AIDS in Africa: sense at last

It is not often that a research report packs the kind of punch recently provided by independent consultant David Gisselquist and his colleagues (1). Gisselquist’s devastatingly simple investigation associates the bulk of HIV prevalence in Africa with healthcare exposure – dirty needles used within clinics and hospitals – rather than with heterosexual activity.

Gisselquist and his colleagues did not even have to do any primary research to reach this conclusion – they simply used the research reports available through to 1988 that reported risk-factors associated with HIV infection, including sexual behaviour, socioeconomic variables, prostitution, presence of other sexually transmitted diseases (STDs) and healthcare utilisation.

The team identified over 40 studies published between 1984 and 1988 that included the necessary data. The largest association with HIV infection was found to be the number of medical injections, far higher than the risk associated with blood transfusion or the number of sexual partners. In total, medical injections appear to account for about half the prevalence of HIV in Africa up until1988.

Contrast this with the consensus view back in 1988 of what was causing the spread of HIV. At that time, the World Health Organisation (WHO)’s Global Programme on AIDS circulated estimates that 80 percent of HIV infections in Africa were due to heterosexual transmission. Gisselquist’s research suggests that this consensus was reached despite glaringly obvious evidence to the contrary.

Between 1984 and 1988, individuals with STDs but without a history of medical injection, for example, were experiencing lower rates of HIV infection than individuals with STDs receiving injections. While such association does not prove causation, it is certainly cause for concern. More startling, however, is that children whose mothers were HIV negative were reported turning up HIV positive in surprisingly high numbers. In one study, 39 percent of children aged between one and 24 months were found to be HIV positive, despite having an HIV negative mother; and another study found 24 percent of children aged between one and 48 months were HIV positive, with HIV negative mothers.

In both studies the HIV positive children had a higher frequency of injections than HIV negative children born around the same time. The obvious conclusion that injection was the source of infection was avoided by suggesting that the mothers were incorrectly diagnosed and/or that the children were victims of sexual abuse. It is surprising that scientists with even a modicum of training would rule out the likely in favour of reaching for the improbable. But then perhaps the scientists involved thought it was more likely Africans were having sex with their own children than getting infected from another source.

Consideration of the much more reasonable possibility that injection was the source of infection could have led to a focus on dirty needles, unsanitary conditions, and other problems associated with healthcare in third world countries – and an attempt to bring about the wholesale improvement of African healthcare. Yet instead, the assumption that heterosexual transmission was to blame for the rise of AIDS has resulted in patronising, intrusive Western-led campaigns to change individual sexual behaviour.

Gisselquist and his colleagues barely contain their frustration. Their report is unusually barbed, and contains the following flourish to explain the tunnel vision of AIDS research:

‘First, it was in the interests of AIDS researchers in developed countries – where HIV seemed stubbornly confined to [homosexual males], [intravenous drug users], and their partners – to present AIDS in Africa as a heterosexual epidemic…. Second, there may have been an inclination to emphasise sexual transmission as an argument for condom promotion, coinciding with pre-existing programmes and efforts to curb Africa’s rapid population growth.

‘Third, “the role of sexual promiscuity in the spread of AIDS in Africa appears to have evolved in part out of prior assumptions about the sexuality of Africans”.… Fourth, health professionals in WHO and elsewhere worried that public discussion of HIV risks during healthcare might lead people to avoid immunisations. In short, tangential, opportunistic, and irrational considerations may have contributed to ignoring and misinterpreting epidemiologic evidence.’ (2)

In my view, the authors are correct in their interpretation and are right to be angry. The history of AIDS commentary and research is one of misinformation, hyperbole and plain lies (3). It should be no surprise that elementary facts about the disease were overlooked in the rush to declare AIDS an international heterosexual calamity. This view was always informed more by political correctness in the West, and by a prurient observation of immoral fecklessness on the part of Africa, than by any rational assessment of empirical data (4).

I fully expect that the inevitable flaws of Gisselquist’s report will be blown up and exploited. There are always limitations to a paper that draws associations from past data. It would certainly be desirable to have up-to-date evidence of HIV transmission via medical injection – and even better would be some form of controlled field experiment to demonstrate the association in action. But these criticisms are nitpicking. All of us who have written about AIDS should be grateful for now having such a simple explanation for the radically different progression of HIV in Africa.

AIDS in Africa no longer need be seen as an aberration, or as a view of our desolate future, but can now be properly understood as being a variation on a known theme long established and reluctantly accepted in the West. HIV is difficult to catch outside of the high-risk groups – and those directly injected with the virus have always been included as high risk (5).

All those tortured suggestions of Africans having sex with monkeys, children or dozens of prostitutes, of having too much anal sex or injecting vast amounts of drugs, can now finally be put aside as the embarrassing lunacy that they surely were.

Stuart Derbyshire is an assistant professor in the University of Pittsburgh Department of Anaethesiology. He is a contributor to Animal Experimentation: Good or Bad?, Hodder Murray, 2002 (buy this book from Amazon (UK) or Amazon (USA)).

Read on:

AIDS in Africa: why the West is interested, by Stuart Derbyshire

AIDS in Britain: why complacency is justified

(1) David Gisselquist, John J Potterat, StuartBrody, Francois Vachon, ‘Let it be sexual: how health care transmission of AIDS in Africa was ignored’, International Journal of STD & AIDS 2003, 14, p148 -161

(2) David Gisselquist, John J Potterat, StuartBrody, Francois Vachon, ‘Let it be sexual: how health care transmission of AIDS in Africa was ignored’, International Journal of STD & AIDS 2003, 14, p11

(3) AIDS in Africa: why the West is interested, by Stuart Derbyshire

(4) WHO criticized for ‘inflating’ AIDS figures, AIDS Analysis Africa, December 1995, p4-5

(5) Fitzpatrick M, Milligan D, The Truth About the AIDS Panic, 1987