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Medical Forum / Diseases and Disorders / AIDS / March 2007Move Away People, Nothing To See Here, It Was All A Joke
It took them a quarter of a century to state the obvious. And the exceptionalist reasoning for Africa is laughable, and internally inconsistent. If heterosexual sex is not a vector for transmission in the west, why should it be in Africa. The truth is, there is no epidemic, and that is that. http://news.bbc.co.uk/2/hi/health/6321683.stm Expert doubts widespread HIV risk Intravenous drug user Intravenous drug users are a key high-risk group HIV/Aids campaigners are circulating "misconceptions" about who is at risk, a former World Health Organization expert has warned. Dr James Chin was head of a WHO Global Programme on Aids unit from 1987-1992. In a new book, he says people in the general population outside Africa are unlikely to contract HIV/Aids, as it is restricted to certain high-risk groups. Campaigners have promoted a message of safer sex which involves the use of condoms for protection. UK experts said Dr Chin's views were inaccurate, and misrepresented current thinking among HIV/Aids bodies. Dr Chin says HIV prevalence is low in most populations throughout the world and can be expected to remain low. He believes this is not because of effective HIV prevention work, but because infection rates are limited by the numbers in groups whose behaviour puts them at high risk. Dr Chin says it is only in sub-Saharan Africa, where unprotected sex outside marriage is common, that the risk of heterosexual HIV transmission is high. In other parts of the world, he says HIV is seen only in men who have sex with other men, intravenous drug users and female sex workers. And he says that, unless the clients or partners of people in these groups also indulge in high-risk behaviour, the virus will not spread. 'Difficult to transmit' However Dr Chin says these facts have been "minimised and ignored" by UNAids and Aids activists because it is "politically and socially more acceptable" to say HIV risk behaviours are present in all populations. Writing in "The Aids Pandemic", Dr Chin says: "These activists do not want to further stigmatise persons or population groups who have such high risk levels of HIV risk behaviours and who are already marginalised. "By refusing to accept the fact that HIV is very difficult to transmit sexually without the highest levels of sexual risk behaviours, Aids programmes have avoided labelling some populations as being more promiscuous than others. "It is a much more socially and politically correct public health message to say that sexual promiscuity exists in all populations and thus the risk of epidemic heterosexual HIV transmission to the general public, or to ordinary people can be prevented only by aggressive programmes directed at the general population, and especially to youth." He cited studies which showed the risk of someone in the general population of contracting HIV from any single sexual act was, at the highest estimate, one in 1,000. And he says the failure to recognise this means that scarce public health resources in countries where HIV prevalence is low are being wasted on prevention programmes being targeted at the public, when it is the high-risk groups who should be targeted. 'Disservice' Dr Purnima Mane, director of policy evidence and partnerships at UNAids said: "Without having access to the full text of the book, it is very difficult for UNAids to comment on it." But she said: "The Aids response has always invited a high-level of debate and discussion. UNAids welcomes this debate and stands by its scientific approach. "Twenty-five years into the Aids epidemic has shown the world how the epidemic has continued to evolve and how the response must also evolve. Dr Mane added: "UNAids data is not influenced by political or fundraising agendas." Lisa Power, head of policy at the UK's Terrence Higgins Trust said Dr Chin's views may have been accurate 10 to 15 years ago, but were not true now. "He is overstating his case. Sub-Saharan Africa is not the only place to have heterosexual epidemics and most AIDS activists no longer espouse a one-size-fits-all approach to HIV prevention work. "Some authorities are wrong to misrepresent their HIV epidemiology in order to maximise public interest in the issue. "But Chin is doing a similar disservice by misrepresenting current HIV planning and thinking in order to maximise public interest in his book." Ms Power said there was a need for campaigns targeted at high-risk groups and more general information to ensure better public understanding of HIV and sexual health in order to tackle the stigma surrounding the disease." The Aids Pandemic: the collision of epidemiology with political correctness is published by Radcliffe Publishing at £27.50. >It took them a quarter of a century to state the obvious. >And the exceptionalist reasoning for Africa is laughable, >and internally inconsistent. If heterosexual sex is not a >vector for transmission in the west, why should it be >in Africa. Who are "them"? What "exceptionalist reasoning"? Rest of article binned, because a) the subject line indicates that it isn't worth reading <PEDANT> b) If you can't say clearly in the subject line and first paragraph what it's about, it's probably not worth reading. </pedant>  SignatureTerms and conditions apply. Steve Hayes hayesmstw@hotmail.com > Dr Chin says HIV prevalence is low in most populations throughout the world > and can be expected to remain low. > > He believes this is not because of effective HIV prevention work, but because > infection rates are limited by the numbers in groups whose behaviour puts them > at high risk. Africa has a hugely prevalent high risk perversion. Dry sex. This make a huge difference to the spread of all infections. http://www.cirp.org/library/disease/HIV/baleta1/ Unfortunately, public education in this regard wouldn't make us the biggest potential market for .. anything. As everyone that's at all informed knows, lesion-causing virus-permeable condoms, extremely deadly poisons and unlikely abstinence are the entire answer. Until, of course, there's a useless and possibly harmful vaccine. Get with the program. Obviously with a scam this size, there's money to be made. Invest in big pharm. Place a bet on who manages to pull off a PR campaign to force their vaccines on schoolchildren. Maybe one of them can convince us that with 100000000000 of us getting infected every minute or so, we'd better just buy all their stocks of AZT and put it in our water supply. Big money. Love, however it looks SignatureRahasya nospam_rahasya@meditate.co.za > Alex <avdeelen.REMOFETHIS1@wanadoo.nl> wrot > > Dr Chin says HIV prevalence is low in most populations throughout the worl > > and can be expected to remain low > > > He believes this is not because of effective HIV prevention work, but becaus > > infection rates are limited by the numbers in groups whose behaviour puts the > > at high risk > Africa has a hugely prevalent high risk perversion. Dry sex. This make > huge difference to the spread of all infections > http://www.cirp.org/library/disease/HIV/baleta1 Oh yes, the myth of 'dry sex'. If this is so good or widespread, ho come no one in the West is practicing it I thought this hoardy myth was buried at the same time as 'mosquito spread HIV' Chin's claim for exceptionalism in Africa is that people in Africa hav sex 'more often' than people in the rest of the world, not 'differently than people in the rest of the world Both claims of course are ridiculous, and an appeal to racis mythology, rather than common sense evidence or statistical proof Again, no one outside the AIDS indutry has proven that either exist Either claim would need confirmation from mainstream publications Ale http://www.virusmyth.net/aids/data/cgstereotypes.ht Aside from the voyeurism and the lack of verification that attends these sensationalist claims, n one has ever shown that people in Rwanda, Uganda, Zaire, and Kenya - the so-called "AIDS belt" - ar more sexually active than people in Nigeria which has reported only 21,905 AIDS cases out of population of 120 million or Cameroon which reported 13,576 cases in 14 million.(25) N continent-wide sex surveys have ever been carried out in Africa. Nevertheless, conventiona researchers perpetuate racist stereotypes about insatiable sexual appetites and carnal exotica. The assume that AIDS cases in Africa are driven by a sexual promiscuity similar to what produced - i combination with recreational drugs, sexual stimulants, venereal disease, and the over-use o antibiotics - the early epidemic of immunological dysfunction among a small sub-culture of urban ga men in the West.(26 The research from Africa suggests nothing of the sort. In 1991 researchers from Médicins San Frontières and the Harvard School of Public Health did a survey of sexual behavior in Moyo distric of northwest Uganda. Their findings revealed behavior that was not very different from that of th West. On average, women had their first sex at age 17, men at 19. Eighteen per cent of women and 50 of men reported premarital sex; 1.6% of the women and 4.1% of the men had had casual sex in th month preceding the study, while 2% of women and 15% of men had done so in the preceding year.(27 http://www.cirp.org/library/disease/HIV/brewer1 Mounting anomalies in the epidemiology of HI in Africa: cry the beloved paradig Devon D Brewer PhD1, Stuart Brody PhD2, Ernest Drucker PhD3 David Gisselquist PhD4, Stephen F Minkin BA6, John J Potterat BA5 Richard B Rothenberg MD MPH7 and François Vachon MD (Authors are listed alphabetically 1University of Washington, Seattle, Washington, USA, 2Institute of Medical Psychology and Behaviora Neurobiology, University of Tübingen, Germany, 3Department of Epidemiology and Social Medicine Montefiore Medical Center/Albert Einstein College of Medicine, New York City, USA, 4Hershey, PA USA, 5Colorado Springs, Colorado, USA, 6Network for Infection Prevention, Brattleboro, Vermon 05302, USA, 7 Department of Family and Preventive Medicine, Emory University School of Medicine Atlanta, GA, USA, 8University of Paris 7, Franc Keywords: HIV, Africa, risk factors, epidemiology, heterosexual transmission, medical transmissio Introductio There is substantial dissonance between much of the epidemiologic evidence and the current orthodox that nearly all of the HIV burden in sub-Saharan Africa can be accounted for by heterosexua transmission and the sexual behaviour of Africans. The mounting toll of HIV infection in Africa i paralleled by a mounting number of anomalies in the many studies seeking to account for it. We propose that existing data can no longer be reconciled with the received wisdom about the exceptional role of sex in the African AIDS epidemic. Anomalies in sub-Saharan Africa Discontinuity between HIV and STIs During the 1990s HIV propagated rapidly in Zimbabwe, increasing at an estimated rate of 12% annually. At the same time, the overall sexually transmitted infections (STI) burden declined an estimated 25% and while there was a parallel increase in reported condom use by high-risk persons (prostitutes, lorry drivers, miners, and young people)1. This example frames the problem: why would a relatively low efficiency sexually transmitted virus like HIV outrun more efficiently transmitted STI2? In the notable four-cities study3, many common sexual risk factors linked to HIV transmission (eg, high rate of partner change, sex with prostitutes, and low condom use) were not correlated with HIV prevalence-although some risk markers (young age at first coitus or marriage, large age difference between partners) and presumed facilitating factors (lack of circumcision, genital herpes, and trichomoniasis, but not bacterial STI) were. In addition, concurrency of sexual partnerships was not correlated with HIV prevalence, yet was associated with bacterial STI4.It is of concern that many key sexual transmission variables are not associated with a large HIV epidemic in Africa, yet do correlate, as expected, with other STIs. Transmission efficiency A study of HIV transmission efficiency in Africa, using data from serodiscordant couples5, produced estimates remarkably similar to those reported for couples in the developed world6. Observed probabilities presumably reflect some of the influence of facilitating factors (eg, unorthodox sexual practices, circumcision status, STI exposure, etc) recruited to explain the 'turbo effect'7 noted in Africa's epidemiologic context. Recent empiric research casts doubt that such co-factors can sufficiently amplify the force of infectivity to account for observed trends in the sexual transmission of HIV in Africa8. The anomalies regarding transmission efficiency are well illustrated by a recent study in South Africa9. The authors recognized that, to explain HIV acquisition by 16-18 year old women in their study, they needed to postulate a per partnership transmission probability of 0.92 (0.49, assuming double the number of reported partnerships per woman). By extension, the per-contact probability of transmission would be 0.34, making heterosexual sex in this context second only to transfusion in HIV transmission efficiency. Similarly, a model developed to assess the impact of STI on transmission of HIV posited an extraordinary 33-fold increase in transmission efficiency of the latter in the presence of the former10. Reported sexual activity Levels of sexual activity reported in a dozen general population surveys in Africa11 are comparable to those reported elsewhere, especially in North America and Europe. Perhaps more importantly, there appears to be little correlation with the level of risky sexual behaviour shown in these surveys and the epidemic trajectories observed in these countries. (Comparison with country-specific data reported by UNAIDS 2000; data not shown.) The four-city study provides similar discordance12. For example, Yaounde (in Cameroon, a nation with low and stable prevalence) had the highest level of risky behavioural markers. Ndola (in Zambia, a nation that has experienced a rapid rise in HIV) had the smallest proportion of both men and women who reported a non-spousal sex partner in the previous 12 months. Ndola's other markers were similar to those in Dakar, Senegal and Cotonou, Benin, other areas with low, stable prevalence. Transmission dynamics Rapid propagation (of at least bacterial STI) has been associated with core groups13, which make up a small proportion of the susceptible population and are proposed to be responsible for most community transmission. Such groups appear to be associated with differing forms of sexual net-work 'geometry'. This geometry demonstrably differs with transmission intensity14-16. Evidence suggests that endemic and declining HIV/STI burdens are associated with dendritic (many open-ended termini) patterns of sexual partner connections, while epidemicity is associated with cyclic (closed loops, reflecting cohesiveness and density) patterns. There are few data on the architecture of sociosexual networks in Africa, but the available information suggests predominantly dendritic patterns (eg, contact with prostitutes and then contact with stable and usually monogamous consorts who are network termini). We are aware of no study from sub-Saharan Africa suggesting cyclic sexual network architecture. Without evidence of appropriate network configurations on a scale considerably larger than that observed in developed countries, rapid propagation of HIV in Africa would be difficult to sustain. Studies have associated putative sexual core groups with HIV transmission in Africa. For example, women who work as prostitutes and their partners have frequently been observed to have high HIV prevalence. Confusion may arise, however, over conflating the terms 'high risk person' and 'core group'. The former have been labelled in some way, but are not necessarily part of an interconnected group of individuals through whom infection percolates (ie, core group). As noted, such persons would have to be part of an interactive, cyclic group, rather than nodes along a dendritic chain. Other anomalous findings A higher HIV prevalence has been observed in women seen in prenatal, postpartum, and induced abortion settings than in their community counter-parts17. In a number of studies, there appears to be a discrepancy between the observed prevalence in women undergoing reproductive medical care, and the prevalence that would be observed in such a group from heterosexual transmission alone. Though few in number, there continue to be reports of HIV seropositivity in persons denying coital exposure and in persons claiming a sole lifetime sexual partner who is reportedly HIV negative17. Similarly, there are persistent reports of HIV in infants with seronegative mothers17. A recent large survey from South Africa measured an HIV prevalence of 5.6% in children 2-14 years of age 18. Given mortality from HIV among children who acquire it in Africa, there would appear to be a substantial proportion of such a disease burden that is unexplained by maternal and sexual transmission. Alternatives A number of these observations raise the question of an alternative route of transmission, for which medical care and the use of injections are prime candidates17,19-22. Prostitutes, for example, are often recruited for studies from STI clinics, where treatment is frequently given by injection, where non-sterile equipment is used with high frequency, and wherein the underlying prevalence of HIV is high7. Many studies that have assessed the impact of sexual activity on HI transmission -notably those in Mwanza and Rakai, whose discordant results are still a subject o debate23-failed to consider the potential confounding effects of medical care in the propagation o HIV24 Rapid HIV transmission in Africa has often occurred in countries with good access to medical care like Botswana, Zimbabwe, and South Africa. For example, high rates in rural South Africa hav paralleled aggressive efforts to deliver health care to rural populations. It is difficult t understand how improved access to health care, with its offers of public health messages, fre condoms, and preventive services, would be associated with increased HIV transmission. Similarly HIV prevalence is often higher in cities and among persons of high socioeconomic attainment than i rural areas or among less fortunate persons. Favourable access to health care is one of th differences that distinguishes between these groups Reactions to the anomalies and alternative Since early in the African epidemic, when AIDS was demographically associated with sexually activ populations25, studies of HIV transmission in Africa have generally failed to control for possibl parenteral confounding26. The importance of this route of infection was well known in the West an in Asia but quickly dismissed in Africa27. The risk of parenteral transmission of HIV is based o good estimates of transmission efficiency, which varies depending on type of injection an circumstances that produce reuse of contaminated equipment. For example, needle stick exposure (HI transmission probability: about one in 30028, medical injection (recently estimated at approximatel one in 3020), or illicit-drug injection (about one in 10029), is much more efficient tha penile-vaginal exposure (about one in 100030) There is the expectation that, were iatrogenic transmission of HIV common, one would notic substantial HIV prevalence in populations of (non-sexually experienced) children. Regrettably although a large proportion of Africa's population falls in that category, few serosurveys conducte in Africa have included large enough samples from, say, children aged five through 12 to confidentl dismiss this possibility. As more information accumulates that addresses this issue, a cleare perspective on the magnitude of non-sexual, non-maternal transmission in children will emerge The risk of exposure to HIV via medical injections is likely to vary with background prevalence an with the specific medical practices in different settings. The demand for consistency and coherenc that we have placed on the heterosexual hypothesis should be applied to estimating the role o medical transmission. Its role should vary with background (initial) prevalence, and should b related to the degree of medical hygiene exercised. The same biological basis that exists fo heterosexual transmission should be established for medical transmission. (As an aside, such demonstration poses substantial ethical problems. No investigator should knowingly observe the us of a needle that has a high probability of being contaminated with HIV, but at a minimum, th demonstration of HIV RNA in needles that were to have been used on patients would be an importan element in establishing a biological base.) The transmission of blood-borne pathogens with differin biological characteristics, notably hepatitis B and C31, should be consistent with parentera transmission of HIV. Finally, the social epidemiology of HIV (male to female ratios, for example should be consistent with observations about non-sexual exposure Conclusio In North America, Europe, and many parts of Asia, the ignition of regional epidemics and rapid HI transmission has been associated principally with the sharing of contaminated injecting equipmen and with anal intercourse. Though heterosexual intercourse has been virtually the sole explanatio offered for the AIDS epidemic in sub-Saharan Africa, to our knowledge in no other part of the worl has penile-vaginal exposure (as opposed to 'heterosexual sex') been demonstrated to initiate o sustain rapid HIV propagation. HIV is not transmitted by 'sex', but only by specific risky practices. It is not transmitted by 'injections', but only by contaminated implements, which need to be clearly differentiated as to type and frequency of injection and by the conditions of the exposure setting. In virtually all societies affected by HIV to date, both routes seem to play important roles. If we are to understand and intervene in each of these epidemics, well-designed studies at both the population and individual levels are urgently needed. It is vital that these be properly controlled for parenteral exposure, specific sexual practices, and other co-factors2,17,24,32 and the complex and specific social patterns and networks that accompany them33. Dispassionate assessment of our conclusions admittedly depends on a willing suspension of disbelief, since the current paradigm is deeply embedded. Counter arguments can (and will) be levelled at each of the anomalies noted, but the depth and breadth of concerns deserve fair scrutiny. At issue in a re-evaluation of the heterosexual hypothesis are the profound implications for our interventive approach, and for the kinds of social and financial commitments that must be made. Finally, Africans deserve scientifically sound information on the epidemiologic determinants of their calamitous AIDS epidemic. References 1 Decosas J, Padian N. The profile and context of the epidemics of sexually transmitted infections including HIV in Zimbabwe. Sex Transm Infect 2002;78(Suppl 1):140-6 2 Potterat JJ, Brody S. HIV epidemicity in context of STI declines: a telling discordance (letter). Sex Transm Infect 2002; 78:467 [Full Text] 3 Buve A, Carael M, Hayes RJ, et al. The multicentre study on factors determining the differential spread of HIV in four African cities: summary and conclusions. AIDS 2001;5(Suppl 4):S127-31 [Abstract] 4 Rothenberg R, Potterat J, Gisselquist D. Concurrency and sexual transmission (letter). AIDS 2002;16:678-80 5 Gray RH, Wawer MJ, Brookmeyer R, et al. Probability of HIV-1 transmission per coital act in monogamous, heterosexual, HIV-1 discordant couples in Rakai, Uganda. Lancet 2001;357:1149-53 6 Downs AM, De Vicenzi I, European Group on Heterosexual Transmission of HIV: relationship to the number of unprotected sexual contacts. J Acquir Immune Defic Syndr 1996;11:388-95 7 Vachon F, Coulaud JP, Katlama C. Epidémiologie actuelle du syndrome d'immunodéficit acquis en dehors des groupes à risque. Presse Médicale 1985;14:1949-50 8 Gisselquist D, Potterat JJ. Heterosexual transmission of HIV in Africa: an empiric estimate. Int J STD AIDS 2003;14:162-73 9 Auvert B, Ballard R, Campbell C, et al. HIV infection among youth in a South African mining town is associated with herpes simplex virus-2 seropositivity and sexual behavior. AIDS 2001;15:883-98 10 Robinson NJ, Mulder DW, Auvert B, Hayes RJ. Modelling the impact of alternative HIV intervention strategies in rural Uganda. AIDS 1995;9:1263-70 [PubMed] 11 Carael M, Cleland J, Deheneffe J-C, Ferry B, Ingham R. Sexual behavior in developing countries: implications for HIV control. AIDS 1995;9:1171-5 12 Buve A, Lagarde E, Carael M, et al. Interpreting sexual behaviour data: validity issues in the multicentre study on factors determining the differential spread of HIV in four African cities. AIDS 2001;15(Suppl 4):S1117-26 [Abstract] 13 Thomas JC, Tucker MJ. The development and use of the concept of a sexually transmitted disease core. J Infect Dis 1996;176(Suppl 2):S134-43 [PubMed] 14 Potterat JJ, Muth SQ, Rothenberg RB, et al. Network structure as an indicator of epidemic phase. Sex Transm Infect 2002;78(Suppl 1):i152-8 15 Potterat JJ, Phillips-Plummer L, Muth SQ, et al. Risk network structure in the early epidemic phase of HIV transmission in Colorado Springs. Sex Transm Infect 2002; 78(Suppl 1):i159-63 16 Potterat JJ, Rothenberg RB, Muth SQ. Network structural dynamics and infectious disease propagation. Int J STD AIDS 1999;10:182-5 [PubMed] 17 Gisselquist D, Rothenberg R, Potterat J, et al. HIV infections in sub-Saharan Africa not explained by sexual or vertical transmission. Int J STD AIDS 2002;13:657-66 [PubMed] 18 Shisana O, Simbayi L, Bezuidenhout F, et al. Nelson Mandela/HSCR study of HIV/AIDS: South African national HIV prevalence, behavioural risks and mass media: household survey 2002. Cape Town, Human Sciences Research Council 2002. http://www.hsrc.ac.za/research/npa/SAHA/news/20021205Keynote.html 19 Simonsen L, Kane A, Lloyd J, et al. Unsafe injections in the developing world and transmission of bloodborne pathogens: a review. WHO Bull 1999;77:789-800 20 Gisselquist DP. Estimating HIV-1 transmission efficiency through unsafe medical injections. Int J STD AIDS 2002; 13:152-9 [Abstract] 21 Drucker EM, Alcabes PG, Marx PA. The injection century: consequences of massive unsterile injecting for the emergence of human pathogens. Lancet 2001;358:1989-92 22 Potterat JJ, Brody S. Does sex explain HIV transmission dynamics in developing countries? (Letter) Sex Transm Dis 2001;28:730 23 Grosskurth H, Gray R, Hayes R, et al. Control of sexually transmitted diseases for HIV-1 prevention: understanding the implications of the Mwanza and Rakai trials. Lancet 2000;355:1981-7 [PubMed] 24 Gisselquist D, Potterat J. Confound it: latent lessons from the Mwanza trial of STD treatment to reduce HIV transmission. Int J STD AIDS 2003;14:179-84 [Abstract] 25 Quinn TC, Mann JM, Curran JW, Piot P. AIDS in Africa: an epidemiologic paradigm. Science 1986;234:955-63 [Abstract] 26 Gisselquist D, Rothenberg R, Potterat J, Drucker E. Non-sexual transmission of HIV has been overlooked in developing countries (letter). BMJ 2002;324:235 27 Gisselquist D, Potterat J, Brody S, Vachon F. Let it be sexual: how health care transmission of AIDS in Africa was ignored. Int J STD AIDS 2003;14:148-61 28 Tokars JI, Marcus R, Culver DH. Surveillance of HIV infection and zidovudine use among health care workers after occupational exposure to HIV-infected blood. Ann Intern Med 1993;118:913-19 [Full Text] 29 Kaplan EH, Heimer R. A model-based estimate of HIV infectivity via needle sharing. JAIDS 1992;5:1116-18 [PubMed] 30 Royce RA, Sena A, Cates W Jr, Cohen MS. Sexual transmission of HIV. N Engl J Med 1997;336:1072-8 31 Madhava V, Burgess C, Drucker E. Epidemiology of chronic hepatitis C virus infection in sub-Saharan Africa. Lancet Infect Dis 2002;2:293-302 [PubMed] 32 Gisselquist D, Potterat JJ. Uncontrolled HSV-2 as a co-factor in HIV transmission (response to Sutcliffe et al.). JAIDS (in press) 33 Aral SO, Holmes KK. Social and behavioral determinants of the epidemiology of STDs: industrialized and developing countries, in Holmes KK, Sparling PF, Mårdh P-A, et al. (eds): Sexually transmitted diseases (3rd edn). New York: McGraw-Hill Book Co, Inc., 1999:39-76 (Accepted 15 December 2002) Correspondence to: Mr J J Potterat, 301 South Union Blvd, Colorado Springs, Colorado USA 80910 Settle down Alex. You might have a heart attack. /DH >> > Dr Chin says HIV prevalence is low in most populations throughout the >> > world [quoted text clipped - 535 lines] > Correspondence to: Mr J J Potterat, 301 South Union Blvd, > Colorado Springs, Colorado USA 80910 Settle down Alex. You might have a heart attack /D >> Alex <avdeelen.REMOFETHIS1@wanadoo.nl> wrot > [quoted text clipped - 11 lines] >> huge difference to the spread of all infections >> http://www.cirp.org/library/disease/HIV/baleta1 > Oh yes, the myth of 'dry sex'. If this is so good or widespread, ho > come no one in the West is practicing it > I thought this hoardy myth was buried at the same time as 'mosquito > spread HIV' > Chin's claim for exceptionalism in Africa is that people in Africa hav > sex 'more often' than people in the rest of the world, not 'differently > than people in the rest of the world > Both claims of course are ridiculous, and an appeal to racis > mythology, rather than common sense evidence or statistical proof > Again, no one outside the AIDS indutry has proven that either exist > Either claim would need confirmation from mainstream publications > Ale > http://www.virusmyth.net/aids/data/cgstereotypes.ht > Aside from the voyeurism and the lack of verification that attends these > sensationalist claims, n [quoted text clipped - 15 lines] > small sub-culture of urban ga > men in the West.(26 > The research from Africa suggests nothing of the sort. In 1991 researchers > from Médicins San [quoted text clipped - 8 lines] > month preceding the study, while 2% of women and 15% of men had done so in > the preceding year.(27 > http://www.cirp.org/library/disease/HIV/brewer1 > Mounting anomalies in the epidemiology of HI > in Africa: cry the beloved paradig > Devon D Brewer PhD1, Stuart Brody PhD2, Ernest Drucker PhD3 > David Gisselquist PhD4, Stephen F Minkin BA6, John J Potterat BA5 > Richard B Rothenberg MD MPH7 and François Vachon MD > (Authors are listed alphabetically > 1University of Washington, Seattle, Washington, USA, 2Institute of Medical > Psychology and Behaviora [quoted text clipped - 182 lines] > care in the propagation o > HIV24 > Rapid HIV transmission in Africa has often occurred in countries with good > access to medical care [quoted text clipped - 11 lines] > care is one of th > differences that distinguishes between these groups > Reactions to the anomalies and alternative > Since early in the African epidemic, when AIDS was demographically > associated with sexually activ [quoted text clipped - 13 lines] > efficient tha > penile-vaginal exposure (about one in 100030) > There is the expectation that, were iatrogenic transmission of HIV common, > one would notic [quoted text clipped - 8 lines] > perspective on the magnitude of non-sexual, non-maternal transmission in > children will emerge > The risk of exposure to HIV via medical injections is likely to vary with > background prevalence an [quoted text clipped - 21 lines] > female ratios, for example > should be consistent with observations about non-sexual exposure > Conclusio > In North America, Europe, and many parts of Asia, the ignition of regional > epidemics and rapid HI [quoted text clipped - 193 lines] > Correspondence to: Mr J J Potterat, 301 South Union Blvd, > Colorado Springs, Colorado USA 80910 > > Dr Chin says HIV prevalence is low in most populations throughout the world > > and can be expected to remain low. [quoted text clipped - 6 lines] > huge difference to the spread of all infections. > http://www.cirp.org/library/disease/HIV/baleta1/ Oh yes, the myth of 'dry sex'. If this is so good or widespread, how come no one in the West is practicing it? I thought this hoardy myth was buried at the same time as 'mosquitos spread HIV'? Chin's claim for exceptionalism in Africa is that people in Africa have sex 'more often' than people in the rest of the world, not 'differently' than people in the rest of the world. Both claims of course are ridiculous, and an appeal to racist mythology, rather than common sense evidence or statistical proof. Again, no one outside the AIDS indutry has proven that either exist. Either claim would need confirmation from mainstream publications. Alex http://www.virusmyth.net/aids/data/cgstereotypes.htm Aside from the voyeurism and the lack of verification that attends these sensationalist claims, no one has ever shown that people in Rwanda, Uganda, Zaire, and Kenya - the so-called "AIDS belt" - are more sexually active than people in Nigeria which has reported only 21,905 AIDS cases out of a population of 120 million or Cameroon which reported 13,576 cases in 14 million.(25) No continent-wide sex surveys have ever been carried out in Africa. Nevertheless, conventional researchers perpetuate racist stereotypes about insatiable sexual appetites and carnal exotica. They assume that AIDS cases in Africa are driven by a sexual promiscuity similar to what produced - in combination with recreational drugs, sexual stimulants, venereal disease, and the over-use of antibiotics - the early epidemic of immunological dysfunction among a small sub-culture of urban gay men in the West.(26) The research from Africa suggests nothing of the sort. In 1991 researchers from Médicins Sans Frontières and the Harvard School of Public Health did a survey of sexual behavior in Moyo district of northwest Uganda. Their findings revealed behavior that was not very different from that of the West. On average, women had their first sex at age 17, men at 19. Eighteen per cent of women and 50% of men reported premarital sex; 1.6% of the women and 4.1% of the men had had casual sex in the month preceding the study, while 2% of women and 15% of men had done so in the preceding year.(27) http://www.cirp.org/library/disease/HIV/brewer1/ Mounting anomalies in the epidemiology of HIV in Africa: cry the beloved paradigm Devon D Brewer PhD1, Stuart Brody PhD2, Ernest Drucker PhD3, David Gisselquist PhD4, Stephen F Minkin BA6, John J Potterat BA5, Richard B Rothenberg MD MPH7 and François Vachon MD8 (Authors are listed alphabetically) 1University of Washington, Seattle, Washington, USA, 2Institute of Medical Psychology and Behavioral Neurobiology, University of Tübingen, Germany, 3Department of Epidemiology and Social Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, New York City, USA, 4Hershey, PA, USA, 5Colorado Springs, Colorado, USA, 6Network for Infection Prevention, Brattleboro, Vermont 05302, USA, 7 Department of Family and Preventive Medicine, Emory University School of Medicine, Atlanta, GA, USA, 8University of Paris 7, France Keywords: HIV, Africa, risk factors, epidemiology, heterosexual transmission, medical transmission Introduction There is substantial dissonance between much of the epidemiologic evidence and the current orthodoxy that nearly all of the HIV burden in sub-Saharan Africa can be accounted for by heterosexual transmission and the sexual behaviour of Africans. The mounting toll of HIV infection in Africa is paralleled by a mounting number of anomalies in the many studies seeking to account for it. We propose that existing data can no longer be reconciled with the received wisdom about the exceptional role of sex in the African AIDS epidemic. Anomalies in sub-Saharan Africa Discontinuity between HIV and STIs During the 1990s HIV propagated rapidly in Zimbabwe, increasing at an estimated rate of 12% annually. At the same time, the overall sexually transmitted infections (STI) burden declined an estimated 25% and while there was a parallel increase in reported condom use by high-risk persons (prostitutes, lorry drivers, miners, and young people)1. This example frames the problem: why would a relatively low efficiency sexually transmitted virus like HIV outrun more efficiently transmitted STI2? In the notable four-cities study3, many common sexual risk factors linked to HIV transmission (eg, high rate of partner change, sex with prostitutes, and low condom use) were not correlated with HIV prevalence-although some risk markers (young age at first coitus or marriage, large age difference between partners) and presumed facilitating factors (lack of circumcision, genital herpes, and trichomoniasis, but not bacterial STI) were. In addition, concurrency of sexual partnerships was not correlated with HIV prevalence, yet was associated with bacterial STI4.It is of concern that many key sexual transmission variables are not associated with a large HIV epidemic in Africa, yet do correlate, as expected, with other STIs. Transmission efficiency A study of HIV transmission efficiency in Africa, using data from serodiscordant couples5, produced estimates remarkably similar to those reported for couples in the developed world6. Observed probabilities presumably reflect some of the influence of facilitating factors (eg, unorthodox sexual practices, circumcision status, STI exposure, etc) recruited to explain the 'turbo effect'7 noted in Africa's epidemiologic context. Recent empiric research casts doubt that such co-factors can sufficiently amplify the force of infectivity to account for observed trends in the sexual transmission of HIV in Africa8. The anomalies regarding transmission efficiency are well illustrated by a recent study in South Africa9. The authors recognized that, to explain HIV acquisition by 16-18 year old women in their study, they needed to postulate a per partnership transmission probability of 0.92 (0.49, assuming double the number of reported partnerships per woman). By extension, the per-contact probability of transmission would be 0.34, making heterosexual sex in this context second only to transfusion in HIV transmission efficiency. Similarly, a model developed to assess the impact of STI on transmission of HIV posited an extraordinary 33-fold increase in transmission efficiency of the latter in the presence of the former10. Reported sexual activity Levels of sexual activity reported in a dozen general population surveys in Africa11 are comparable to those reported elsewhere, especially in North America and Europe. Perhaps more importantly, there appears to be little correlation with the level of risky sexual behaviour shown in these surveys and the epidemic trajectories observed in these countries. (Comparison with country-specific data reported by UNAIDS 2000; data not shown.) The four-city study provides similar discordance12. For example, Yaounde (in Cameroon, a nation with low and stable prevalence) had the highest level of risky behavioural markers. Ndola (in Zambia, a nation that has experienced a rapid rise in HIV) had the smallest proportion of both men and women who reported a non-spousal sex partner in the previous 12 months. Ndola's other markers were similar to those in Dakar, Senegal and Cotonou, Benin, other areas with low, stable prevalence. Transmission dynamics Rapid propagation (of at least bacterial STI) has been associated with core groups13, which make up a small proportion of the susceptible population and are proposed to be responsible for most community transmission. Such groups appear to be associated with differing forms of sexual net-work 'geometry'. This geometry demonstrably differs with transmission intensity14-16. Evidence suggests that endemic and declining HIV/STI burdens are associated with dendritic (many open-ended termini) patterns of sexual partner connections, while epidemicity is associated with cyclic (closed loops, reflecting cohesiveness and density) patterns. There are few data on the architecture of sociosexual networks in Africa, but the available information suggests predominantly dendritic patterns (eg, contact with prostitutes and then contact with stable and usually monogamous consorts who are network termini). We are aware of no study from sub-Saharan Africa suggesting cyclic sexual network architecture. Without evidence of appropriate network configurations on a scale considerably larger than that observed in developed countries, rapid propagation of HIV in Africa would be difficult to sustain. Studies have associated putative sexual core groups with HIV transmission in Africa. For example, women who work as prostitutes and their partners have frequently been observed to have high HIV prevalence. Confusion may arise, however, over conflating the terms 'high risk person' and 'core group'. The former have been labelled in some way, but are not necessarily part of an interconnected group of individuals through whom infection percolates (ie, core group). As noted, such persons would have to be part of an interactive, cyclic group, rather than nodes along a dendritic chain. Other anomalous findings A higher HIV prevalence has been observed in women seen in prenatal, postpartum, and induced abortion settings than in their community counter-parts17. In a number of studies, there appears to be a discrepancy between the observed prevalence in women undergoing reproductive medical care, and the prevalence that would be observed in such a group from heterosexual transmission alone. Though few in number, there continue to be reports of HIV seropositivity in persons denying coital exposure and in persons claiming a sole lifetime sexual partner who is reportedly HIV negative17. Similarly, there are persistent reports of HIV in infants with seronegative mothers17. A recent large survey from South Africa measured an HIV prevalence of 5.6% in children 2-14 years of age 18. Given mortality from HIV among children who acquire it in Africa, there would appear to be a substantial proportion of such a disease burden that is unexplained by maternal and sexual transmission. Alternatives A number of these observations raise the question of an alternative route of transmission, for which medical care and the use of injections are prime candidates17,19-22. Prostitutes, for example, are often recruited for studies from STI clinics, where treatment is frequently given by injection, where non-sterile equipment is used with high frequency, and wherein the underlying prevalence of HIV is high7. Many studies that have assessed the impact of sexual activity on HIV transmission -notably those in Mwanza and Rakai, whose discordant results are still a subject of debate23-failed to consider the potential confounding effects of medical care in the propagation of HIV24. Rapid HIV transmission in Africa has often occurred in countries with good access to medical care, like Botswana, Zimbabwe, and South Africa. For example, high rates in rural South Africa have paralleled aggressive efforts to deliver health care to rural populations. It is difficult to understand how improved access to health care, with its offers of public health messages, free condoms, and preventive services, would be associated with increased HIV transmission. Similarly, HIV prevalence is often higher in cities and among persons of high socioeconomic attainment than in rural areas or among less fortunate persons. Favourable access to health care is one of the differences that distinguishes between these groups. Reactions to the anomalies and alternatives Since early in the African epidemic, when AIDS was demographically associated with sexually active populations25, studies of HIV transmission in Africa have generally failed to control for possible parenteral confounding26. The importance of this route of infection was well known in the West and in Asia but quickly dismissed in Africa27. The risk of parenteral transmission of HIV is based on good estimates of transmission efficiency, which varies depending on type of injection and circumstances that produce reuse of contaminated equipment. For example, needle stick exposure (HIV transmission probability: about one in 30028, medical injection (recently estimated at approximately one in 3020), or illicit-drug injection (about one in 10029), is much more efficient than penile-vaginal exposure (about one in 100030). There is the expectation that, were iatrogenic transmission of HIV common, one would notice substantial HIV prevalence in populations of (non-sexually experienced) children. Regrettably, although a large proportion of Africa's population falls in that category, few serosurveys conducted in Africa have included large enough samples from, say, children aged five through 12 to confidently dismiss this possibility. As more information accumulates that addresses this issue, a clearer perspective on the magnitude of non-sexual, non-maternal transmission in children will emerge. The risk of exposure to HIV via medical injections is likely to vary with background prevalence and with the specific medical practices in different settings. The demand for consistency and coherence that we have placed on the heterosexual hypothesis should be applied to estimating the role of medical transmission. Its role should vary with background (initial) prevalence, and should be related to the degree of medical hygiene exercised. The same biological basis that exists for heterosexual transmission should be established for medical transmission. (As an aside, such a demonstration poses substantial ethical problems. No investigator should knowingly observe the use of a needle that has a high probability of being contaminated with HIV, but at a minimum, the demonstration of HIV RNA in needles that were to have been used on patients would be an important element in establishing a biological base.) The transmission of blood-borne pathogens with differing biological characteristics, notably hepatitis B and C31, should be consistent with parenteral transmission of HIV. Finally, the social epidemiology of HIV (male to female ratios, for example) should be consistent with observations about non-sexual exposure. Conclusion In North America, Europe, and many parts of Asia, the ignition of regional epidemics and rapid HIV transmission has been associated principally with the sharing of contaminated injecting equipment and with anal intercourse. Though heterosexual intercourse has been virtually the sole explanation offered for the AIDS epidemic in sub-Saharan Africa, to our knowledge in no other part of the world has penile-vaginal exposure (as opposed to 'heterosexual sex') been demonstrated to initiate or sustain rapid HIV propagation. HIV is not transmitted by 'sex', but only by specific risky practices. It is not transmitted by 'injections', but only by contaminated implements, which need to be clearly differentiated as to type and frequency of injection and by the conditions of the exposure setting. In virtually all societies affected by HIV to date, both routes seem to play important roles. If we are to understand and intervene in each of these epidemics, well-designed studies at both the population and individual levels are urgently needed. It is vital that these be properly controlled for parenteral exposure, specific sexual practices, and other co-factors2,17,24,32 and the complex and specific social patterns and networks that accompany them33. Dispassionate assessment of our conclusions admittedly depends on a willing suspension of disbelief, since the current paradigm is deeply embedded. Counter arguments can (and will) be levelled at each of the anomalies noted, but the depth and breadth of concerns deserve fair scrutiny. At issue in a re-evaluation of the heterosexual hypothesis are the profound implications for our interventive approach, and for the kinds of social and financial commitments that must be made. Finally, Africans deserve scientifically sound information on the epidemiologic determinants of their calamitous AIDS epidemic. References 1 Decosas J, Padian N. The profile and context of the epidemics of sexually transmitted infections including HIV in Zimbabwe. Sex Transm Infect 2002;78(Suppl 1):140-6 2 Potterat JJ, Brody S. HIV epidemicity in context of STI declines: a telling discordance (letter). Sex Transm Infect 2002; 78:467 [Full Text] 3 Buve A, Carael M, Hayes RJ, et al. The multicentre study on factors determining the differential spread of HIV in four African cities: summary and conclusions. AIDS 2001;5(Suppl 4):S127-31 [Abstract] 4 Rothenberg R, Potterat J, Gisselquist D. Concurrency and sexual transmission (letter). AIDS 2002;16:678-80 5 Gray RH, Wawer MJ, Brookmeyer R, et al. Probability of HIV-1 transmission per coital act in monogamous, heterosexual, HIV-1 discordant couples in Rakai, Uganda. Lancet 2001;357:1149-53 6 Downs AM, De Vicenzi I, European Group on Heterosexual Transmission of HIV: relationship to the number of unprotected sexual contacts. J Acquir Immune Defic Syndr 1996;11:388-95 7 Vachon F, Coulaud JP, Katlama C. Epidémiologie actuelle du syndrome d'immunodéficit acquis en dehors des groupes à risque. Presse Médicale 1985;14:1949-50 8 Gisselquist D, Potterat JJ. Heterosexual transmission of HIV in Africa: an empiric estimate. Int J STD AIDS 2003;14:162-73 9 Auvert B, Ballard R, Campbell C, et al. HIV infection among youth in a South African mining town is associated with herpes simplex virus-2 seropositivity and sexual behavior. AIDS 2001;15:883-98 10 Robinson NJ, Mulder DW, Auvert B, Hayes RJ. Modelling the impact of alternative HIV intervention strategies in rural Uganda. AIDS 1995;9:1263-70 [PubMed] 11 Carael M, Cleland J, Deheneffe J-C, Ferry B, Ingham R. Sexual behavior in developing countries: implications for HIV control. AIDS 1995;9:1171-5 12 Buve A, Lagarde E, Carael M, et al. Interpreting sexual behaviour data: validity issues in the multicentre study on factors determining the differential spread of HIV in four African cities. AIDS 2001;15(Suppl 4):S1117-26 [Abstract] 13 Thomas JC, Tucker MJ. The development and use of the concept of a sexually transmitted disease core. J Infect Dis 1996;176(Suppl 2):S134-43 [PubMed] 14 Potterat JJ, Muth SQ, Rothenberg RB, et al. Network structure as an indicator of epidemic phase. Sex Transm Infect 2002;78(Suppl 1):i152-8 15 Potterat JJ, Phillips-Plummer L, Muth SQ, et al. Risk network structure in the early epidemic phase of HIV transmission in Colorado Springs. Sex Transm Infect 2002; 78(Suppl 1):i159-63 16 Potterat JJ, Rothenberg RB, Muth SQ. Network structural dynamics and infectious disease propagation. Int J STD AIDS 1999;10:182-5 [PubMed] 17 Gisselquist D, Rothenberg R, Potterat J, et al. HIV infections in sub-Saharan Africa not explained by sexual or vertical transmission. Int J STD AIDS 2002;13:657-66 [PubMed] 18 Shisana O, Simbayi L, Bezuidenhout F, et al. Nelson Mandela/HSCR study of HIV/AIDS: South African national HIV prevalence, behavioural risks and mass media: household survey 2002. Cape Town, Human Sciences Research Council 2002. http://www.hsrc.ac.za/research/npa/SAHA/news/20021205Keynote.html 19 Simonsen L, Kane A, Lloyd J, et al. Unsafe injections in the developing world and transmission of bloodborne pathogens: a review. WHO Bull 1999;77:789-800 20 Gisselquist DP. Estimating HIV-1 transmission efficiency through unsafe medical injections. Int J STD AIDS 2002; 13:152-9 [Abstract] 21 Drucker EM, Alcabes PG, Marx PA. The injection century: consequences of massive unsterile injecting for the emergence of human pathogens. Lancet 2001;358:1989-92 22 Potterat JJ, Brody S. Does sex explain HIV transmission dynamics in developing countries? (Letter) Sex Transm Dis 2001;28:730 23 Grosskurth H, Gray R, Hayes R, et al. Control of sexually transmitted diseases for HIV-1 prevention: understanding the implications of the Mwanza and Rakai trials. Lancet 2000;355:1981-7 [PubMed] 24 Gisselquist D, Potterat J. Confound it: latent lessons from the Mwanza trial of STD treatment to reduce HIV transmission. Int J STD AIDS 2003;14:179-84 [Abstract] 25 Quinn TC, Mann JM, Curran JW, Piot P. AIDS in Africa: an epidemiologic paradigm. Science 1986;234:955-63 [Abstract] 26 Gisselquist D, Rothenberg R, Potterat J, Drucker E. Non-sexual transmission of HIV has been overlooked in developing countries (letter). BMJ 2002;324:235 27 Gisselquist D, Potterat J, Brody S, Vachon F. Let it be sexual: how health care transmission of AIDS in Africa was ignored. Int J STD AIDS 2003;14:148-61 28 Tokars JI, Marcus R, Culver DH. Surveillance of HIV infection and zidovudine use among health care workers after occupational exposure to HIV-infected blood. Ann Intern Med 1993;118:913-19 [Full Text] 29 Kaplan EH, Heimer R. A model-based estimate of HIV infectivity via needle sharing. JAIDS 1992;5:1116-18 [PubMed] 30 Royce RA, Sena A, Cates W Jr, Cohen MS. Sexual transmission of HIV. N Engl J Med 1997;336:1072-8 31 Madhava V, Burgess C, Drucker E. Epidemiology of chronic hepatitis C virus infection in sub-Saharan Africa. Lancet Infect Dis 2002;2:293-302 [PubMed] 32 Gisselquist D, Potterat JJ. Uncontrolled HSV-2 as a co-factor in HIV transmission (response to Sutcliffe et al.). JAIDS (in press) 33 Aral SO, Holmes KK. Social and behavioral determinants of the epidemiology of STDs: industrialized and developing countries, in Holmes KK, Sparling PF, Mårdh P-A, et al. (eds): Sexually transmitted diseases (3rd edn). New York: McGraw-Hill Book Co, Inc., 1999:39-76 (Accepted 15 December 2002) Correspondence to: Mr J J Potterat, 301 South Union Blvd, Colorado Springs, Colorado USA 80910 > Alex <avdeelen.REMOFETHIS1@wanadoo.nl> wrot > > Dr Chin says HIV prevalence is low in most populations throughout the worl > > and can be expected to remain low > > > He believes this is not because of effective HIV prevention work, but becaus > > infection rates are limited by the numbers in groups whose behaviour puts the > > at high risk > Africa has a hugely prevalent high risk perversion. Dry sex. This make > huge difference to the spread of all infections > http://www.cirp.org/library/disease/HIV/baleta1 Oh yes, the myth of 'dry sex'. If this is so good or widespread, ho come no one in the West is practicing it I thought this hoardy myth was buried at the same time as 'mosquito spread HIV' Chin's claim for exceptionalism in Africa is that people in Africa hav sex 'more often' than people in the rest of the world, not 'differently than people in the rest of the world Both claims of course are ridiculous, and an appeal to racis mythology, rather than common sense evidence or statistical proof Again, no one outside the AIDS indutry has proven that either exist Either claim would need confirmation from mainstream publications Ale http://www.virusmyth.net/aids/data/cgstereotypes.ht Aside from the voyeurism and the lack of verification that attends these sensationalist claims, n one has ever shown that people in Rwanda, Uganda, Zaire, and Kenya - the so-called "AIDS belt" - ar more sexually active than people in Nigeria which has reported only 21,905 AIDS cases out of population of 120 million or Cameroon which reported 13,576 cases in 14 million.(25) N continent-wide sex surveys have ever been carried out in Africa. Nevertheless, conventiona researchers perpetuate racist stereotypes about insatiable sexual appetites and carnal exotica. The assume that AIDS cases in Africa are driven by a sexual promiscuity similar to what produced - i combination with recreational drugs, sexual stimulants, venereal disease, and the over-use o antibiotics - the early epidemic of immunological dysfunction among a small sub-culture of urban ga men in the West.(26 The research from Africa suggests nothing of the sort. In 1991 researchers from Médicins San Frontières and the Harvard School of Public Health did a survey of sexual behavior in Moyo distric of northwest Uganda. Their findings revealed behavior that was not very different from that of th West. On average, women had their first sex at age 17, men at 19. Eighteen per cent of women and 50 of men reported premarital sex; 1.6% of the women and 4.1% of the men had had casual sex in th month preceding the study, while 2% of women and 15% of men had done so in the preceding year.(27 http://www.cirp.org/library/disease/HIV/brewer1 Mounting anomalies in the epidemiology of HI in Africa: cry the beloved paradig Devon D Brewer PhD1, Stuart Brody PhD2, Ernest Drucker PhD3 David Gisselquist PhD4, Stephen F Minkin BA6, John J Potterat BA5 Richard B Rothenberg MD MPH7 and François Vachon MD (Authors are listed alphabetically 1University of Washington, Seattle, Washington, USA, 2Institute of Medical Psychology and Behaviora Neurobiology, University of Tübingen, Germany, 3Department of Epidemiology and Social Medicine Montefiore Medical Center/Albert Einstein College of Medicine, New York City, USA, 4Hershey, PA USA, 5Colorado Springs, Colorado, USA, 6Network for Infection Prevention, Brattleboro, Vermon 05302, USA, 7 Department of Family and Preventive Medicine, Emory University School of Medicine Atlanta, GA, USA, 8University of Paris 7, Franc Keywords: HIV, Africa, risk factors, epidemiology, heterosexual transmission, medical transmissio Introductio There is substantial dissonance between much of the epidemiologic evidence and the current orthodox that nearly all of the HIV burden in sub-Saharan Africa can be accounted for by heterosexua transmission and the sexual behaviour of Africans. The mounting toll of HIV infection in Africa i paralleled by a mounting number of anomalies in the many studies seeking to account for it. We propose that existing data can no longer be reconciled with the received wisdom about the exceptional role of sex in the African AIDS epidemic. Anomalies in sub-Saharan Africa Discontinuity between HIV and STIs During the 1990s HIV propagated rapidly in Zimbabwe, increasing at an estimated rate of 12% annually. At the same time, the overall sexually transmitted infections (STI) burden declined an estimated 25% and while there was a parallel increase in reported condom use by high-risk persons (prostitutes, lorry drivers, miners, and young people)1. This example frames the problem: why would a relatively low efficiency sexually transmitted virus like HIV outrun more efficiently transmitted STI2? In the notable four-cities study3, many common sexual risk factors linked to HIV transmission (eg, high rate of partner change, sex with prostitutes, and low condom use) were not correlated with HIV prevalence-although some risk markers (young age at first coitus or marriage, large age difference between partners) and presumed facilitating factors (lack of circumcision, genital herpes, and trichomoniasis, but not bacterial STI) were. In addition, concurrency of sexual partnerships was not correlated with HIV prevalence, yet was associated with bacterial STI4.It is of concern that many key sexual transmission variables are not associated with a large HIV epidemic in Africa, yet do correlate, as expected, with other STIs. Transmission efficiency A study of HIV transmission efficiency in Africa, using data from serodiscordant couples5, produced estimates remarkably similar to those reported for couples in the developed world6. Observed probabilities presumably reflect some of the influence of facilitating factors (eg, unorthodox sexual practices, circumcision status, STI exposure, etc) recruited to explain the 'turbo effect'7 noted in Africa's epidemiologic context. Recent empiric research casts doubt that such co-factors can sufficiently amplify the force of infectivity to account for observed trends in the sexual transmission of HIV in Africa8. The anomalies regarding transmission efficiency are well illustrated by a recent study in South Africa9. The authors recognized that, to explain HIV acquisition by 16-18 year old women in their study, they needed to postulate a per partnership transmission probability of 0.92 (0.49, assuming double the number of reported partnerships per woman). By extension, the per-contact probability of transmission would be 0.34, making heterosexual sex in this context second only to transfusion in HIV transmission efficiency. Similarly, a model developed to assess the impact of STI on transmission of HIV posited an extraordinary 33-fold increase in transmission efficiency of the latter in the presence of the former10. Reported sexual activity Levels of sexual activity reported in a dozen general population surveys in Africa11 are comparable to those reported elsewhere, especially in North America and Europe. Perhaps more importantly, there appears to be little correlation with the level of risky sexual behaviour shown in these surveys and the epidemic trajectories observed in these countries. (Comparison with country-specific data reported by UNAIDS 2000; data not shown.) The four-city study provides similar discordance12. For example, Yaounde (in Cameroon, a nation with low and stable prevalence) had the highest level of risky behavioural markers. Ndola (in Zambia, a nation that has experienced a rapid rise in HIV) had the smallest proportion of both men and women who reported a non-spousal sex partner in the previous 12 months. Ndola's other markers were similar to those in Dakar, Senegal and Cotonou, Benin, other areas with low, stable prevalence. Transmission dynamics Rapid propagation (of at least bacterial STI) has been associated with core groups13, which make up a small proportion of the susceptible population and are proposed to be responsible for most community transmission. Such groups appear to be associated with differing forms of sexual net-work 'geometry'. This geometry demonstrably differs with transmission intensity14-16. Evidence suggests that endemic and declining HIV/STI burdens are associated with dendritic (many open-ended termini) patterns of sexual partner connections, while epidemicity is associated with cyclic (closed loops, reflecting cohesiveness and density) patterns. There are few data on the architecture of sociosexual networks in Africa, but the available information suggests predominantly dendritic patterns (eg, contact with prostitutes and then contact with stable and usually monogamous consorts who are network termini). We are aware of no study from sub-Saharan Africa suggesting cyclic sexual network architecture. Without evidence of appropriate network configurations on a scale considerably larger than that observed in developed countries, rapid propagation of HIV in Africa would be difficult to sustain. Studies have associated putative sexual core groups with HIV transmission in Africa. For example, women who work as prostitutes and their partners have frequently been observed to have high HIV prevalence. Confusion may arise, however, over conflating the terms 'high risk person' and 'core group'. The former have been labelled in some way, but are not necessarily part of an interconnected group of individuals through whom infection percolates (ie, core group). As noted, such persons would have to be part of an interactive, cyclic group, rather than nodes along a dendritic chain. Other anomalous findings A higher HIV prevalence has been observed in women seen in prenatal, postpartum, and induced abortion settings than in their community counter-parts17. In a number of studies, there appears to be a discrepancy between the observed prevalence in women undergoing reproductive medical care, and the prevalence that would be observed in such a group from heterosexual transmission alone. Though few in number, there continue to be reports of HIV seropositivity in persons denying coital exposure and in persons claiming a sole lifetime sexual partner who is reportedly HIV negative17. Similarly, there are persistent reports of HIV in infants with seronegative mothers17. A recent large survey from South Africa measured an HIV prevalence of 5.6% in children 2-14 years of age 18. Given mortality from HIV among children who acquire it in Africa, there would appear to be a substantial proportion of such a disease burden that is unexplained by maternal and sexual transmission. Alternatives A number of these observations raise the question of an alternative route of transmission, for which medical care and the use of injections are prime candidates17,19-22. Prostitutes, for example, are often recruited for studies from STI clinics, where treatment is frequently given by injection, where non-sterile equipment is used with high frequency, and wherein the underlying prevalence of HIV is high7. Many studies that have assessed the impact of sexual activity on HI transmission -notably those in Mwanza and Rakai, whose discordant results are still a subject o debate23-failed to consider the potential confounding effects of medical care in the propagation o HIV24 Rapid HIV transmission in Africa has often occurred in countries with good access to medical care like Botswana, Zimbabwe, and South Africa. For example, high rates in rural South Africa hav paralleled aggressive efforts to deliver health care to rural populations. It is difficult t understand how improved access to health care, with its offers of public health messages, fre condoms, and preventive services, would be associated with increased HIV transmission. Similarly HIV prevalence is often higher in cities and among persons of high socioeconomic attainment than i rural areas or among less fortunate persons. Favourable access to health care is one of th differences that distinguishes between these groups Reactions to the anomalies and alternative Since early in the African epidemic, when AIDS was demographically associated with sexually activ populations25, studies of HIV transmission in Africa have generally failed to control for possibl parenteral confounding26. The importance of this route of infection was well known in the West an in Asia but quickly dismissed in Africa27. The risk of parenteral transmission of HIV is based o good estimates of transmission efficiency, which varies depending on type of injection an circumstances that produce reuse of contaminated equipment. For example, needle stick exposure (HI transmission probability: about one in 30028, medical injection (recently estimated at approximatel one in 3020), or illicit-drug injection (about one in 10029), is much more efficient tha penile-vaginal exposure (about one in 100030) There is the expectation that, were iatrogenic transmission of HIV common, one would notic substantial HIV prevalence in populations of (non-sexually experienced) children. Regrettably although a large proportion of Africa's population falls in that category, few serosurveys conducte in Africa have included large enough samples from, say, children aged five through 12 to confidentl dismiss this possibility. As more information accumulates that addresses this issue, a cleare perspective on the magnitude of non-sexual, non-maternal transmission in children will emerge The risk of exposure to HIV via medical injections is likely to vary with background prevalence an with the specific medical practices in different settings. The demand for consistency and coherenc that we have placed on the heterosexual hypothesis should be applied to estimating the role o medical transmission. Its role should vary with background (initial) prevalence, and should b related to the degree of medical hygiene exercised. The same biological basis that exists fo heterosexual transmission should be established for medical transmission. (As an aside, such demonstration poses substantial ethical problems. No investigator should knowingly observe the us of a needle that has a high probability of being contaminated with HIV, but at a minimum, th demonstration of HIV RNA in needles that were to have been used on patients would be an importan element in establishing a biological base.) The transmission of blood-borne pathogens with differin biological characteristics, notably hepatitis B and C31, should be consistent with parentera transmission of HIV. Finally, the social epidemiology of HIV (male to female ratios, for example should be consistent with observations about non-sexual exposure Conclusio In North America, Europe, and many parts of Asia, the ignition of regional epidemics and rapid HI transmission has been associated principally with the sharing of contaminated injecting equipmen and with anal intercourse. Though heterosexual intercourse has been virtually the sole explanatio offered for the AIDS epidemic in sub-Saharan Africa, to our knowledge in no other part of the worl has penile-vaginal exposure (as opposed to 'heterosexual sex') been demonstrated to initiate o sustain rapid HIV propagation. HIV is not transmitted by 'sex', but only by specific risky practices. It is not transmitted by 'injections', but only by contaminated implements, which need to be clearly differentiated as to type and frequency of injection and by the conditions of the exposure setting. In virtually all societies affected by HIV to date, both routes seem to play important roles. If we are to understand and intervene in each of these epidemics, well-designed studies at both the population and individual levels are urgently needed. It is vital that these be properly controlled for parenteral exposure, specific sexual practices, and other co-factors2,17,24,32 and the complex and specific social patterns and networks that accompany them33. Dispassionate assessment of our conclusions admittedly depends on a willing suspension of disbelief, since the current paradigm is deeply embedded. Counter arguments can (and will) be levelled at each of the anomalies noted, but the depth and breadth of concerns deserve fair scrutiny. At issue in a re-evaluation of the heterosexual hypothesis are the profound implications for our interventive approach, and for the kinds of social and financial commitments that must be made. Finally, Africans deserve scientifically sound information on the epidemiologic determinants of their calamitous AIDS epidemic. References 1 Decosas J, Padian N. The profile and context of the epidemics of sexually transmitted infections including HIV in Zimbabwe. Sex Transm Infect 2002;78(Suppl 1):140-6 2 Potterat JJ, Brody S. HIV epidemicity in context of STI declines: a telling discordance (letter). Sex Transm Infect 2002; 78:467 [Full Text] 3 Buve A, Carael M, Hayes RJ, et al. The multicentre study on factors determining the differential spread of HIV in four African cities: summary and conclusions. AIDS 2001;5(Suppl 4):S127-31 [Abstract] 4 Rothenberg R, Potterat J, Gisselquist D. Concurrency and sexual transmission (letter). AIDS 2002;16:678-80 5 Gray RH, Wawer MJ, Brookmeyer R, et al. Probability of HIV-1 transmission per coital act in monogamous, heterosexual, HIV-1 discordant couples in Rakai, Uganda. Lancet 2001;357:1149-53 6 Downs AM, De Vicenzi I, European Group on Heterosexual Transmission of HIV: relationship to the number of unprotected sexual contacts. J Acquir Immune Defic Syndr 1996;11:388-95 7 Vachon F, Coulaud JP, Katlama C. Epidémiologie actuelle du syndrome d'immunodéficit acquis en dehors des groupes à risque. Presse Médicale 1985;14:1949-50 8 Gisselquist D, Potterat JJ. Heterosexual transmission of HIV in Africa: an empiric estimate. Int J STD AIDS 2003;14:162-73 9 Auvert B, Ballard R, Campbell C, et al. HIV infection among youth in a South African mining town is associated with herpes simplex virus-2 seropositivity and sexual behavior. AIDS 2001;15:883-98 10 Robinson NJ, Mulder DW, Auvert B, Hayes RJ. Modelling the impact of alternative HIV intervention strategies in rural Uganda. AIDS 1995;9:1263-70 [PubMed] 11 Carael M, Cleland J, Deheneffe J-C, Ferry B, Ingham R. Sexual behavior in developing countries: implications for HIV control. AIDS 1995;9:1171-5 12 Buve A, Lagarde E, Carael M, et al. Interpreting sexual behaviour data: validity issues in the multicentre study on factors determining the differential spread of HIV in four African cities. AIDS 2001;15(Suppl 4):S1117-26 [Abstract] 13 Thomas JC, Tucker MJ. The development and use of the concept of a sexually transmitted disease core. J Infect Dis 1996;176(Suppl 2):S134-43 [PubMed] 14 Potterat JJ, Muth SQ, Rothenberg RB, et al. Network structure as an indicator of epidemic phase. Sex Transm Infect 2002;78(Suppl 1):i152-8 15 Potterat JJ, Phillips-Plummer L, Muth SQ, et al. Risk network structure in the early epidemic phase of HIV transmission in Colorado Springs. Sex Transm Infect 2002; 78(Suppl 1):i159-63 16 Potterat JJ, Rothenberg RB, Muth SQ. Network structural dynamics and infectious disease propagation. Int J STD AIDS 1999;10:182-5 [PubMed] 17 Gisselquist D, Rothenberg R, Potterat J, et al. HIV infections in sub-Saharan Africa not explained by sexual or vertical transmission. Int J STD AIDS 2002;13:657-66 [PubMed] 18 Shisana O, Simbayi L, Bezuidenhout F, et al. Nelson Mandela/HSCR study of HIV/AIDS: South African national HIV prevalence, behavioural risks and mass media: household survey 2002. Cape Town, Human Sciences Research Council 2002. http://www.hsrc.ac.za/research/npa/SAHA/news/20021205Keynote.html 19 Simonsen L, Kane A, Lloyd J, et al. Unsafe injections in the developing world and transmission of bloodborne pathogens: a review. WHO Bull 1999;77:789-800 20 Gisselquist DP. Estimating HIV-1 transmission efficiency through unsafe medical injections. Int J STD AIDS 2002; 13:152-9 [Abstract] 21 Drucker EM, Alcabes PG, Marx PA. The injection century: consequences of massive unsterile injecting for the emergence of human pathogens. Lancet 2001;358:1989-92 22 Potterat JJ, Brody S. Does sex explain HIV transmission dynamics in developing countries? (Letter) Sex Transm Dis 2001;28:730 23 Grosskurth H, Gray R, Hayes R, et al. Control of sexually transmitted diseases for HIV-1 prevention: understanding the implications of the Mwanza and Rakai trials. Lancet 2000;355:1981-7 [PubMed] 24 Gisselquist D, Potterat J. Confound it: latent lessons from the Mwanza trial of STD treatment to reduce HIV transmission. Int J STD AIDS 2003;14:179-84 [Abstract] 25 Quinn TC, Mann JM, Curran JW, Piot P. AIDS in Africa: an epidemiologic paradigm. Science 1986;234:955-63 [Abstract] 26 Gisselquist D, Rothenberg R, Potterat J, Drucker E. Non-sexual transmission of HIV has been overlooked in developing countries (letter). BMJ 2002;324:235 27 Gisselquist D, Potterat J, Brody S, Vachon F. Let it be sexual: how health care transmission of AIDS in Africa was ignored. Int J STD AIDS 2003;14:148-61 28 Tokars JI, Marcus R, Culver DH. Surveillance of HIV infection and zidovudine use among health care workers after occupational exposure to HIV-infected blood. Ann Intern Med 1993;118:913-19 [Full Text] 29 Kaplan EH, Heimer R. A model-based estimate of HIV infectivity via needle sharing. JAIDS 1992;5:1116-18 [PubMed] 30 Royce RA, Sena A, Cates W Jr, Cohen MS. Sexual transmission of HIV. N Engl J Med 1997;336:1072-8 31 Madhava V, Burgess C, Drucker E. Epidemiology of chronic hepatitis C virus infection in sub-Saharan Africa. Lancet Infect Dis 2002;2:293-302 [PubMed] 32 Gisselquist D, Potterat JJ. Uncontrolled HSV-2 as a co-factor in HIV transmission (response to Sutcliffe et al.). JAIDS (in press) 33 Aral SO, Holmes KK. Social and behavioral determinants of the epidemiology of STDs: industrialized and developing countries, in Holmes KK, Sparling PF, Mårdh P-A, et al. (eds): Sexually transmitted diseases (3rd edn). New York: McGraw-Hill Book Co, Inc., 1999:39-76 (Accepted 15 December 2002) Correspondence to: Mr J J Potterat, 301 South Union Blvd, Colorado Springs, Colorado USA 80910 > Alex <avdeelen.REMOFETHIS1@wanadoo.nl> wrot > > Dr Chin says HIV prevalence is low in most populations throughout the worl > > and can be expected to remain low > > > He believes this is not because of effective HIV prevention work, but becaus > > infection rates are limited by the numbers in groups whose behaviour puts the > > at high risk > Africa has a hugely prevalent high risk perversion. Dry sex. This make > huge difference to the spread of all infections > http://www.cirp.org/library/disease/HIV/baleta1 Oh yes, the myth of 'dry sex'. If this is so good or widespread, ho come no one in the West is practicing it I thought this hoardy myth was buried at the same time as 'mosquito spread HIV' Chin's claim for exceptionalism in Africa is that people in Africa hav sex 'more often' than people in the rest of the world, not 'differently than people in the rest of the world Both claims of course are ridiculous, and an appeal to racis mythology, rather than common sense evidence or statistical proof Again, no one outside the AIDS indutry has proven that either exist Either claim would need confirmation from mainstream publications Ale http://www.virusmyth.net/aids/data/cgstereotypes.ht Aside from the voyeurism and the lack of verification that attends these sensationalist claims, n one has ever shown that people in Rwanda, Uganda, Zaire, and Kenya - the so-called "AIDS belt" - ar more sexually active than people in Nigeria which has reported only 21,905 AIDS cases out of population of 120 million or Cameroon which reported 13,576 cases in 14 million.(25) N continent-wide sex surveys have ever been carried out in Africa. Nevertheless, conventiona researchers perpetuate racist stereotypes about insatiable sexual appetites and carnal exotica. The assume that AIDS cases in Africa are driven by a sexual promiscuity similar to what produced - i combination with recreational drugs, sexual stimulants, venereal disease, and the over-use o antibiotics - the early epidemic of immunological dysfunction among a small sub-culture of urban ga men in the West.(26 The research from Africa suggests nothing of the sort. In 1991 researchers from Médicins San Frontières and the Harvard School of Public Health did a survey of sexual behavior in Moyo distric of northwest Uganda. Their findings revealed behavior that was not very different from that of th West. On average, women had their first sex at age 17, men at 19. Eighteen per cent of women and 50 of men reported premarital sex; 1.6% of the women and 4.1% of the men had had casual sex in th month preceding the study, while 2% of women and 15% of men had done so in the preceding year.(27 http://www.cirp.org/library/disease/HIV/brewer1 Mounting anomalies in the epidemiology of HI in Africa: cry the beloved paradig Devon D Brewer PhD1, Stuart Brody PhD2, Ernest Drucker PhD3 David Gisselquist PhD4, Stephen F Minkin BA6, John J Potterat BA5 Richard B Rothenberg MD MPH7 and François Vachon MD (Authors are listed alphabetically 1University of Washington, Seattle, Washington, USA, 2Institute of Medical Psychology and Behaviora Neurobiology, University of Tübingen, Germany, 3Department of Epidemiology and Social Medicine Montefiore Medical Center/Albert Einstein College of Medicine, New York City, USA, 4Hershey, PA USA, 5Colorado Springs, Colorado, USA, 6Network for Infection Prevention, Brattleboro, Vermon 05302, USA, 7 Department of Family and Preventive Medicine, Emory University School of Medicine Atlanta, GA, USA, 8University of Paris 7, Franc Keywords: HIV, Africa, risk factors, epidemiology, heterosexual transmission, medical transmissio Introductio There is substantial dissonance between much of the epidemiologic evidence and the current orthodox that nearly all of the HIV burden in sub-Saharan Africa can be accounted for by heterosexua transmission and the sexual behaviour of Africans. The mounting toll of HIV infection in Africa i paralleled by amounting number of anomalies in the many studies seeking to account for it. We propose that existing data can no longer be reconciled with the received wisdom about the exceptional role of sex in the African AIDS epidemic. Anomalies in sub-Saharan Africa Discontinuity between HIV and STIs During the 1990s HIV propagated rapidly in Zimbabwe, increasing at an estimated rate of 12% annually. At the same time, the overall sexually transmitted infections (STI) burden declined an estimated 25% and while there was a parallel increase in reported condom use by high-risk persons (prostitutes, lorry drivers, miners, and young people)1. This example frames the problem: why would a relatively low efficiency sexually transmitted virus like HIV outrun more efficiently transmitted STI2? In the notable four-cities study3, many common sexual risk factors linked to HIV transmission (eg, high rate of partner change, sex with prostitutes, and low condom use) were not correlated with HIV prevalence-although some risk markers (young age at first coitus or marriage, large age difference between partners) and presumed facilitating factors (lack of circumcision, genital herpes, and trichomoniasis, but not bacterial STI) were. In addition, concurrency of sexual partnerships was not correlated with HIV prevalence, yet was associated with bacterial STI4.It is of concern that many key sexual transmission variables are not associated with a large HIV epidemic in Africa, yet do correlate, as expected, with other STIs. Transmission efficiency A study of HIV transmission efficiency in Africa, using data from serodiscordant couples5, produced estimates remarkably similar to those reported for couples in the developed world6. Observed probabilities presumably reflect some of the influence of facilitating factors (eg, unorthodox sexual practices, circumcision status, STI exposure, etc) recruited to explain the 'turbo effect'7 noted in Africa's epidemiologic context. Recent empiric research casts doubt that such co-factors can sufficiently amplify the force of infectivity to account for observed trends in the sexual transmission of HIV in Africa8. The anomalies regarding transmission efficiency are well illustrated by a recent study in South Africa9. The authors recognized that, to explain HIV acquisition by 16-18 year old women in their study, they needed to postulate a per partnership transmission probability of 0.92 (0.49, assuming double the number of reported partnerships per woman). By extension, the per-contact probability of transmission would be 0.34, making heterosexual sex in this context second only to transfusion in HIV transmission efficiency. Similarly, a model developed to assess the impact of STI on transmission of HIV posited an extraordinary 33-fold increase in transmission efficiency of the latter in the presence of the former10. Reported sexual activity Levels of sexual activity reported in a dozen general population surveys in Africa11 are comparable to those reported elsewhere, especially in North America and Europe. Perhaps more importantly, there appears to be little correlation with the level of risky sexual behaviour shown in these surveys and the epidemic trajectories observed in these countries. (Comparison with country-specific data reported by UNAIDS 2000; data not shown.) The four-city study provides similar discordance12. For example, Yaounde (in Cameroon, a nation with low and stable prevalence) had the highest level of risky behavioural markers. Ndola (in Zambia, a nation that has experienced a rapid rise in HIV) had the smallest proportion of both men and women who reported a non-spousal sex partner in the previous 12 months. Ndola's other markers were similar to those in Dakar, Senegal and Cotonou, Benin, other areas with low, stable prevalence. Transmission dynamics Rapid propagation (of at least bacterial STI) has been associated with core groups13, which make up a small proportion of the susceptible population and are proposed to be responsible for most community transmission. Such groups appear to be associated with differing forms of sexual net-work 'geometry'. This geometry demonstrably differs with transmission intensity14-16. Evidence suggests that endemic and declining HIV/STI burdens are associated with dendritic (many open-ended termini) patterns of sexual partner connections, while epidemicity is associated with cyclic (closed loops, reflecting cohesiveness and density) patterns. There are few data on the architecture of sociosexual networks in Africa, but the available information suggests predominantly dendritic patterns (eg, contact with prostitutes and then contact with stable and usually monogamous consorts who are network termini). We are aware of no study from sub-Saharan Africa suggesting cyclic sexual network architecture. Without evidence of appropriate network configurations on a scale considerably larger than that observed in developed countries, rapid propagation of HIV in Africa would be difficult to sustain. Studies have associated putative sexual core groups with HIV transmission in Africa. For example, women who work as prostitutes and their partners have frequently been observed to have high HIV prevalence. Confusion may arise, however, over conflating the terms 'high risk person' and 'core group'. The former have been labelled in some way, but are not necessarily part of an interconnected group of individuals through whom infection percolates (ie, core group). As noted, such persons would have to be part of an interactive, cyclic group, rather than nodes along a dendritic chain. Other anomalous findings A higher HIV prevalence has been observed in women seen in prenatal, postpartum, and induced abortion settings than in their community counter-parts17. In a number of studies, there appears to be a discrepancy between the observed prevalence in women undergoing reproductive medical care, and the prevalence that would be observed in such a group from heterosexual transmission alone. Though few in number, there continue to be reports of HIV seropositivity in persons denying coital exposure and in persons claiming a sole lifetime sexual partner who is reportedly HIV negative17. Similarly, there are persistent reports of HIV in infants with seronegative mothers17. A recent large survey from South Africa measured an HIV prevalence of 5.6% in children 2-14 years of age 18. Given mortality from HIV among children who acquire it in Africa, there would appear to be a substantial proportion of such a disease burden that is unexplained by maternal and sexual transmission. Alternatives A number of these observations raise the question of an alternative route of transmission, for which medical care and the use of injections are prime candidates17,19-22. Prostitutes, for example, are often recruited for studies from STI clinics, where treatment is frequently given by injection, where non-sterile equipment is used with high frequency, and wherein the underlying prevalence of HIV is high7. Many studies that have assessed the impact of sexual activity on HI transmission -notably those in Mwanza and Rakai, whose discordant results are still a subject o debate23-failed to consider the potential confounding effects of medical care in the propagation o HIV24 Rapid HIV transmission in Africa has often occurred in countries with good access to medical care like Botswana, Zimbabwe, and South Africa. For example, high rates in rural South Africa hav paralleled aggressive efforts to deliver health care to rural populations. It is difficult t understand how improved access to health care, with its offers of public health messages, fre condoms, and preventive services, would be associated with increased HIV transmission. Similarly HIV prevalence is often higher in cities and among persons of high socioeconomic attainment than i rural areas or among less fortunate persons. Favourable access to health care is one of th differences that distinguishes between these groups Reactions to the anomalies and alternative Since early in the African epidemic, when AIDS was demographically associated with sexually activ populations25, studies of HIV transmission in Africa have generally failed to control for possibl parenteral confounding26. The importance of this route of infection was well known in the West an in Asia but quickly dismissed in Africa27. The risk of parenteral transmission of HIV is based o good estimates of transmission efficiency, which varies depending on type of injection an circumstances that produce reuse of contaminated equipment. For example, needle stick exposure (HI transmission probability: about one in 30028, medical injection (recently estimated at approximatel one in 3020), or illicit-drug injection (about one in 10029), is much more efficient tha penile-vaginal exposure (about one in 100030) There is the expectation that, were iatrogenic transmission of HIV common, one would notic substantial HIV prevalence in populations of (non-sexually experienced) children. Regrettably although a large proportion of Africa's population falls in that category, few serosurveys conducte in Africa have included large enough samples from, say, children aged five through 12 to confidentl dismiss this possibility. As more information accumulates that addresses this issue, a cleare perspective on the magnitude of non-sexual, non-maternal transmission in children will emerge The risk of exposure to HIV via medical injections is likely to vary with background prevalence an with the specific medical practices in different settings. The demand for consistency and coherenc that we have placed on the heterosexual hypothesis should be applied to estimating the role o medical transmission. Its role should vary with background (initial) prevalence, and should b related to the degree of medical hygiene exercised. The same biological basis that exists fo heterosexual transmission should be established for medical transmission. (As an aside, such demonstration poses substantial ethical problems. No investigator should knowingly observe the us of a needle that has a high probability of being contaminated with HIV, but at a minimum, th demonstration of HIV RNA in needles that were to have been used on patients would be an importan element in establishing a biological base.) The transmission of blood-borne pathogens with differin biological characteristics, notably hepatitis B and C31, should be consistent with parentera transmission of HIV. Finally, the social epidemiology of HIV (male to female ratios, for example should be consistent with observations about non-sexual exposure Conclusio In North America, Europe, and many parts of Asia, the ignition of regional epidemics and rapid HI transmission has been associated principally with the sharing of contaminated injecting equipmen and with anal intercourse. Though heterosexual intercourse has been virtually the sole explanatio offered for the AIDS epidemic in sub-Saharan Africa, to our knowledge in no other part of the worl has penile-vaginal exposure (as opposed to 'heterosexual sex') been demonstrated to initiate o sustain rapid HIV propagation. HIV is not transmitted by 'sex', but only by specific risky practices. It is not transmitted by 'injections', but only by contaminated implements, which need to be clearly differentiated as to type and frequency of injection and by the conditions of the exposure setting. In virtually all societies affected by HIV to date, both routes seem to play important roles. If we are to understand and intervene in each of these epidemics, well-designed studies at both the population and individual levels are urgently needed. It is vital that these be properly controlled for parenteral exposure, specific sexual practices, and other co-factors2,17,24,32 and the complex and specific social patterns and networks that accompany them33. Dispassionate assessment of our conclusions admittedly depends on a willing suspension of disbelief, since the current paradigm is deeply embedded. Counter arguments can (and will) be levelled at each of the anomalies noted, but the depth and breadth of concerns deserve fair scrutiny. At issue in a re-evaluation of the heterosexual hypothesis are the profound implications for our interventive approach, and for the kinds of social and financial commitments that must be made. Finally, Africans deserve scientifically sound information on the epidemiologic determinants of their calamitous AIDS epidemic. References 1 Decosas J, Padian N. The profile and context of the epidemics of sexually transmitted infections including HIV in Zimbabwe. Sex Transm Infect 2002;78(Suppl 1):140-6 2 Potterat JJ, Brody S. HIV epidemicity in context of STI declines: a telling discordance (letter). Sex Transm Infect 2002; 78:467 [Full Text] 3 Buve A, Carael M, Hayes RJ, et al. The multicentre study on factors determining the differential spread of HIV in four African cities: summary and conclusions. AIDS 2001;5(Suppl 4):S127-31 [Abstract] 4 Rothenberg R, Potterat J, Gisselquist D. Concurrency and sexual transmission (letter). AIDS 2002;16:678-80 5 Gray RH, Wawer MJ, Brookmeyer R, et al. Probability of HIV-1 transmission per coital act in monogamous, heterosexual, HIV-1 discordant couples in Rakai, Uganda. Lancet 2001;357:1149-53 6 Downs AM, De Vicenzi I, European Group on Heterosexual Transmission of HIV: relationship to the number of unprotected sexual contacts. J Acquir Immune Defic Syndr 1996;11:388-95 7 Vachon F, Coulaud JP, Katlama C. Epidémiologie actuelle du syndrome d'immunodéficit acquis en dehors des groupes à risque. Presse Médicale 1985;14:1949-50 8 Gisselquist D, Potterat JJ. Heterosexual transmission of HIV in Africa: an empiric estimate. Int J STD AIDS 2003;14:162-73 9 Auvert B, Ballard R, Campbell C, et al. HIV infection among youth in a South African mining town is associated with herpes simplex virus-2 seropositivity and sexual behavior. AIDS 2001;15:883-98 10 Robinson NJ, Mulder DW, Auvert B, Hayes RJ. Modelling the impact of alternative HIV intervention strategies in rural Uganda. AIDS 1995;9:1263-70 [PubMed] 11 Carael M, Cleland J, Deheneffe J-C, Ferry B, Ingham R. Sexual behavior in developing countries: implications for HIV control. AIDS 1995;9:1171-5 12 Buve A, Lagarde E, Carael M, et al. Interpreting sexual behaviour data: validity issues in the multicentre study on factors determining the differential spread of HIV in four African cities. AIDS 2001;15(Suppl 4):S1117-26 [Abstract] 13 Thomas JC, Tucker MJ. The development and use of the concept of a sexually transmitted disease core. J Infect Dis 1996;176(Suppl 2):S134-43 [PubMed] 14 Potterat JJ, Muth SQ, Rothenberg RB, et al. Network structure as an indicator of epidemic phase. Sex Transm Infect 2002;78(Suppl 1):i152-8 15 Potterat JJ, Phillips-Plummer L, Muth SQ, et al. Risk network structure in the early epidemic phase of HIV transmission in Colorado Springs. Sex Transm Infect 2002; 78(Suppl 1):i159-63 16 Potterat JJ, Rothenberg RB, Muth SQ. Network structural dynamics and infectious disease propagation. Int J STD AIDS 1999;10:182-5 [PubMed] 17 Gisselquist D, Rothenberg R, Potterat J, et al. HIV infections in sub-Saharan Africa not explained by sexual or vertical transmission. Int J STD AIDS 2002;13:657-66 [PubMed] 18 Shisana O, Simbayi L, Bezuidenhout F, et al. Nelson Mandela/HSCR study of HIV/AIDS: South African national HIV prevalence, behavioural risks and mass media: household survey 2002. Cape Town, Human Sciences Research Council 2002. http://www.hsrc.ac.za/research/npa/SAHA/news/20021205Keynote.html 19 Simonsen L, Kane A, Lloyd J, et al. Unsafe injections in the developing world and transmission of bloodborne pathogens: a review. WHO Bull 1999;77:789-800 20 Gisselquist DP. Estimating HIV-1 transmission efficiency through unsafe medical injections. Int J STD AIDS 2002; 13:152-9 [Abstract] 21 Drucker EM, Alcabes PG, Marx PA. The injection century: consequences of massive unsterile injecting for the emergence of human pathogens. Lancet 2001;358:1989-92 22 Potterat JJ, Brody S. Does sex explain HIV transmission dynamics in developing countries? (Letter) Sex Transm Dis 2001;28:730 23 Grosskurth H, Gray R, Hayes R, et al. Control of sexually transmitted diseases for HIV-1 prevention: understanding the implications of the Mwanza and Rakai trials. Lancet 2000;355:1981-7 [PubMed] 24 Gisselquist D, Potterat J. Confound it: latent lessons from the Mwanza trial of STD treatment to reduce HIV transmission. Int J STD AIDS 2003;14:179-84 [Abstract] 25 Quinn TC, Mann JM, Curran JW, Piot P. AIDS in Africa: an epidemiologic paradigm. Science 1986;234:955-63 [Abstract] 26 Gisselquist D, Rothenberg R, Potterat J, Drucker E. Non-sexual transmission of HIV has been overlooked in developing countries (letter). BMJ 2002;324:235 27 Gisselquist D, Potterat J, Brody S, Vachon F. Let it be sexual: how health care transmission of AIDS in Africa was ignored. Int J STD AIDS 2003;14:148-61 28 Tokars JI, Marcus R, Culver DH. Surveillance of HIV infection and zidovudine use among health care workers after occupational exposure to HIV-infected blood. Ann Intern Med 1993;118:913-19 [Full Text] 29 Kaplan EH, Heimer R. A model-based estimate of HIV infectivity via needle sharing. JAIDS 1992;5:1116-18 [PubMed] 30 Royce RA, Sena A, Cates W Jr, Cohen MS. Sexual transmission of HIV. N Engl J Med 1997;336:1072-8 31 Madhava V, Burgess C, Drucker E. Epidemiology of chronic hepatitis C virus infection in sub-Saharan Africa. Lancet Infect Dis 2002;2:293-302 [PubMed] 32 Gisselquist D, Potterat JJ. Uncontrolled HSV-2 as a co-factor in HIV transmission (response to Sutcliffe et al.). JAIDS (in press) 33 Aral SO, Holmes KK. Social and behavioral determinants of the epidemiology of STDs: industrialized and developing countries, in Holmes KK, Sparling PF, Mårdh P-A, et al. (eds): Sexually transmitted diseases (3rd edn). New York: McGraw-Hill Book Co, Inc., 1999:39-76 (Accepted 15 December 2002) Correspondence to: Mr J J Potterat, 301 South Union Blvd, Colorado Springs, Colorado USA 80910 > Alex <avdeelen.REMOFETHIS1@wanadoo.nl> wrot > > Dr Chin says HIV prevalence is low in most populations throughout the worl > > and can be expected to remain low > > > He believes this is not because of effective HIV prevention work, but becaus > > infection rates are limited by the numbers in groups whose behaviour puts the > > at high risk > Africa has a hugely prevalent high risk perversion. Dry sex. This make > huge difference to the spread of all infections > http://www.cirp.org/library/disease/HIV/baleta1 Oh yes, the myth of 'dry sex'. If this is so good or widespread, ho come no one in the West is practicing it I thought this hoardy myth was buried at the same time as 'mosquito spread HIV' Chin's claim for exceptionalism in Africa is that people in Africa hav sex 'more often' than people in the rest of the world, not 'differently than people in the rest of the world Both claims of course are ridiculous, and an appeal to racis mythology, rather than common sense evidence or statistical proof Again, no one outside the AIDS indutry has proven that either exist Either claim would need confirmation from mainstream publications Ale http://www.virusmyth.net/aids/data/cgstereotypes.ht Aside from the voyeurism and the lack of verification that attends these sensationalist claims, n one has ever shown that people in Rwanda, Uganda, Zaire, and Kenya - the so-called "AIDS belt" - ar more sexually active than people in Nigeria which has reported only 21,905 AIDS cases out of population of 120 million or Cameroon which reported 13,576 cases in 14 million.(25) N continent-wide sex surveys have ever been carried out in Africa. Nevertheless, conventiona researchers perpetuate racist stereotypes about insatiable sexual appetites and carnal exotica. The assume that AIDS cases in Africa are driven by a sexual promiscuity similar to what produced - i combination with recreational drugs, sexual stimulants, venereal disease, and the over-use o antibiotics - the early epidemic of immunological dysfunction among a small sub-culture of urban ga men in the West.(26 The research from Africa suggests nothing of the sort. In 1991 researchers from Médicins San Frontières and the Harvard School of Public Health did a survey of sexual behavior in Moyo distric of northwest Uganda. Their findings revealed behavior that was not very different from that of th West. On average, women had their first sex at age 17, men at 19. Eighteen per cent of women and 50 of men reported premarital sex; 1.6% of the women and 4.1% of the men had had casual sex in th month preceding the study, while 2% of women and 15% of men had done so in the preceding year.(27 http://www.cirp.org/library/disease/HIV/brewer1 Mounting anomalies in the epidemiology of HI in Africa: cry the beloved paradig Devon D Brewer PhD1, Stuart Brody PhD2, Ernest Drucker PhD3 David Gisselquist PhD4, Stephen F Minkin BA6, John J Potterat BA5 Richard B Rothenberg MD MPH7 and François Vachon MD (Authors are listed alphabetically 1University of Washington, Seattle, Washington, USA, 2Institute of Medical Psychology and Behaviora Neurobiology, University of Tübingen, Germany, 3Department of Epidemiology and Social Medicine Montefiore Medical Center/Albert Einstein College of Medicine, New York City, USA, 4Hershey, PA USA, 5Colorado Springs, Colorado, USA, 6Network for Infection Prevention, Brattleboro, Vermon 05302, USA, 7 Department of Family and Preventive Medicine, Emory University School of Medicine Atlanta, GA, USA, 8University of Paris 7, Franc Keywords: HIV, Africa, risk factors, epidemiology, heterosexual transmission, medical transmissio Introductio There is substantial dissonance between much of the epidemiologic evidence and the current orthodox that nearly all of the HIV burden in sub-Saharan Africa can be accounted for by heterosexua transmission and the sexual behaviour of Africans. The mounting toll of HIV infection in Africa i paralleled by amounting number of anomalies in the many studies seeking to account for it. We propose that existing data can no longer be reconciled with the received wisdom about the exceptional role of sex in the African AIDS epidemic. Anomalies in sub-Saharan Africa Discontinuity between HIV and STIs During the 1990s HIV propagated rapidly in Zimbabwe, increasing at an estimated rate of 12% annually. At the same time, the overall sexually transmitted infections (STI) burden declined an estimated 25% and while there was a parallel increase in reported condom use by high-risk persons (prostitutes, lorry drivers, miners, and young people)1. This example frames the problem: why would a relatively low efficiency sexually transmitted virus like HIV outrun more efficiently transmitted STI2? In the notable four-cities study3, many common sexual risk factors linked to HIV transmission (eg, high rate of partner change, sex with prostitutes, and low condom use) were not correlated with HIV prevalence-although some risk markers (young age at first coitus or marriage, large age difference between partners) and presumed facilitating factors (lack of circumcision, genital herpes, and trichomoniasis, but not bacterial STI) were. In addition, concurrency of sexual partnerships was not correlated with HIV prevalence, yet was associated with bacterial STI4.It is of concern that many key sexual transmission variables are not associated with a large HIV epidemic in Africa, yet do correlate, as expected, with other STIs. Transmission efficiency A study of HIV transmission efficiency in Africa, using data from serodiscordant couples5, produced estimates remarkably similar to those reported for couples in the developed world6. Observed probabilities presumably reflect some of the influence of facilitating factors (eg, unorthodox sexual practices, circumcision status, STI exposure, etc) recruited to explain the 'turbo effect'7 noted in Africa's epidemiologic context. Recent empiric research casts doubt that such co-factors can sufficiently amplify the force of infectivity to account for observed trends in the sexual transmission of HIV in Africa8. The anomalies regarding transmission efficiency are well illustrated by a recent study in South Africa9. The authors recognized that, to explain HIV acquisition by 16-18 year old women in their study, they needed to postulate a per partnership transmission probability of 0.92 (0.49, assuming double the number of reported partnerships per woman). By extension, the per-contact probability of transmission would be 0.34, making heterosexual sex in this context second only to transfusion in HIV transmission efficiency. Similarly, a model developed to assess the impact of STI on transmission of HIV posited an extraordinary 33-fold increase in transmission efficiency of the latter in the presence of the former10. Reported sexual activity Levels of sexual activity reported in a dozen general population surveys in Africa11 are comparable to those reported elsewhere, especially in North America and Europe. Perhaps more importantly, there appears to be little correlation with the level of risky sexual behaviour shown in these surveys and the epidemic trajectories observed in these countries. (Comparison with country-specific data reported by UNAIDS 2000; data not shown.) The four-city study provides similar discordance12. For example, Yaounde (in Cameroon, a nation with low and stable prevalence) had the highest level of risky behavioural markers. Ndola (in Zambia, a nation that has experienced a rapid rise in HIV) had the smallest proportion of both men and women who reported a non-spousal sex partner in the previous 12 months. Ndola's other markers were similar to those in Dakar, Senegal and Cotonou, Benin, other areas with low, stable prevalence. Transmission dynamics Rapid propagation (of at least bacterial STI) has been associated with core groups13, which make up a small proportion of the susceptible population and are proposed to be responsible for most community transmission. Such groups appear to be associated with differing forms of sexual net-work 'geometry'. This geometry demonstrably differs with transmission intensity14-16. Evidence suggests that endemic and declining HIV/STI burdens are associated with dendritic (many open-ended termini) patterns of sexual partner connections, while epidemicity is associated with cyclic (closed loops, reflecting cohesiveness and density) patterns. There are few data on the architecture of sociosexual networks in Africa, but the available information suggests predominantly dendritic patterns (eg, contact with prostitutes and then contact with stable and usually monogamous consorts who are network termini). We are aware of no study from sub-Saharan Africa suggesting cyclic sexual network architecture. Without evidence of appropriate network configurations on a scale considerably larger than that observed in developed countries, rapid propagation of HIV in Africa would be difficult to sustain. Studies have associated putative sexual core groups with HIV transmission in Africa. For example, women who work as prostitutes and their partners have frequently been observed to have high HIV prevalence. Confusion may arise, however, over conflating the terms 'high risk person' and 'core group'. The former have been labelled in some way, but are not necessarily part of an interconnected group of individuals through whom infection percolates (ie, core group). As noted, such persons would have to be part of an interactive, cyclic group, rather than nodes along a dendritic chain. Other anomalous findings A higher HIV prevalence has been observed in women seen in prenatal, postpartum, and induced abortion settings than in their community counter-parts17. In a number of studies, there appears to be a discrepancy between the observed prevalence in women undergoing reproductive medical care, and the prevalence that would be observed in such a group from heterosexual transmission alone. Though few in number, there continue to be reports of HIV seropositivity in persons denying coital exposure and in persons claiming a sole lifetime sexual partner who is reportedly HIV negative17. Similarly, there are persistent reports of HIV in infants with seronegative mothers17. A recent large survey from South Africa measured an HIV prevalence of 5.6% in children 2-14 years of age 18. Given |
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