% and 84.5% respectively.
105 If the results improved and returned to previous levels, then the risks would decrease significantly. He expected, however, that the defendant was more likely to progress than to remit, especially in view of the Hepatitis C co-infection.
106 Hepatitis C, he explained, was a condition commonly found in injecting drug users. Around 25 to 30% of those infected are at risk of chronic hepatitis, cirrhosis of the liver, and liver cancer. These adverse outcomes usually take between 15 to 40 years to develop, although HIV infected individuals have a more rapid progression, with higher rates of chronic liver disease. He thought it likely, from the history of the defendant's drug use, that he had been infected for at least 10 years. His recent rise in ALT levels suggested that his Hepatitis C was progressing, and in need of further assessment. The test for damage to the liver, he explained, was a liver biopsy, which is an uncomfortable and potentially dangerous procedure. Another option available is a genotype test which would be relevant for the likely response to treatment.
107 The mainstay treatment for Hepatitis C, in patients with a chronic condition and abnormal liver function tests, he said, was a combination of Interferon injections with Ribavirin tablets for at least 24 weeks. The treatment can be difficult to tolerate, and its success rate depends on the type of Hepatitis C present. Those patients infected with both HIV and Hepatitis C, he said, need preferably to be treated with the new Pergylated interferon and oral Ribavirin, for at least 6, and preferably 12, months. Pergylated Interferon, he said, is difficult to access at present, and it is likely that those needing it would have to enter a clinical trial.
108 One of the most common and significant effects of interferon, he explained, was major depression, which can be so severe as to require cessation of treatment. This he saw to be a potential problem in the case of the defendant, although without treatment his condition may progress to the point of irreversible liver damage. If that ensues, then the complications of HIV therapy would be amplified, since many of the drugs used in its treatment are metabolised in the liver and can cause "severe and potentially life-threatening liver toxicities." He said that, in the defendant's case, the cure rate may be less than 20% given his HIV status and the possibility of a less than favourable genotype result.
109 The HIV treatment, he explained, involved three main classes of drugs, each of which acts in a different way, to interfere with the life cycle of the virus. Most involve oral tablets that need to be taken once, twice, or three times daily. Therapeutic monitoring, he said, was necessary, in view of the variation between individuals in their ability to metabolise drugs, and the fact that the more drugs used, the greater is the risk of side effects and toxicity occurring.
110 All HIV drugs have side effects, he explained, sometimes involving fatal toxicity, and otherwise being of a nuisance value. Additionally, there is the problem of adhering to a sometimes complicated regime of taking up to 30 pills per day. "Pill fatigue" he said, is a common phenomenon, which can lead to suboptimal viral control and drug resistance, as well as enormous psychosocial impacts.
111 Treatment of the defendant's HIV, Dr White said, would be indicated, if significant HIV symptoms developed, or if his CD4 count dropped below 200. This could occur as soon as 6 to 12 months, or it may not appear for 5 to 10 years.
112 Such treatment, he agreed should follow treatment, and successful clearing, of his Hepatitis C condition. An initial regime of 2 NRTI drugs and 1 IV NRTI drug, he said, could be expected to have an 80-90% success rate of controlling the disease. Benefits of the treatment, however, he said were only likely if the defendant was able to adhere to his treatment regimen, to tolerate any side effects, and to avoid long-term toxicities. In that event his life expectancy could be 15 to 20 years given the currently available therapies. New and improving therapies might lead to an improved outcome.
113 Dr White said that if the defendant was unable to clear his Hepatitis C, or if he elected not to have it treated, then there was still "a good chance" that the progression of his HIV disease could be halted with the HIV treatment, that is, subject to the emergence of toxicities.
114 As Dr White noted, the impact of incarceration may be significant, in that it has the potential for preventing or interrupting a continuous supply of anti HIV medications. That arises from the circumstance previously noted, that any interruption in the daily dosing schedule may result in a rebound of viral load levels, and the development of resistant HIV strains, which then may not be easy to treat. Obstacles which, he suggested, had been experienced by other HIV positive patients while in prison, including those associated with dosing being restricted to one or two times daily, problems with access to and storage of medication, theft of drugs, the need for meal times and food types to coincide with the treatment regime, difficulties in providing medication and in passing on medical records when prisoners are transferred to a new facility, the need for access to specialist medical care, and the need for the maintenance of good general health which is itself associated with an adequate diet, rest and avoidance or minimisation of stress.
115 These circumstances have obvious relevance in relation to the sentences to be imposed, so far as they may impact upon the defendant in a way that is likely to make his imprisonment more arduous than that of other prisoners, and may also adversely impact upon the successful medical treatment of his life threatening illnesses, the symptoms of which can be significantly debilitating. In that event they may properly be taken into account in mitigation of sentence, and as a special circumstance: R v Burrell [2000] NSWCCA 262, and R v L NSWCCA 17 June 1996; see also R v Smith (1987) 44 SASR 587 at 589, and Bailey v DPP (1988) 62 ALJR 319. Otherwise ill health cannot be allowed to become a licence to commit crime or to be a basis for escaping punishment.
116 While the plea of guilty came relatively late, the matter having been committed for trial on 18 March 2002, and the defendant having been arraigned on 3 May 2002, it had always been the case that he had been prepared to enter a plea of guilty to manslaughter. The delay in the plea arose from the need for psychiatric assessment, which led to the adjournment of the trial which had been fixed for 22 July 2002. In those circumstances, in accordance with s 22 of the Crimes (Sentencing Procedure) Act, and the principles expressed in R v Thomson and Houlton (2000) 49 NSWLR 338 and R v Sharma [2002] NSWCCA 142, I propose to allow a discount in the order of 15% for the plea.
117 The criminality of the defendant involved needs to be addressed in two respects. First, in sentencing the defendant in relation to the murder of Akai, it is necessary to increase the sentence for that offence to some extent because of the Form 1 offences, in accordance with the reasoning noted in decisions such as R v Bavadra (2000) 115 A Crim R 152 and R v Barton (2001) 121 A Crim R 185.
118 Secondly, by reason of the fact that the defendant has committed two entirely separate murders, it is necessary to reflect the total criminality involved in that circumstance, and in accordance with the principles discussed in Pearce v The Queen (1998) 194 CLR 610, that there be an accumulation of sentence.
119 Had the case not shown the exceptional circumstances previously mentioned, the combination of two killings occurring within the space of one year, and the very great callousness displayed in the dismemberment of the bodies, would have left the defendant in the position where life sentences were a real possibility.
120 However, as I have noted, there were exceptional circumstances which reduced his objective criminality, to the point where determinant sentences should properly be imposed.
121 Nevertheless, the elements of personal deterrence and retribution continue to have considerable relevance for the present case, in view of the very serious criminality involved. While general deterrence is also important, for the reasons explained in R v Alexander (1995) 78 A Crim R 141, and R v Camilleri NSWCCA 8 February 1990, its relevance is, to a degree, muted by the somewhat exceptional circumstances which accompanied each killing, and by the mental state of the defendant, which together reduce its significance as a warning to others of the consequences of similarly offending: R v Scognamiglio (1991) 56 A Crim R 81.
122 The case is one where I am satisfied, in accordance with the principles outlined in R v Simpson [2001] NSWCCA 534, that special circumstances exist.
123 That follows particularly from the unusual hardship relating to the defendant's health, and to the fact that imprisonment is not conducive to the effective treatment of his medical conditions. It also relates to the need for an extended period of supervision on parole, if the defendant survives the non parole period, and to the fact that there will need to be a partial accumulation of sentence.
124 As I understand the evidence concerning the defendant's current HIV and Hepatitis C status, his prognosis for survival varies between 8 years and 20 years, depending upon whether he has antiretroviral treatment or not, and also depending upon how well he responds to it. The certainty of response is itself questionable, in view of his history of depression, his history of significant drug abuse, his concurrent Hepatitis C status, and the unpredictability of his tolerance for, or reaction to, the more potent antiretroviral drugs currently available.
125 In prison, for the reasons mentioned by Dr Michelmore, optimal HIV care may not be possible, so that any sentence imposed may in fact shorten his life span. Moreover, if he develops serious symptoms of the illness, they may not be treated as successfully within the prison medical system, as elsewhere.
126 The relevance of HIV/AIDS in sentencing has been considered by the Court of Criminal Appeal in a number of cases including R v Whittaker NSWCCA 15 July 1994, R v Doyle NSWCCA 25 March 1992, R v Niketic [2002] NSWCCA 425 and R v Giardini NSWCCA 25 February 1993.
127 What is known in the present case is that the defendant's HIV and Hepatitis C conditions have each progressed, in the way which was considered relevant in R v Doyle, and which permits R v Niketic to be distinguished.
128 Also of relevance is the remorse which the defendant has exhibited, and the significant progress which he has made towards rehabilitation since being taken into custody. The fact of reconciliation with his family and his desire to be free of illicit drugs into the future, do require encouragement through long-term supervision on parole.
129 These special circumstances, in my view, require a substantial reduction of the statutory ratio between the non parole periods and the head sentences. In coming to this conclusion I have not overlooked the circumstance that Executive Release, through the Royal prerogative of mercy or through exercise by the Parole Board of its powers under s 160(1) of the Crimes (Administration of Sentences) Act 1999, also remain a possibility, in the case of an offender facing a terminal illness, or an unexpected deterioration in his physical condition. The relevance of these factors in a case where the offender's life expectancy has been reduced by illness, itself a proper matter for consideration in the sentencing process, was noted in R v Jones (1993) 70 A Crim R 449. Notwithstanding that circumstance, the case remains an exceptional one, in which a significant departure in the statutory ratio is justified.
130 Damien Anthony Peters, I sentence you in relation the murder of Tereupii Akai, taking in account the matters on the Form 1, to imprisonment for 17 years to commence from 11 September 2001 and to expire on 10 September 2018. I fix a non-parole period in respect of that offence of 9 years, to date from 11 September 2001 and to expire on 10 September 2010.
131 In relation to the murder of Bevan James Frost, I sentence you to imprisonment for 17 years, to commence from 11 September 2005, and to expire on 10 September 2022. I fix a non-parole period of 9 years to date from 11 September 2005 and to expire on 10 September 2014. That will be the earliest date on which you will be eligible for release on parole. The overall head sentence is accordingly one of 21 years, with an effective non-parole period of 13 years.
132 The sentence for the second offence is to be partially concurrent with, and partially accumulative upon, that for the first offence. I have imposed equivalent head sentences for each offence, notwithstanding the fact that Form 1 offences have been taken into account in relation to the murder of Akai, as I consider the objective severity of the later offence to have been considerably greater. That follows from the short term nature of the relationship into which the defendant entered with the victim, being one into which he voluntarily entered, for his own purposes, and from the lesser degree of provocation offered by Frost, who unlike Akai, had not been responsible for the defendant's HIV status.
133 Finally, I add that I have received and considered, in accordance with the principles expressed in R v Mansour [1999] NSWCCA 180, and R v Bollen (1998) 99 A Crim R 510, a victim impact statement from the sister of Mr Akai, which clearly depicts the loss suffered by her, arising out of his death.