We have lived with HIV/Aids for 20 years
A call for an open discussion of contradictory facts

AIDS in Africa : the way forward
Christian Fiala. 6/7 May 2000

 

Retrospective from a European point of view

In Europe (and the US) in the late 80s and early 90s there was an unprecedented media campaign on HIV/Aids. On the basis of steeply rising statistics (1) Aids experts explained that the whole population was facing an Aids epidemic because the infection had broken out of the original high-risk groups ­ part of the male homosexual population and intravenous drug users. "In a few years Aids will be killing more people in the western industrialised countries than all other illnesses and infectious diseases put together." This was one of the many horror scenarios of the time. (2) And the American Aids specialist Robert Gallo was quoted as saying: "Aids could mean the end of humanity." (3)

The message was that basically there was no escape. Only a major change in the sexual behaviour of the heterosexual population could prevent the worst. Thus campaigns for greater faithfulness were launched, something the Catholic church has been doing for 2,000 years, and the use of condoms was promoted for young people in particular. The extent of the hysteria that prevailed at the time is hard to imagine in retrospect. Isolated voices arguing that the forecasts were based on false assumptions and unscientific conclusions were either suppressed "because they contradicted the consensus of the general population" (4) or they were accused of recklessly playing with innocent lives.

Most statisticians have added all Aids cases since the beginning of the 1980s together ­ that is, they have presented them cumulatively. This form of presentation is unusual in medicine as it produces useless results. The figures automatically rise, even if only a few new cases are still coming in each year. Thus the monthly publication of the German Medical Board (Deutsches Ärzteblatt) writes as early as 1989, under the headline "Cumulative Confusion": "Nobody thinks of adding up the case figures for mumps, tuberculosis or scarlet fever from the day the law on epidemics was passed" Consequently, the only sense in such a form of presentation is that "Large figures bring in large amounts of public money." (5) (Also to be found in the book So lügt man mit Statistik [How to lie with statistics] (6).) With rare openness this article puts its finger on the main issue in health politics: whoever shouts the loudest and whoever most convincingly sets the general public in a state of fear, gets the most support. In this regard the institutions engaged in the fight against Aids over the last 20 years have been extremely successful.

In the end the actual developments in Europe were less dramatic. (7) From 1993 to 1994 the number of new cases of Aids reached a highpoint at a low level compared to other illnesses. Thus Aids is responsible for less than 0.2 per cent of all deaths in Germany. (8) At the same time the number of Aids sufferers had risen partly because the definition of the Aids illness has repeatedly been changed. (9-20) This definition-conditioned increase in numbers even amounted to 100 per cent in the US in 1993. (21) (Apart from which, since 1993 the definition of Aids has differed between the US and Europe on one essential point. (10) (In the US, HIV-positive people with a particular laboratory count, <200 CD4-cells, are considered as having Aids even if they display no symptoms or complaints).

After 1993-94 the number of new cases of Aids fell significantly. This regression happened because there was no independent spread of Aids outside the original risk groups. In retrospect this is also confirmed by the Robert Koch Institute in Berlin, which is responsible for the evaluation of the German figures, (22) and the European Centre for the Epidemiological Monitoring of Aids in Paris. (23) In one study the average ten years' incubation time (between HIV infection and full-blown Aids) was subtracted from the reported Aids-cases. This showed that new HIV infections had reached a highpoint as early as 1984, long before the first "prevention" campaigns.

These, incidentally, have hardly raised condom use in Germany at all. The annual usage in 1980 was two condoms per inhabitant; in 1995 it was 2.3 (44, 45)

And in the evaluation of anonymous, unlinked testing of umbilical-cord blood since 1993 the Robert Koch institute in Berlin has come to the following conclusion: "The results ­ HIV prevalence significantly under one per thousand among women giving birth ­ confirm the assumption of a low distribution of HIV in the general heterosexual population so far." (23)

To sum up, it can be said that:

This means that the great financial and personnel investments in Aids prevention and the Aids institutions have had no demonstrable effect on the number of positive HIV tests and Aids sufferers. Europe has coped with this squandering of resources without obvious harm. Nevertheless the financial and human resources could have been more sensibly employed elsewhere.

What is the meaning of Aids in Africa?

The Aids diagnosis in Africa is essentially made on the basis of the Bangui definition published by the World Health Organisation. (24, 25) However, this has been individually adjusted by many countries. It was created by the WHO uniquely for developing countries and is fundamentally different from the definitions uses in Europe and the US.

Tab. 1: WHO Aids Definition (1986) for adults in developing countries: (24,25)

 Major signs:

- weight loss >10%
- chronic diarrhoea > 1 month
- fever > 1 month (intermittent or constant)

 Minor signs:

- cough for > 1 month
- generalised itching
- recurrent herpes zoster
- oro-pharyngeal candidiasis
- chronic progressive and disseminated herpes simplex infection
- generalised lymphadenopathy

 Exclusion criteria:

- cancer
- severe malnutrition
- other recognised causes

 Aids is defined by the existence of:

- at least 2 major signs
and
- at least 1 minor sign
and
- in absence of any exclusion criteria
or
- in a patient with generalised Kaposi's sarcoma
or
- in a patient with cryptococcal meningitis

Under this, someone is declared to be suffering from Aids if they have had, for example, diarrhoea for more than a month, pronounced weight loss and coughing or general itching and no other cause can be ascertained with available means. On this definition an HIV test is not necessary, and shortage of funds means that a test is still only carried out occasionally today. And on the Ugandan health ministry's registration form for people with Aids the possibility of an HIV test is not even mentioned. Even the exclusion criteria will hardly prevent someone from beeing misdiagnosed of having Aids, as this definition was intended for poor countries. If they do not even have the possibility to perform an HIV-test it is hard to imagine how they should do any other diagnostic examination. (Based on this way of registering Aids cases Uganda was long considered the epicentre of the Aids epidemic.)

This means that Aids, the illness that in the words of Professor Luc Montagnier, the man who discovered HIV, "has no typical symptoms", is being diagnosed in developing countries exclusively on the basis of unspecific symptoms. (26) The symptoms called for are not exactly rare in a continent where, because of the many infectious illnesses and poor hygienic conditions, the average life expectancy is around 50 years. If a doctor in Europe formed his or her Aids diagnosis on such a basis they would probably have to face legal action and presumably be struck off the register.

On this issue, Dr Chin, the former Chief of the Forecasting and Impact Assessment unit at the Global Programme on Aids at the WHO, was writing as long ago as 1990: "It should be emphasised that surveillance definitions for Aids were not intended to be reliable indicators for HIV infection. Thus, in areas where the prevalence of HIV infection is very low, the WHO clinical definition primarily identifies patients with tuberculosis, severe malnutrition or diarrhoea." (27)

And even the US American Centers for Disease Control and the Pan-American Health Organisation arrived independently of each other at the conclusion that the WHO definition "may not be adequate for clinical work" because of "the potential inapplicability of that definition". They therefore established two further definitions for the diagnosis of Aids in developing countries. (28, 29)

It follows that the diagnosis of Aids in Africa has little to do with what is understood by this in Europe or the US. Rather, people who are suffering from well-known infectious diseases are now officially described as suffering from Aids. (30,31) This was tragically confirmed in the case of an Aids-infected child from Africa who was treated and re-nourished in Belgium. As a result the child no longer fulfilled the criteria of the African definition of Aids. (32)

Who is HIV positive in Africa ?

Fundamentally, all HIV tests do not identify the virus but particular antibodies in the blood. As always the controversy is over which antibodies are supposed to be typical for HIV and what methods can be used to determine this.

Interestingly, different antibodies are regarded as being typical for HIV in different countries and institutions. (33) The reliability of the various tests is also to some extent differently evaluated. Thus, for example, in England the Western Blot is not accepted in HIV diagnosis.

Regardless of this, however, some antibodies are very similar, so there is occasionally confusion. This means an HIV test wrongly gives a positive result when antibodies against a completely different pathogen are present. (This is essentially true for all such tests.) At the moment more than 70 illnesses or situations are recognised in which such positive results can occur, among others malaria, following blood transfusions, and leprosy. (34)

One study of the reliability of tests thus recommended that "the usual HIV tests (Elisa or Western Blot) are possibly not sufficient to diagnose infection with HIV in Central Africa." (35)

The current WHO estimates however, in particular for Africa, are based precisely on the results of these HIV tests on a small group of people. The spread of HIV in the rest of the population is then estimated on the basis of this data. The funds that the African countries should provide for preventative measures ­ such as, for example, one billion US dollars as deemed necessary by UNAIDS­ are derived from just such an estimate of 23.3m people with HIV/Aids in Africa. (36, 37)

How are the figures interpreted?

All registered figures for Aids cases are collected at the WHO. These figures are added together even though they are based on totally different definitions. As the WHO writes in it's Bulletin: "Reports of AIDS cases from most of the industrialized countries of Europe, North America and Oceania are based primarily on the CDC/WHO definition; those from Africa are, in general, based on nationally adapted versions of the WHO clinical (Bangui) definition; and those from other countries involve a combination of these definitions." (27)

Finally, another figure is added on top of the registered cases in order to take account of the non-registered cases. Interestingly the number of registered cases in Africa has been relatively low in recent years. In contrast to this the estimate of non-registered cases has assumed unbelievable proportions. Thus the total number of Aids cases in Africa consists almost entirely not of registered cases but of cases estimated by he WHO.

Number of Aids-cases in Africa according to the WHO

Cases in Africa (cumulative since 1980) Reported
in millions
Estimated underreporting in millions Estimated total
in millions
Estimated cases in % of the total
WHO report July 1994 0.33   2.35  2.68  88%
WHO report January 1995  0.35  2.8  3.15  89%
WHO report July 1996  0.5  5.43  5.93  91,6%
WHO report November 1997  0.62  9.78  10.4  94%
Cases between July 96 and November 97  0.12  4.4  4.5  97,3%


Why should HIV be transmitted heterosexually in Africa?

As has already been mentioned, studies show that there is no independent spread of HIV/Aids in the heterosexual population in the US and Europe. The assumption that this should therefore happen in Africa and Thailand, for example, is not comprehensible. Further, it is without precedent in medicine that the transmission of a pathogen should be so different in different countries and continents.

The theory of the supposed heterosexual transmission of HIV in Africa and Thailand because of widespread promiscuity is based solely on the HIV tests described, which, as has been shown, often cannot be interpreted under tropical conditions. This belief among other things is contradicted by an international comparison of the number of sexual partners and sexual activity. Here the US leads, followed by France, Australia and Germany. In contrast, South Africa and Thailand are below the world average. (38)

It is logical to suppose that the widespread explanation has been so readily accepted because it fits in with the deep-rooted prejudices of the Christian countries concerning the sexuality of Africans (and Thailanders).

And if one reads the latest UNAIDS report the impression arises that HIV/Aids is being used as an apparently scientific proof of an enduring prejudice:

"Indeed, since not every encounter between an HIV-positive and an HIV-negative partner will result in a new infection, a sustain heterosexual epidemic suggests that a substantial proportion of the population, both male and female, have a number of sex partners over their lifetimes." (36)

This fixation on heterosexual transmission shows the extent to which the public discussion is shaped by Western convictions. In contrast, the dissemination of Western medicine as a possible cause for the spread of infectious diseases is played down. Yet it is generally well known that the extent of invasive techniques with injections, blood transfusions and operations, which characterises this form of medicine, can very quickly become dangerous if standards of hygiene are not observed. (39-41) And even the WHO confirms that "at minimum 12 billion injections are performed every year throughout the world", and "at least one third are not being carried out in a safe manner and may be spreading disease". The situation is particularly dramatic in Africa, where more than 80 per cent of disposable single-use syringes are used more than once." (42)

In contrast, traditional medicine is less successful, but also less dangerous when applied under poor hygiene conditions.

In view of the poverty in most African countries ­ more than half of the population has no access to clean drinking water (43) ­ the European fixation with a supposedly heterosexually transmitted Aids epidemic in Africa due to a promiscuous lifestyle can only be regarded as cynical.

What should be done?

Where is the information coming from?

This consideration is essential for an understanding of developments over the last 20 years, even if strictly speaking it does not have a medical aspect.

Most scientific information on HIV/Aids and advice on what to do about it comes from the US and to some extent from Europe or from organisations which operate from there. Developing countries are thereby particularly dependent on the industrialised countries when it comes to issues in their own country. Or, looked at from the other side, through the Aids discussion the industrialised countries have ensured themselves of a right to a say in the internal affairs of the developing countries, such as budget distribution and assessment of health priorities.

The international protest at the President of South Africa's initiative to raise critical questions has impressively demonstrated that developing countries are accorded no right to change this concept or to introduce their own considerations.

This monopolisation of information and control of the media facilitates manipulations that recall memories of colonial times.

People in Africa need our help and support. It is neither helpful nor effective if wrong data and absurd definitions are employed to mislead us and to divert attention from a country's real problems.

And most often these lie in well-known and treatable infectious diseases and are essentially caused by low standards of living.

Christian Fiala MD
Mollardg. 12a
1060 Vienna
Austria
e-mail: christian.fiala@aon.at
Fax +43-1-597 31 92

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