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

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:

• at no time was an Aids epidemic to be expected in Europe and the US
  
• the catastrophe prophesied by many Aids experts has not happened
  
• the forecasts in relation to this were based on false assumptions and unscientific conclusions
  
• in fact there have been relatively few cases of Aids
  
• the heterosexual population in particular is not affected by Aids
  
• an effect of "preventative" measures on these developments cannot be demonstrated
  
• the sexual behaviour of heterosexual Europeans, in particular of young people, has not demonstrably changed despite the years of fear-mongering media reports.

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.

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.

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?

• Any Western country would strictly forbid foreign intervention in the distribution of its budget. Consequently, lobbying for so-called preventative measures in other countries should also be stopped.
• In view of the shortage of resources, it is not medically comprehensible why such funds should be invested precisely in the documentation of HIV on the basis of unreliable tests, and of Aids on the basis of unsatisfactory definitions. Ultimately, these funds are then not available in other areas. These activities should thus be significantly reduced.
• It is sufficiently recognised that people's health is essentially dependent on their standard of living. Consequently, the available resources should be invested there, for example in clean drinking water and sewerage.
• In the health sector the focus should again be on prevention and using tried and tested treatment for well-known infectious diseases.
• Invasive treatment should be avoided if it cannot be carried out under strict hygienic conditions.
  

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

References:

1 Der Spiegel, Hamburg1994, no 32, page 148-50; also at http://www.uni-tuebingen.de/uni/tbi/kmw/t96pogf3.htm
2 Der Spiegel, Hamburg, 1985, no 39, page 85
3 Der Spiegel, Hamburg, 1990, no 26, page 193
4 Reason given by an Austrian Radio journalist for the cancellation of a planned interview with the author.
5 "Kumulative Verwirrung", Deutsches Ärzteblatt, 1989, 86, vol. 17, B 853/C 749
6 Krämer W., So lügt man mit Statistik, 1997, Frankfurt, Campus Verlag
7 European Centre for the epidemiological monitoring of Aids; HIV/AIDS Surveillance in Europe, 1998, Quarterly Report no 60, St. Maurice, France
8 "Todesursachen in Deutschland", Statistisches Bundesamt Wiesbaden, 1994
9 Centers for Disease Control (CDC), Update on acquired immune deficiency syndrome (Aids) - United States, MMWR, 1982, vol. 31, no 37; 507-14
10 CDC, "Revision of the case definition of Aids for national reporting - United States", MMWR, 1985, vol. 34; 373-5
11 CDC, "Revision of the CDC surveillance case definition for Aids", MMWR, 1987, vol. 36; 1-15 S
12 CDC, "1993 Revised classification system for HIV infection and expanded surveillance case definition for Aids among adolescents and adults", MMWR, 1992, December 18, vol. 41, no RR-17; 1-19
13 Steward; "Changing case-definition for AIDS", The Lancet, 1992, vol. 340, Dec 5; 1414
14 Ancelle-Park R et al.; "Impact of 1993 revision of adult/adolescent AIDS surveillance case definition for Europe", The Lancet, 1995; 345, 789-90
15 Selik-RM et al.; "Impact of the 1987 revision of the case definition of acquired immune deficiency syndrome in the United States", J-Acquir-Immune-Defic-Syndr, 1990; 3(1): 73-82
16 Vella-S et al.; "Differential survival of patients with AIDS according to the 1987 and 1993 CDC case definitions", JAMA, 1994; Apr 20; 271(15): 1197-9
17 Stehr-Green-JK et al.; "Potential effect of revising the CDC surveillance case definition for AIDS", The Lancet, 1988; Mar. 5; 1(8584): 520-1
18 Smith-E et al.; Isager-H, "Impact of the 1987 revised AIDS case definition in Denmark: a follow-up study 2 years after its adoption", Scand-J-Infect-Dis, 1992; 24(3): 293-9
19 Cayla Joan et al; L'impact de la nouvelle definition de Sida à Barcelone, V. Int Conf Aids Montreal, 1989; Abstract T.A.O. 3
20 Pezzotti P et al.; "The effect of the 1993 European revision of the Aids case definition in Italy: implications for modeling the HIV epidemic", AIDS, 1997; 11: 95-9
21 1.7 CDC; Update: "Impact of the expanded Aids surveillance case definition for adolescents and adults on case reporting - United States", MMWR, 1994, March 11, vol. 43 no 9; 160-70
22 Robert Koch Institut, AIDS/HIV 1997, Berlin, 1999
23 Downs A et al., "Reconstruction and prediction of the HIV/Aids epidemic among adults in the European Union and in the low prevalence countries of central and eastern Europe", Aids, 1997; 11: 649-62
24 WHO; Workshop on Aids in Central Africa, Bangui 22-25 October 1985, Dokument WHO/CDS/AIDS/85.1, Geneva, 1985
25 WHO, "Global programme on AIDS; Provisional WHO clinical case definition for AIDS", Wkly-Epidemiol-Rec, 1986; March 7; no 10: 72-3
26 Luc Montagnier; "Des Virus et des Hommes, 1994", Editions Odile Jacob, Paris (German translation: Von Viren und Menschen, Rowohlt, 1997)
27 Chin J; "Public health surveillance of Aids and HIV infections", Bulletin of the WHO, 1990; 68(5): 529-36
28 De Cock et al.; "Aids surveillance in Africa: a reappraisal of case definitions", BMJ, 1991; 303: 1185-8
29 Weniger et al.; "A simplified surveillance case definition of AIDS derived from empirical clinical data", Journal Of Acquired Immune Deficiency Syndromes , 1992; 5: 1212-23
30 Gilks; "What use is a clinical case definition for AIDS in Africa?", BMJ, 1991; 303: 1189-90
31 Strecker-W et al.; "Epidemiology and clinical manifestation of HIV infection in northern Zaire", Eur-J-Epidemiol, 1994; Feb; 10(1): 95-8
32 Irova; "Aids-resembling disease in a non-HIV-infected African born to an HIV-positive mother", Pediatric Hematology and Oncology, 1995; 12: 495-8
33 Turner V; Perth, www.virusmyth.com/aids/data/vtwbtests.htm
34 Zenger's, 1996, published in Continuum, vol. 4, No 3, page 5
35 Kashala O. et al; Infection with HIV-1 and HTLV among leprosy patients and contacts: Correlation between HIV-1 cross-ractivity and antibodies to lipoarabinomannan, J Infect Dis , 1994; 169: 296-304
36 UNAIDS, AIDS epidemic update: December 1999, Geneva www.unaids.org/
37 UNAIDS, HIV/AIDS in Africa - Socio-economic impact and response, Conference 6-8 May 1999, Addis Ababa, www.unaids.org/
38 Durex, Global Sex Survey, London, 1997, http://www.durex.com
39 Salehe O. et al.; The amount of HIV-infections caused by syringes and needles in Mbeya-region, Second National Seminar on Aids Research in Tanzania, Dar es Salaam 1994
40 Wyatt HV. et al., "Unnecessary injections and paralytic poliomyelitis in India", Transactions of the Royal Society of Tropical Medicine, 1992; 86: 546-9
41 Wyatt HV et al., "Unnecessary injections in developing countries: the risk and costs", International Journal of Risk & Safety in Medicine, 1993; 4: 167-76
42 WHO, GPV declares war on unsafe injections, Geneva, The newsletter of the Global Programme for Vaccines and Immunization, 5, 1997, GPV/VIN/97.03
43 WHO Water supply an sanitation sector monitoring report 1996, Geneva WHO/EOS/96.15
44 Deutsche Latex Forschung, Kondom-Absatz in Deutschland, Düsseldorf
45 Statistisches Jahrbuch 1996, Statistisches Bundesamt Wiesbaden