AIDS in Africa: A Call For Sense Not Hysteria

by Dr Christian Fiala

Rapid response in BMJ 19 August 2003
Sir,
Pat Sidley makes dire predictions indeed. However, the claim of saving
such a high number of lives is based on estimates and certain assumptions.
It seems essential to substantiate these claims before asking for wide
ranging interventions. The case of Uganda provides an important lesson in
this respect. A detailed analysis seems mandatory before engaging in
costly and potentially dangerous interventions in South Africa.
The absence of the predicted Aids catastrophe in Uganda calls the basic
assumptions about the epidemic into question. It is high time to
reconsider the priorities of health policy.
“Can Africa be saved?” asked Newsweek on it’s front page as far back as
1984, reflecting the old Western belief that Africa is doomed to
starvation, terror, disaster and death. (1) This was repeated two years
later in an article in the same journal in a story about Aids in Africa.
The title set the scene: “Africa in the Plague Years”. (2) It continued:
“Nowhere is the disease more rampant than in the Rakai region of
south-west Uganda, where 30 percent of the people are estimated to be
seropositive.” The World Health Organisation (WHO) confirmed “by mid-1991
an estimated 1,5 million Ugandans, or about 9% of the general population
and 20% of the sexually active population, had HIV infection”. (3) Similar
reports were repeatedly published during the last 15 years, declaring as
much as 30% of the population doomed to premature death, with all the
consequences on the families and the society as a whole. The predictions
announced the practically inevitable collapse of the country in which the
worldwide epidemic supposedly originated.
Today, however, one reads little about Aids in Uganda. Because all
prophesies have proved false, as the results of the (ten-year) census in
September 2002 show. (4) Summing up, the Uganda Bureau of Statistics says,
“Uganda’s population grew at an average annual rate of 3.4% between 1991
and 2002. The high rate of population growth is mainly due to the
persistently high fertility levels (about seven children per woman) that
have been observed for the past four decades. The decline in mortality
reflected by a decline in Infant and Childhood Mortality Rates as revealed
by the Uganda Demographic and Health Surveys (UDHS) of 1995 and 2000-2001,
have also contributed to the high population growth rate.” In other words,
the already high population growth in Uganda has further increased over
the past 10 years and is now among the highest in the world. (5) Similarly
economic development has shown a constant growth over the same period
reflecting the energy and determination of Ugandans to improve their
living conditions. (6)
How can this contradiction be explained, that a land condemned to death
has not only avoided the predicted catastrophe but that population growth
has even dramatically accelerated in this period and economic development
has been positive? And more specifically, how has it been possible to
reduce HIV-prevalence without antiretroviral therapy, the so-called
Aids-drugs.
It is often mentioned that the energetic action of the government and the
aid organisations as well as the numerous campaigns against Aids could
have led to a change in sexual behaviour and thus to a fall in HIV
infections. This belief, however, cannot be sustained on the basis of the
indicators of sexual behaviour in Uganda, as the latest household survey
in 2001 shows. (7) The following indicators have been stable, some for 30
years: fertility (seven children per woman), the average age of women at
the time of first sexual intercourse (16.7 years), the time of marriage
(18 years) and first childbirth (18.5 years). The only indicator that has
slightly changed is the proportion of married women using contraception.
This has risen over the last five years from 15 to 23 percent – still very
low by international comparison. (8) And only 2 percent regularly use a
condom. (But 35% have unmet needs for Family Planning!) There is thus no
reliable evidence showing a change in sexual behaviour of people in
Uganda.
Actually the explanation is to be sought elsewhere. The horror scenarios
were based on the large number of people testing HIV positive in Uganda in
antenatal surveys and numerous other studies. (9) Most of these HIV
positives, according to the underlying assumption, would contract Aids in
eight to ten years and consequently die relatively fast. Surprisingly
however, mortality did not increase over the last decade – obviously
therefore this assumption has been wrong. The reason is suggested by a
1994 survey of reliability of HIV tests: “ELISA and Western Blot [the most
frequently used tests] are possibly not sufficient for the diagnosis of
HIV infection in central Africa.” (10) Numerous other studies since then
have confirmed this statement and the unreliability of HIV tests. In
Africa in particular, people have a high number of antibodies against
infectious diseases or against foreign proteins after receiving blood or
dirty injections. Some of these antibodies may lead to a false positive
HIV test. As these people do indeed have a positive HIV test but are not
infected with HIV, they also do not die after the allotted time.
Not only are the figures on HIV infections unreliable and misleading, but
so are the official Aids statistics. The diagnosis of Aids in Africa is
based on a special definition for developing countries (the so called
“Bangui definition”), which WHO decided in 1985. (11, 12) According to
this definition, Aids is diagnosed on the basis of non-specific clinical
symptoms and without an HIV test. Even today in Uganda and other African
countries, people with for example continuous diarrhoea, weight loss and
itching are declared to be suffering from Aids. But also the typical
symptoms for tuberculosis – fever, weight loss and coughing – are
officially considered to be Aids, even without an HIV test. (13)
In order to get a total estimate of Aids cases, WHO at it’s headquarters
in Geneva adds the registered Aids sufferers to a high number of
unreported cases, which WHO presumes to have occurred. Thus in November
1997, the WHO announced that since its previous report in July 1996, there
had been a further 4.5 million Aids cases in Africa. In this period,
however, only 120,000 Aids sufferers were actually registered. In other
words, 97 percent of the supposed new Aids cases during this period
occurred only at the WHO headquarters in Geneva. The WHO has since been
avoiding this absurdity by preparing the statistics differently. Now,
healthy people with a positive HIV test are included in the WHO statistics
together with those suffering from Aids. Again this procedure is highly
unusual in medicine. As for example in tuberculosis no one has suggested
putting together sick people actually suffering from tuberculosis and
those that are healthy but having antibodies against the bacteria.
The fight against Aids conducted on this misleading basis has fatal
consequences however. Thus for example, UNAIDS 1999 recommended finance
ministers in the African countries cut their budgets for social security,
education, health, infrastructure and rural development in order to have
more funds available for the fight against Aids. (14) And if, just in
Uganda, 4,000 aid organisations are active in the struggle against Aids
(as of 1994), the priorities of the health system are clear. Powerlessly,
Uganda authors remark: “Because local decision-makers are so dependent on
donations, they tend to accept aid projects indiscriminately.” (15)
Other problems are widely neglected in the fight against Aids. Thus a
large part of Uganda’s population has no access to clean drinking water.
In 1990 the figure was 56 percent. Ten years and millions of dollars of
donations later it was 50 percent. (16) The situation in Kyotera, a town
in the Rakai district, is particularly cynical for example. In this
district a particularly large amount of money has been spent on the fight
against Aids, because it is supposed to be most heavily affected by the
epidemic. Despite millions of aid funds, campaigns for abstinence and the
distribution of condoms, the people of Kyotera still have to get their
water during most time of the year from an unprotected water hole, which
they share with cattle.
Maternal mortality in Uganda is also one of the highest in the world and
has not fallen over recent decades. As before, one in 16 women die during
their years of fertility. (17) One major reason for this is the
consequences of unsafe abortions. (Abortions are illegal in most parts of
Africa based on the medieval laws of the former colonialist countries.) A
second reason is the lack of the most important medicament in obstetrics:
prostaglandins are used world-wide and there is also a very good and
inexpensive preparation. But even WHO does not include a single
prostaglandin in their list of essential drugs and in Africa this life-
saving medication is only approved in three countries. (18) Uganda has
only been among them since last autumn.
In the meantime, Aids experts drive around the country in four-
wheel-drive air-conditioned vehicles, if they are not saving the world
from Aids in their comfortable offices or presenting their latest medical
experiments on Africans at an overseas conference. The government has not
only bought condoms for millions of dollars on credit, but borrows even
more money from the industrialised countries in order to buy imprecise HIV
tests and toxic Aids medications. Previously there were only isolated
voices against this sometimes cynically understood imbalance. Thus a
reader of the daily New Vision in Kampala wrote recently: “Most people die
from malaria. So give us free mosquito nets instead of condoms and Aids
medicaments.”
To draw a balance: the Aids hysteria of the last 20 years was indeed
politically correct, but led to a neglect of other far more important
aspects in health care. Unfortunately, not only did the commitment to
fight Aids cost a lot of money, but it was also to the disadvantage of
people in Africa. Innumerable western companies, NGOs, international
organisations and Aids experts profited from it. HIV/Aids is indeed a new
disease in this world of virtual reality and Infotainment: The celebrated
discoverer of HIV later admits that he could in fact never purify the
virus and the supposedly deadly disease leads to a real explosion in
population growth in the so-called “epicentre”, the country most heavily
affected. (19) Now, to err is human, however, a policy that is obviously
based on false assumptions and has predominantly negative effects for
those concerned has to be discarded or adapted. Adhering to it leads to
questions regarding the responsibility of the decision makers. The ever
more urgent question thus arises of when the current policy will be
rethought and adapted to the priorities of the population. People in
Africa need help and support. But it is neither helpful nor effective if
wrong data and absurd definitions are employed to mislead and divert
attention from the real problems.
Literature:
1. Newsweek 1984, November 19
2. Newsweek 1986, December 1
3. Taso Uganda – The inside story, Taso - WHO, 1995; WHO/GPA/ TCO/HCS/95.1

4. Results from the Population Census from September 2002, Uganda Bureau
of Statistics, Entebbe, Uganda, www.ubos.org 
5. The State of World Population 2001, Demographic, Social and Economic
Indicators, http://www.unfpa.org/swp/2001/english/
indicators/indicators2.html
6. Gross domestic product (GDP) 1991 to 2000 according to Uganda Bureau of
Statistics
7. Demographic and Health Survey 2000-2001. Uganda Bureau of Statistics,
Entebbe, Uganda
8. Contraceptive use 2001, Population Division of the Department of
Economic and Social Affairs of the United Nations, New York
9. HIV/Aids Surveillance Report, STD/Aids Control Programme, Ministry of
Health, Kampala, Uganda, June 2001
10. Infection with HIV Type 1 and Human T Cell Lymphotropic Viruses among
Leprosy Patients and Contacts: Correlation between HIV-1 cross-reactivity
and antibodies to Lipoarabinomannan, The Journal of Infectious Diseases,
1994;169:296-304
11. WHO; Workshop on Aids in Central Africa, Bangui22.-25. October 1985,
Dokument WHO/CDS/AIDS/85.1, Genf, 1985
12. WHO, Global programme on AIDS; Provisional WHO clinical case
definition for AIDS, Wkly-Epidemiol-Rec, 1986; March 7; no 10: 72-3
13. Reporting form for Aids; Ministry of Health, Kampala, Uganda: online
at: http://aids-kritik.de/aids/SA/meldeformulare.htm 
14. Joint Conference of African Ministers of Finance & Ministers of
Economic Development and Planning, 1999 – Addis Ababa, Ethiopia, UNAIDS,
http://www.unaids.org/publications/graphics/ addis/sld025.htm
15. Reproductive Health in Policy and Practice Uganda, Florence Mirembe,
Freddie Ssengooba, Rosalind Lubanga, September 1998, Population Reference
Bureau, USA
16. WHO, Global Water Supply and Sanitation Assessment 2000 Report,
http://www.who.int/docstore/water_sanitation_health/
Globassessment/Global6-2.htm
17. Maternal mortality in 1995. Estimates developed by WHO, UNICEF and
UNFPWHO/RHR/01.9, http://www.who.int/ reproductive-health/publications/
RHR_01_9_maternal_mortality_estimates/index.en.html
18. WHO Model List of Essential Medicines, http://mednet3.who.int/
mf/userscripts/p_eml_qrymenu.asp
19. Luc Montagnier in an interview with Djamel Tahi, Continuum 1997, vol
5, no 2, 30-4, available on the net at: http://
www.virusmyth.net/aids/data/dtinterviewlm.htm
Dire predictions about the imminent deaths of thousands and even millions
of innocent people seem to be part of the HIV/Aids era. Numerous
predictions of this kind have been published since the first days of the
media coverage of HIV, first for the US, then for Europe, Uganda and
Thailand. All those predictions had one thing in common: they were
completely wrong. But usually it took several years before reliable data
could be produced to prove them wrong. By that time, the media attention
had already turned to more „sexy„ subjects and coverage of the correction
has usually been minor.
South Africa may be in the comfortable situation to learn from past
experience. The recent article by Pat Sidley (BMJ 26 July 2003) predicted
the imminent deaths of 1,7 million people due to HIV/ Aids in case
so-called HIV drugs would not be made available. (1) However, earlier this
year Statistics South Africa announced the results of the latest
population census in 2001: the total population was found to be at 44,8
million, an increase of 4,3 million during the 5 years since the census in
1996. (2) This is equivalent to an annually population growth rate of
about 2%.
We are used to learning new things in medicine. Nevertheless, there seems
to be a contradiction between the dire predictions of more than a million
deaths due to a deadly epidemic said to have been ravaging South Africa
for more than 10 years and the finding of a growing population. At least
there is no historical precedent where a deadly epidemic had a similar
effect.
Furthermore one may ask, why the article by Pat Sidle contained only
speculations and rumours about unpublished estimates, while existing data
on the continuous population growth were not mentioned.
1, Pat Sidley , Free retroviral drugs could save up to 1.7 million South
Africans, BMJ 2003;327:184 (26 July)
2. Results from the Census 2001, Statistics South Africa, "Census 2001"
www.statssa.gov.za