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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 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 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 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 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 > > 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/ > > Oh yes, the myth of 'dry sex'. If this is so good or widespread, how > come no one in the West is practicing it? Why should they copy crazy african habits? Apparently african males find it more pleasurable when the woman has painful coitus. The women are forced to seek herbal 'remedies' that keep their tw*ts dry. I'm surprised you missed this, it was even discussed in the more serious dutch newspapers in connection with Mr Zuma's raping of an HIV+ woman while he was chaiman of the S.African AIDS council (and vice president of the country!) > 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. of course they do, mainly more casual sex. > Both claims of course are ridiculous, and an appeal to racist > mythology, rather than common sense evidence or statistical proof. [quoted text clipped - 3 lines] > > Alex <snip> > Mounting anomalies in the epidemiology of HIV in Africa: cry the beloved > paradigm [quoted text clipped - 11 lines] > 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 [quoted text clipped - 18 lines] > Transmission efficiency > A study of HIV transmission efficiency in Africa, using data from <snip> > Reported sexual activity > Levels of sexual activity reported in a dozen general population surveys [quoted text clipped - 10 lines] > 12 months. Ndola's other markers were similar to those in Dakar, Senegal > and Cotonou, Benin, other areas with low, stable prevalence. they lie more the further south they live...? <snip> > 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. Hello?... Never heard of african pedophilic behaviour (AKA virgin rape) as the recommended cure for AIDS by witchdoctors? >Alternatives > A number of these observations raise the question of an alternative route [quoted text clipped - 7 lines] > debate -failed to consider the potential confounding effects of medical > care in the propagation of HIV. Medical 'care'? Oh, right, the hospitals are to blame. Mind you, anythings possible in Africa. However there is no reason for healthy pregnant females to be getting injections in Africa. No molly-coddling pregnant women there. The bottom line which this bunch of liberal aid workers ignore is: The more you f.ck around the more likely it is you'll become pregnant and thus more likely to end up in a prenatal clinic (and in their HIV statistics). > Rapid HIV transmission in Africa has often occurred in countries with good > access to medical care, like Botswana, Zimbabwe, and South Africa. For [quoted text clipped - 7 lines] > health care is one of the differences that distinguishes between these > groups. More access = more testing = 'higher' rates.. > Reactions to the anomalies and alternatives <snip> > Dispassionate assessment of our conclusions admittedly depends on a > willing suspension of disbelief, since the current paradigm is deeply [quoted text clipped - 5 lines] > deserve scientifically sound information on the epidemiologic determinants > of their calamitous AIDS epidemic. References So basically black doctors & nurses are so ignorant they are infecting their people with HIV by injections with dirty needles and its not due to lots of sex. The millions of HIV-infected 'patients' doesn't gel with the lax work ethic in Africa, they could never have given so many a dirty jab. bigD "bigdude" <dude@JRranch.com> wrote in message > Why should they copy crazy african habits? Apparently african males find > it more pleasurable when the woman has painful coitus. The women are [quoted text clipped - 3 lines] > while he was chaiman of the S.African AIDS council (and vice president > of the country!) Alleged rape. He was acquitted of the rape charge. He admitted to having unprotected sex with her, but that was ok, in his books, because he showered afterwards. -- Moira de Swardt posting from Johannesburg, South Africa Remove the dot in my address to find me at home. > "bigdude" <dude@JRranch.com> wrote in message > [quoted text clipped - 9 lines] > having unprotected sex with her, but that was ok, in his books, > because he showered afterwards. Yes, and OJ didn't massacre his ex.. C'mon Moira, justice was a van der Merwe joke in JZ's case. I bet he's bought himself a possie in Hawaii by now. Money talks in SA like it does in the USA, not to mention the threat of violence.. SignaturebigD "bigdude" <dude@JRranch.com> wrote in message > > Alleged rape. He was acquitted of the rape charge. He admitted to > > having unprotected sex with her, but that was ok, in his books, > > because he showered afterwards. > Yes, and OJ didn't massacre his ex.. > C'mon Moira, justice was a van der Merwe joke in JZ's case. Having followed the case, I'm not any more sure that it was rape than the court was. > I bet he's bought himself a possie in Hawaii by now. > Money talks in SA like it does in the USA, not to mention the threat of > violence.. Just because one is a thoroughly destestable bastard doesn't mean one is guilty of everything levelled at one. -- Moira de Swardt posting from Johannesburg, South Africa Remove the dot in my address to find me at home. > "bigdude" <dude@JRranch.com> wrote in message > [quoted text clipped - 8 lines] > Having followed the case, I'm not any more sure that it was rape > than the court was. I am profoundly surprised, and dissapointed that you would actually come to a conclusion like that. Having followed the case from a certain mindset. You possibly did not get the part about the culture of rape that existed in the liberation camps, or how it was interpreted in the context of the JZ case as being a man's privelege. But then hey the woman wore nothing under her nightie, so it is alright! This was therefore not the first rape that was justified by the old "you had it coming sweetie" argument. > > I bet he's bought himself a possie in Hawaii by now. > > Money talks in SA like it does in the USA, not to mention the [quoted text clipped - 3 lines] > Just because one is a thoroughly destestable bastard doesn't mean > one is guilty of everything levelled at one. In the case of JZ he is not a thoroughly detestable bastard. He is a very charming person who would bowl you over if he met you socially. He has also done some very noble and excellent work in his time. It is however very sad that he has gone bad like all of the other ANC heroes. Is it not sad that there are men who would compromise their struggle credentials and sell their integrity for a few rands. Is it not also sad that they would allow their old age and diabetic condition to propel themselves into these desperate sexual activities that are frequently reported and sometimes brought to court. ----------------- I dunno if the skinny from people in the protection services is always true, perhaps there is a lot of urban legend, but I empathise with the one that supports the case for increased supply of AZT to AIDS sufferers instead of massive booster vitamin B and Insulin injections and 150 Mg strength Viagra on a daily basis to ageing politicians. Maybe the invigorating effect of having a cold shower instead would stimulate the circulation and get the old blood flowing. But ey - Aren't you glad that none of our politicians have these problems. (Aaah I can hear the outcry - COLD SHOWERS DO NOT STIMULATE SMALL CAPILLARY BLOOD FLOW. - Yes they do if you have a nice run, jog and exercise beforehand.) "Skokkie" <glenton@hotmail.com> wrote in message > "Moira de Swardt" <moira.ds@wol.co.za> wrote in message > > Having followed the case, I'm not any more sure that it was rape > > than the court was. > I am profoundly surprised, and dissapointed that you would actually come to > a conclusion like that. The first two days, while her side of the story was being told, I was very sympathetic to her story. Once his side of the story started to be told, I heard things which made me doubt the exact story as she told it. I can't remember exactly which piece of evidence swayed me over to the belief that Zuma was, in fact, not guilty of rape in this case, but there was something. > Having followed the case from a certain mindset. You possibly did not get > the part about the culture of rape that existed in the liberation camps, or [quoted text clipped - 3 lines] > therefore not the first rape that was justified by the old "you had it > coming sweetie" argument. The perception that "all men are raping bastards who should be castrated" is not always accurate. The fact that Zuma was guilty of very poor judgment, and breaking his marriage vows, doesn't actually mean that he raped the woman. > > Just because one is a thoroughly destestable bastard doesn't mean > > one is guilty of everything levelled at one. > In the case of JZ he is not a thoroughly detestable bastard. He is a very > charming person who would bowl you over if he met you socially. He has also > done some very noble and excellent work in his time. It is however very sad > that he has gone bad like all of the other ANC heroes. Well, there one has it. I'm not a fan, but then I haven't ever met him. > Is it not sad that there are men who would compromise their struggle > credentials and sell their integrity for a few rands. Is it not also sad > that they would allow their old age and diabetic condition to propel > themselves into these desperate sexual activities that are frequently > reported and sometimes brought to court. Sometimes maliciously reported. -- Moira de Swardt posting from Johannesburg, South Africa Remove the dot in my address to find me at home. > "bigdude" <dude@JRranch.com> wrote in message > [quoted text clipped - 14 lines] > having unprotected sex with her, but that was ok, in his books, > because he showered afterwards. Where is the Reverend Haggard when you need him? Again, nothing out of the ordinary. Alex > "bigdude" <dude@JRranch.com> wrote in messag > > Why should they copy crazy african habits? Apparently africa > males fin [quoted text clipped - 8 lines] > presiden > > of the country! > Alleged rape. He was acquitted of the rape charge. He admitted t > having unprotected sex with her, but that was ok, in his books > because he showered afterwards Where is the Reverend Haggard when you need him Again, nothing out of the ordinary Ale 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 vector for transmission in the west, why should it b in Africa The truth is, there is no epidemic, and that is that http://news.bbc.co.uk/2/hi/health/6321683.st Expert doubts widespread HIV ris Intravenous drug use Intravenous drug users are a key high-risk grou 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 Afric are unlikely to contract HIV/Aids, as it is restricted to certain high-risk groups Campaigners have promoted a message of safer sex which involve the use of condoms for protection UK experts said Dr Chin's views were inaccurate, and misrepresente current thinking among HIV/Aids bodies 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 Dr Chin says it is only in sub-Saharan Africa, where unprotected sex outsid 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 se with other men, intravenous drug users and female sex workers And he says that, unless the clients or partners of people in these group 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" b UNAids and Aids activists because it is "politically and socially mor acceptable" to say HIV risk behaviours are present in all populations Writing in "The Aids Pandemic", Dr Chin says: "These activists do not wan to further stigmatise persons or population groups who have such high ris levels of HIV risk behaviours and who are already marginalised "By refusing to accept the fact that HIV is very difficult to transmit sexuall without the highest levels of sexual risk behaviours, Aids programmes hav avoided labelling some populations as being more promiscuous than others "It is a much more socially and politically correct public health message t say that sexual promiscuity exists in all populations and thus the risk o epidemic heterosexual HIV transmission to the general public, or t ordinary people can be prevented only by aggressive programme directed at the general population, and especially to youth. He cited studies which showed the risk of someone in the genera population of contracting HIV from any single sexual act was, a the highest estimate, one in 1,000 And he says the failure to recognise this means that scarce public healt resources in countries where HIV prevalence is low are being waste on prevention programmes being targeted at the public, when it is th high-risk groups who should be targeted 'Disservice Dr Purnima Mane, director of policy evidence and partnerships at UNAid said: "Without having access to the full text of the book, it is very difficul for UNAids to comment on it. But she said: "The Aids response has always invited a high-level of debat and discussion. UNAids welcomes this debate and stands by its scientifi approach "Twenty-five years into the Aids epidemic has shown the world how th 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 sai Dr Chin's views may have been accurate 10 to 15 years ago, bu were not true now "He is overstating his case. Sub-Saharan Africa is not the only plac to have heterosexual epidemics and most AIDS activists no longe 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. On Sun, 4 Feb 2007 00:41:52 -0000, "Alex" <avdeelen.REMOFETHIS1@wanadoo.nl wrote >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 >vector for transmission in the west, why should it b >in Africa Who are "them" What "exceptionalist reasoning" Rest of article binned, becaus a) the subject line indicates that it isn't worth readin <PEDANT b) If you can't say clearly in the subject line and first paragraph what it' about, it's probably not worth reading </pedant -- Terms and conditions apply. Steve Haye hayesmstw@hotmail.co 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 Unfortunately, public education in this regard wouldn't make us the bigges potential market for .. anything As everyone that's at all informed knows, lesion-causing virus-permeabl condoms, extremely deadly poisons and unlikely abstinence are the entir 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 b made. Invest in big pharm. Place a bet on who manages to pull off a P campaign to force their vaccines on schoolchildren. Maybe one of them ca convince us that with 100000000000 of us getting infected every minute o so, we'd better just buy all their stocks of AZT and put it in our wate supply. Big money Love, however it look -- Rahasy nospam_rahasya@meditate.co.z 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 vector for transmission in the west, why should it b in Africa The truth is, there is no epidemic, and that is that http://news.bbc.co.uk/2/hi/health/6321683.st Expert doubts widespread HIV ris Intravenous drug use Intravenous drug users are a key high-risk grou 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 Afric are unlikely to contract HIV/Aids, as it is restricted to certain high-risk groups Campaigners have promoted a message of safer sex which involve the use of condoms for protection UK experts said Dr Chin's views were inaccurate, and misrepresente current thinking among HIV/Aids bodies 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 Dr Chin says it is only in sub-Saharan Africa, where unprotected sex outsid 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 se with other men, intravenous drug users and female sex workers And he says that, unless the clients or partners of people in these group 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" b UNAids and Aids activists because it is "politically and socially mor acceptable" to say HIV risk behaviours are present in all populations Writing in "The Aids Pandemic", Dr Chin says: "These activists do not wan to further stigmatise persons or population groups who have such high ris levels of HIV risk behaviours and who are already marginalised "By refusing to accept the fact that HIV is very difficult to transmit sexuall without the highest levels of sexual risk behaviours, Aids programmes hav avoided labelling some populations as being more promiscuous than others "It is a much more socially and politically correct public health message t say that sexual promiscuity exists in all populations and thus the risk o epidemic heterosexual HIV transmission to the general public, or t ordinary people can be prevented only by aggressive programme directed at the general population, and especially to youth. He cited studies which showed the risk of someone in the genera population of contracting HIV from any single sexual act was, a the highest estimate, one in 1,000 And he says the failure to recognise this means that scarce public healt resources in countries where HIV prevalence is low are being waste on prevention programmes being targeted at the public, when it is th high-risk groups who should be targeted 'Disservice Dr Purnima Mane, director of policy evidence and partnerships at UNAid said: "Without having access to the full text of the book, it is very difficul for UNAids to comment on it. But she said: "The Aids response has always invited a high-level of debat and discussion. UNAids welcomes this debate and stands by its scientifi approach "Twenty-five years into the Aids epidemic has shown the world how th 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 sai Dr Chin's views may have been accurate 10 to 15 years ago, bu were not true now "He is overstating his case. Sub-Saharan Africa is not the only plac to have heterosexual epidemics and most AIDS activists no longe 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. 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 Unfortunately, public education in this regard wouldn't make us the bigges potential market for .. anything As everyone that's at all informed knows, lesion-causing virus-permeabl condoms, extremely deadly poisons and unlikely abstinence are the entir 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 b made. Invest in big pharm. Place a bet on who manages to pull off a P campaign to force their vaccines on schoolchildren. Maybe one of them ca convince us that with 100000000000 of us getting infected every minute o so, we'd better just buy all their stocks of AZT and put it in our wate supply. Big money Love, however it look -- Rahasy nospam_rahasya@meditate.co.z On Sun, 4 Feb 2007 00:41:52 -0000, "Alex" <avdeelen.REMOFETHIS1@wanadoo.nl wrote >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 >vector for transmission in the west, why should it b >in Africa Who are "them" What "exceptionalist reasoning" Rest of article binned, becaus a) the subject line indicates that it isn't worth readin <PEDANT b) If you can't say clearly in the subject line and first paragraph what it' about, it's probably not worth reading </pedant -- Terms and conditions apply. Steve Haye hayesmstw@hotmail.co 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 vector for transmission in the west, why should it b in Africa The truth is, there is no epidemic, and that is that http://news.bbc.co.uk/2/hi/health/6321683.st Expert doubts widespread HIV ris Intravenous drug use Intravenous drug users are a key high-risk grou 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 Afric are unlikely to contract HIV/Aids, as it is restricted to certain high-risk groups Campaigners have promoted a message of safer sex which involve the use of condoms for protection UK experts said Dr Chin's views were inaccurate, and misrepresente current thinking among HIV/Aids bodies 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 Dr Chin says it is only in sub-Saharan Africa, where unprotected sex outsid 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 se with other men, intravenous drug users and female sex workers And he says that, unless the clients or partners of people in these group 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" b UNAids and Aids activists because it is "politically and socially mor acceptable" to say HIV risk behaviours are present in all populations Writing in "The Aids Pandemic", Dr Chin says: "These activists do not wan to further stigmatise persons or population groups who have such high ris levels of HIV risk behaviours and who are already marginalised "By refusing to accept the fact that HIV is very difficult to transmit sexuall without the highest levels of sexual risk behaviours, Aids programmes hav avoided labelling some populations as being more promiscuous than others "It is a much more socially and politically correct public health message t say that sexual promiscuity exists in all populations and thus the risk o epidemic heterosexual HIV transmission to the general public, or t ordinary people can be prevented only by aggressive programme directed at the general population, and especially to youth. He cited studies which showed the risk of someone in the genera population of contracting HIV from any single sexual act was, a the highest estimate, one in 1,000 And he says the failure to recognise this means that scarce public healt resources in countries where HIV prevalence is low are being waste on prevention programmes being targeted at the public, when it is th high-risk groups who should be targeted 'Disservice Dr Purnima Mane, director of policy evidence and partnerships at UNAid said: "Without having access to the full text of the book, it is very difficul for UNAids to comment on it. But she said: "The Aids response has always invited a high-level of debat and discussion. UNAids welcomes this debate and stands by its scientifi approach "Twenty-five years into the Aids epidemic has shown the world how th 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 sai Dr Chin's views may have been accurate 10 to 15 years ago, bu were not true now "He is overstating his case. Sub-Saharan Africa is not the only plac to have heterosexual epidemics and most AIDS activists no longe 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. > .... If heterosexual sex is not a vector for transmission in the > west, why should it be in Africa. Same reasons you've been given every time you've made that statement over the years. They haven't changed. B/ > .... If heterosexual sex is not a vector for transmission in th > west, why should it be in Africa Same reasons you've been given every time you've made that statemen over the years. They haven't changed B Brian Mailman wrote... >> .... If heterosexual sex is not a vector for transmission in the >> west, why should it be in Africa. > > Same reasons you've been given every time you've made that statement > over the years. They haven't changed. The answer is that Africa is more progressive and its predominant HIV strain is non-discriminatory. The USA is more backwards and its predominant HIV strain is racist and homophobic and bigoted and is in violation of various equal rights statutes. > Brian Mailman wrote... >> [quoted text clipped - 8 lines] > its predominant HIV strain is racist and homophobic and bigoted > and is in violation of various equal rights statutes. Nice try, but that's not it. B/ > > Brian Mailman wrote... > >> [quoted text clipped - 10 lines] > > Nice try, but that's not it. Nice try ? ? ? ? ? ? I think that it was an excellent piece of allusion. Remember that this is the pandemic with a political face. The one that attacks under the cover of ignorance and superstition. I think that he nailed it on the nose. >> > Brian Mailman wrote... >> >> [quoted text clipped - 12 lines] > > Nice try ? ? ? ? ? ? Yeah. You apparently don't know brainfart's/Death's/Diablo's/whatever other sockpuppet's, et al. history here. B/ "Brian Mailman" <bmailman@sfo.invalid> wrote in message > Yeah. You apparently don't know brainfart's/Death's/Diablo's/whatever > other sockpuppet's, et al. history here. Still confused and a shiteater too, how sad to be you. > "Brian Mailman" <bmailman@sfo.invalid> wrote in message > > > > Yeah. You apparently don't know brainfart's/Death's/Diablo's/whatever > > other sockpuppet's, et al. history here. > > Still confused and a shiteater too, how sad to be you. Oh wow - you have displayed such a way with words: That comment is too clever for you - you are not capable of such amazing intelligence and so you have obviously plagiarised it from insult monger. You cannot carry on like this or you will crush our egos completely! Please stop we cannot take anymore you are too intelligent for us. "Skokkie" <glenton@hotmail.com> wrote in message > Please stop we cannot take anymore you are too intelligent for us. Us? Do you speak for the gerbil up your a.s? > "Skokkie" <glenton@hotmail.com> wrote in message > > > > Please stop we cannot take anymore you are too intelligent for us. > > > Us? Do you speak for the gerbil up your a.s? Hey let's end the sarcastic mode and address this fascination that you have for having things shoved up your a.s. Projecting it onto others is not really a valid cry for help and you should come to the realisation that these things are not healthy for you. Besides that, it represents cruelty to animals. There are ways that you can go, there are ways that you can leave this tortured existence. Wouldn't it be nice to be rid of these fantasies, wouldn't it be nice to go out with your own personality instead of a failed attempt to intimidate people with an unimaginative name. We all know that you are not the sparkliest gem in the box, but if you come to terms with your lack of intelligence you can really make lemon juice out of lemons and really be the best person that you can be. There is a whole world of sheltered employment out there for you and you can accomplish much. Do it! Make that call, phone your psychiatric or psychological professional today. Your loved ones, or at least those around you, will thank you. "Skokkie" <glenton@hotmail.com> wrote in message > " Death" <Death@yourdoor.net> wrote in message > > [quoted text clipped - 6 lines] > Hey let's end the sarcastic mode and address this fascination that you have > for having things shoved up your a.s. Projecting it onto others LOL once again you name your own perversion......sKoKKie > "Skokkie" <glenton@hotmail.com> wrote in message > > [quoted text clipped - 10 lines] > > LOL once again you name your own perversion......sKoKKie You are exhibiting a behaviour pattern which is called denial , and it is not convincing any one. Stop trying to blame everyone else for your short comings and get a life you sad git "Skokkie" <glenton@hotmail.com> wrote in message > " Death" <Death@yourdoor.net> wrote in message > > > > LOL once again you name your own perversion......sKoKKie > "Skokkie" <glenton@hotmail.com> wrote in message > > > > " Death" <Death@yourdoor.net> wrote in message > > > > > > LOL once again you name your own perversion......sKoKKie Death - your stuff is all inane drivel that is generated in a process whereby you bleed openly about your perversions. I am killfiling you as you are a tedious bore and a sad git.(As the Bible says " O death, where is thy sting?" ) Goodbye "Death" you are the weakest link. "Skokkie" <glenton@hotmail.com> wrote in message > " Death" <Death@yourdoor.net> wrote in message > > > > > > > > LOL once again you name your own perversion......sKoKKie 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 Unfortunately, public education in this regard wouldn't make us the bigges potential market for .. anything As everyone that's at all informed knows, lesion-causing virus-permeabl condoms, extremely deadly poisons and unlikely abstinence are the entir 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 b made. Invest in big pharm. Place a bet on who manages to pull off a P campaign to force their vaccines on schoolchildren. Maybe one of them ca convince us that with 100000000000 of us getting infected every minute o so, we'd better just buy all their stocks of AZT and put it in our wate supply. Big money Love, however it look -- Rahasy nospam_rahasya@meditate.co.z On Sun, 4 Feb 2007 00:41:52 -0000, "Alex" <avdeelen.REMOFETHIS1@wanadoo.nl wrote >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 >vector for transmission in the west, why should it b >in Africa Who are "them" What "exceptionalist reasoning" Rest of article binned, becaus a) the subject line indicates that it isn't worth readin <PEDANT b) If you can't say clearly in the subject line and first paragraph what it' about, it's probably not worth reading </pedant -- Terms and conditions apply. Steve Haye hayesmstw@hotmail.co > >It took them a quarter of a century to state the obvious. > >And the exceptionalist reasoning for Africa is laughable, [quoted text clipped - 5 lines] > > What "exceptionalist reasoning"? The idea that things in Africa are different from the rest of the world. The idea that there is no heterosexual HIV/AIDS epidemic anywhere except Africa. The idea that Africans 'have sex differently', revived as the 'dry sex', 'baby sex', etc. myths. The idea that Africans 'have sex more often'. The idea that in Africa, HIV is spread by mosquitos, recently revived as the idea that malaria is a vector for vulnerability to HIV infection and transmission. Note that none of these ideas are never confirmed by statistically sound research whether from specialists in the relevant fields or not. The truth is that the cheap tests (ELISA) used for both surveys and diagnosis in Africa are hypersensitive, and are basically unconfirmed, when in the West they are only used to guard the blood supply, for which a hypersensitive test is actually useful. It is used in surveys, but never used on it's own in diagnosis of HIV infection in individual patients. ELISA is too sensitive to be used on it's own in Africa. That is the truth no one is yet willing to own up to. HIV/AIDS figures in Africa will _always_ be overstated, as long as surveys depend on these tests. Alex By the way, dr. Chin had some interesting things to say about HIV, and the downward revision of HIV statistics in Africa. The difference made here, is the switch from Antenatal Clinic Surveys (of small numbers of pregnant women at antenatalc clinics) to DHS surveys (Demographic and Health Surveys), which take about 10,000 people who are statistically representative for the general population (age, gender, income, region, etc.). And what a difference that makes. Read on... BOSTON GLOBE: Estimates on HIV called too high New data cut rates for many nations By John Donnelly, Globe Staff | June 20, 2004 http://www.boston.com/news/world/articles/2004/06/20/estimates_on_hiv_called_too _high/ Washington Post Essentially the same article, two years later (April 2006) http://www.washingtonpost.com/wp-dyn/content/article/2006/04/05/AR2006040502517. html?sub=new Just for some levity, http://www.sciencedaily.com/releases/2005/09/050930080923.htm Frog Peptides Block HIV In Lab Study A new weapon in the battle against HIV may come from an unusual source -- a small tropical frog. Frog Venom Could Be Vital Weapon In Combatting Cancer And Heart Disease (September 21, 2001) -- Researchers at the University of Ulster have uncovered a vital weapon in the fight against killer conditions like cancer and heart Thing ARE different in Africa. /dh >> On Sun, 4 Feb 2007 00:41:52 -0000, "Alex" >> <avdeelen.REMOFETHIS1@wanadoo.nl> [quoted text clipped - 73 lines] > conditions like > cancer and heart Thing ARE different in Africa /d >> On Sun, 4 Feb 2007 00:41:52 -0000, "Alex" >> <avdeelen.REMOFETHIS1@wanadoo.nl [quoted text clipped - 9 lines] > >> What "exceptionalist reasoning" > The idea that things in Africa are different from the rest of the world > The idea that there is no heterosexual HIV/AIDS epidemic anywhere except [quoted text clipped - 5 lines] > the idea tha > malaria is a vector for vulnerability to HIV infection and transmission > Note that none of these ideas are never confirmed by statistically sound > researc > whether from specialists in the relevant fields or not > The truth is that the cheap tests (ELISA) used for both surveys and > diagnosis in Afric [quoted text clipped - 4 lines] > surveys, but never used on it's own in diagnosis of HIV infection in > individual patients > ELISA is too sensitive to be used on it's own in Africa. That is th > truth no one is yet willing to own up to > HIV/AIDS figures in Africa will _always_ be overstated, as long a > surveys depend on these tests > Ale > By the way, dr. Chin had some interesting things to say about HIV, an > the downward revision of HIV statistics in Africa. The difference made [quoted text clipped - 5 lines] > for the general population (age, gender, income, region, etc.). And what > difference that makes. Read on.. > BOSTON GLOBE > Estimates on HIV called too hig > New data cut rates for many nation > By John Donnelly, Globe Staff | June 20, 200 > http://www.boston.com/news/world/articles/2004/06/20/estimates_on_hiv_called_too_high > Washington Pos > Essentially the same article, two years later (April 2006 > http://www.washingtonpost.com/wp-dyn/content/article/2006/04/05/AR2006040502517. html?sub=ne > Just for some levity > http://www.sciencedaily.com/releases/2005/09/050930080923.ht > Frog Peptides Block HIV In Lab Stud > A new weapon in the battle against HIV may come from an unusual source -- [quoted text clipped - 4 lines] > conditions lik > cancer and hear > On Sun, 4 Feb 2007 00:41:52 -0000, "Alex" <avdeelen.REMOFETHIS1@wanadoo.nl > wrote > >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 > >vector for transmission in the west, why should it b > >in Africa > Who are "them" > What "exceptionalist reasoning" The idea that things in Africa are different from the rest of the world The idea that there is no heterosexual HIV/AIDS epidemic anywhere except Africa The idea that Africans 'have sex differently', revived as the 'dry sex', 'baby sex', etc. myths The idea that Africans 'have sex more often' The idea that in Africa, HIV is spread by mosquitos, recently revived as the idea tha malaria is a vector for vulnerability to HIV infection and transmission Note that none of these ideas are never confirmed by statistically sound researc whether from specialists in the relevant fields or not The truth is that the cheap tests (ELISA) used for both surveys and diagnosis in Afric are hypersensitive, and are basically unconfirmed, when in the West they are only use to guard the blood supply, for which a hypersensitive test is actually useful. It is used i surveys, but never used on it's own in diagnosis of HIV infection in individual patients ELISA is too sensitive to be used on it's own in Africa. That is th truth no one is yet willing to own up to HIV/AIDS figures in Africa will _always_ be overstated, as long a surveys depend on these tests Ale By the way, dr. Chin had some interesting things to say about HIV, an the downward revision of HIV statistics in Africa. The difference made here is the switch from Antenatal Clinic Surveys (of small numbers of pregnan women at antenatalc clinics) to DHS surveys (Demographic and Healt Surveys), which take about 10,000 people who are statistically representativ for the general population (age, gender, income, region, etc.). And what difference that makes. Read on.. BOSTON GLOBE Estimates on HIV called too hig New data cut rates for many nation By John Donnelly, Globe Staff | June 20, 200 http://www.boston.com/news/world/articles/2004/06/20/estimates_on_hiv_called_too_high Washington Pos Essentially the same article, two years later (April 2006 http://www.washingtonpost.com/wp-dyn/content/article/2006/04/05/AR2006040502517. html?sub=ne Just for some levity http://www.sciencedaily.com/releases/2005/09/050930080923.ht Frog Peptides Block HIV In Lab Stud A new weapon in the battle against HIV may come from an unusual source -- small tropical frog. Frog Venom Could Be Vital Weapon In Combatting Cance And Heart Disease (September 21, 2001) -- Researchers at the University o Ulster have uncovered a vital weapon in the fight against killer conditions lik cancer and hear > On Sun, 4 Feb 2007 00:41:52 -0000, "Alex" <avdeelen.REMOFETHIS1@wanadoo.nl > wrote > >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 > >vector for transmission in the west, why should it b > >in Africa > Who are "them" > What "exceptionalist reasoning" The idea that things in Africa are different from the rest of the world The idea that there is no heterosexual HIV/AIDS epidemic anywhere except Africa The idea that Africans 'have sex differently', revived as the 'dry sex', 'baby sex', etc. myths The idea that Africans 'have sex more often' The idea that in Africa, HIV is spread by mosquitos, recently revived as the idea tha malaria is a vector for vulnerability to HIV infection and transmission Note that none of these ideas are never confirmed by statistically sound researc whether from specialists in the relevant fields or not The truth is that the cheap tests (ELISA) used for both surveys and diagnosis in Afric are hypersensitive, and are basically unconfirmed, when in the West they are only use to guard the blood supply, for which a hypersensitive test is actually useful. It is used i surveys, but never used on it's own in diagnosis of HIV infection in individual patients ELISA is too sensitive to be used on it's own in Africa. That is th truth no one is yet willing to own up to HIV/AIDS figures in Africa will _always_ be overstated, as long a surveys depend on these tests Ale By the way, dr. Chin had some interesting things to say about HIV, an the downward revision of HIV statistics in Africa. The difference made here is the switch from Antenatal Clinic Surveys (of small numbers of pregnan women at antenatalc clinics) to DHS surveys (Demographic and Healt Surveys), which take about 10,000 people who are statistically representativ for the general population (age, gender, income, region, etc.). And what difference that makes. Read on.. BOSTON GLOBE Estimates on HIV called too hig New data cut rates for many nation By John Donnelly, Globe Staff | June 20, 200 http://www.boston.com/news/world/articles/2004/06/20/estimates_on_hiv_called_too_high Washington Pos Essentially the same article, two years later (April 2006 http://www.washingtonpost.com/wp-dyn/content/article/2006/04/05/AR2006040502517. html?sub=ne Just for some levity http://www.sciencedaily.com/releases/2005/09/050930080923.ht Frog Peptides Block HIV In Lab Stud A new weapon in the battle against HIV may come from an unusual source -- small tropical frog. Frog Venom Could Be Vital Weapon In Combatting Cance And Heart Disease (September 21, 2001) -- Researchers at the University o Ulster have uncovered a vital weapon in the fight against killer conditions lik cancer and hear >It took them a quarter of a century to state the obvious. Ah...which "obvious"? This is just Chin's opinion. HIV has already spread outside "traditional" risk groups in the US. But vulnerable groups like MSM, sex workers and activities like needle sharing remain important areas to target prevention. By contrast, none of what Chin says remotely supports your psychotic viewpoint that HIV doesn't exist or cause AIDS. Say--does Manto have AIDS? George M. Carter > >It took them a quarter of a century to state the obvious. > [quoted text clipped - 10 lines] > > George M. Carter 1. HIV does not cause AIDS 2. The economy is booming and Stats SA are not number fiddlers 3. There are plenty of jobs for everyone including the young people who have left the country and they must now reaffirm their patriotic values and come home. 4. Crime is not out of control in South Africa 5. Banks should not be involved in politics! >> >It took them a quarter of a century to state the obvious. >> [quoted text clipped - 20 lines] > 4. Crime is not out of control in South Africa > 5. Banks should not be involved in politics! Definitely correct when do you pick up your commission cheque from the party offices ? > >> >It took them a quarter of a century to state the obvious. > >> [quoted text clipped - 23 lines] > Definitely correct when do you pick up your commission cheque > from the party offices ? The party does not pay bribes, backhanders or considerations of any kind! And you're out of touch with reality. /dh >>> >It took them a quarter of a century to state the obvious. >>> [quoted text clipped - 23 lines] > Definitely correct when do you pick up your commission cheque > from the party offices ? And you're out of touch with reality /d >>> On Sun, 4 Feb 2007 00:41:52 -0000, "Alex >>> <avdeelen.REMOFETHIS1@wanadoo.nl> wrote [quoted text clipped - 23 lines] >> 4. Crime is not out of control in South Afric >> 5. Banks should not be involved in politics > Definitely correct when do you pick up your commission chequ > from the party offices >1. HIV does not cause AIDS Yes it does. Get infected and find out for yourself. >2. The economy is booming and Stats SA are not number fiddlers Unlike the US government? Booming for whom? Oh...the very rich and the rest get screwed without a kiss....like a worse version of the US economy? >3. There are plenty of jobs for everyone including the young people who have >left the country and they must now reaffirm their patriotic values and come >home. Perhaps if there were FAIR trade agreements.... Hey Carter I was being sarcastic - it is a strange form of humour that we use here. Nobody in their right mind would believe all of those statements to be true, especially the one about the party not paying bribes or considerations. So your replies were not so smart Skokkie > >1. HIV does not cause AIDS > [quoted text clipped - 12 lines] > > Perhaps if there were FAIR trade agreements.... >Hey Carter > >I was being sarcastic - it is a strange form of humour that we use here. That's good to hear! Sorry if I offended you--there are so many folks that actually subscribe to that kind of crap on this list. Look at the deranged squealings and rantings of the little fascist "death" - so I hope you'll forgive me for not seeing the humor off the bat! George M. Carter "GMCarter" <fiar@verizon.net> wrote in message > "Skokkie" <glenton@hotmail.com> > > [quoted text clipped - 8 lines] > "death" - so I hope you'll forgive me for not seeing the humor off the > bat! You still don't see it you moron. That shitty feel good toe the party line bullshit gives you away every-time. > "GMCarter" <fiar@verizon.net> wrote in message > [quoted text clipped - 14 lines] > That shitty feel good toe the party line bullshit > gives you away every-time. Dear Mister small minded bigot who goes under the unimaginative name of "Death" which he thinks is really intimidating and scary. I think that Carter has seen it; it is you who are so completely myopic that you can't see past your nose. I flamed him in my response, and he admitted that he was wrong, but still came back with a polite reply. It made me look a bit small but shows him to be a rational and sensible person. You on the other hand display an insane degree of bigotry and prejudice that prevents you from making any sort of constructive reply. You do not advance the discussion or debate and your responses have no humour value. You are therefore achieving very little through your interaction in these newsgroups, and the mental frame of mind that you display suggests that you should seek professional help. Go and see your pastor or priest and discuss your problems with them or if they have given up on you, then go and see a psychiatrist. You should at least think about putting your crap into proper syntax, form, and grammar so that we can at least understand what you are saying before we dismiss it? It's truly amazing the way you never let sense or reason interrupt the flow of your typing, but then, two way communication isn't your area of expertise, is it? DEATH = Daft Enema Addicted Transsexual Halfwit "Skokkie" <glenton@hotmail.com> wrote in message > Dear Mister small minded bigot who goes under the unimaginative name of > "Death" which he thinks is really intimidating and scary. Oh, lol.......ok skokkie > I think that Carter has seen it; it is you who are so completely myopic that > you can't see past your nose. Gee, you know all that just by magic but you can't see to keep strangers dicks out of your perverted a.shole. > I flamed him in my response, really, damn. I'm glad you passed along that important info. Seems I missed that as well. > "Skokkie" <glenton@hotmail.com> wrote in message > > > > Dear Mister small minded bigot who goes under the unimaginative name of > > "Death" which he thinks is really intimidating and scary. > > Oh, lol.......ok skokkie Lissen a-Merkin you do not even know why I use the name Skokkie so do not comment. You are about as funny as a rectal prolapse. > > I think that Carter has seen it; it is you who are so completely myopic that > > you can't see past your nose. > > Gee, you know all that just by magic but you can't see to keep > strangers dicks out of your perverted a.shole. Really, does it please you to believe this? You seem fascinated with making these allegations. You are definitely projecting your feelings onto other people Mr.small minded bigot who goes under the unimaginative name of "Death" which he thinks is really intimidating and scary. Does your handler know about these delusions? See I do not know these things by magic - you bleed openly, Mr.small minded bigot who goes under the unimaginative name of "Death" which he thinks is really intimidating and scary. Two or three posts and all and sundry have the top and bottom of your malaise. Sad, really sad > > I flamed him in my response, > > really, damn. I'm glad you passed along that important info. > Seems I missed that as well. That and the whole of school after kindergarten. "Skokkie" <glenton@hotmail.com> wrote in message > Lissen a-Merkin you do not even know why I use the name Skokkie so do not > comment. Ain't you just a cute little hypocrite? "Skokkie" <glenton@hotmail.com> wrote in message > Dear Mister small minded bigot who goes under the unimaginative name of > "Death" which he thinks is really intimidating and scary. Typical faggot behavior to project its perversion. You madam are a shiteater hence the nic, sKoKKie. > "Skokkie" <glenton@hotmail.com> wrote in message > > [quoted text clipped - 9 lines] > > Typical faggot behavior to project its perversion. That is no excuse for your behaviour. This continued projection of your wierd fantasies onto other newsgroupers is jeapordising your personal reputation. Wel lets say that people are developing an even lower opinion of you that leans toward total apathy. > You madam are a shiteater hence the nic, sKoKKie. Does it please you to believe that I am a sh.t eater. do you get a feeling of community out of it? Does it make you feel justified? Sad, really sad. "Skokkie" <glenton@hotmail.com> wrote in message > Does it please you to believe that I am a sh.t eater. Is this a weak attempt at denying you suck your own sh.t off a dick? > "Skokkie" <glenton@hotmail.com> wrote in message > > > > Does it please you to believe that I am a sh.t eater. > > Is this a weak attempt at denying you suck your > own sh.t off a dick? The idea never occurred to me, and I will not spend much time thinking about it either. > The idea never occurred to me, and I will not spend much time thinking about > it either. Death/Diablo/brainfart/et. al think about it a lot. Kinda weird for someone to be obsessed with what they claim they hate, huh? B/ > > The idea never occurred to me, and I will not spend much time thinking about > > it either. > > Death/Diablo/brainfart/et. al think about it a lot. Kinda weird for > someone to be obsessed with what they claim they hate, huh? poor confused pervert, and a faggot too, wow. > > > The idea never occurred to me, and I will not spend much time thinking about > > > it either. [quoted text clipped - 3 lines] > > > poor confused pervert, and a faggot too, wow. enough of this inane and sad git Whinge away "death" you are on my killfile and I am ignoring you Silly dipshit "Skokkie" <glenton@hotmail.com> wrote in message > " Death" <Death@yourdoor.net> wrote in message > > > [quoted text clipped - 3 lines] > > Whinge away "death" you are on my killfile and I am ignoring you > Silly dipshit Sure you are, lol I wouldn't have it any other way. Anyone silly enough to still use that ole killfile sh.t and have a sig: silly dipshit, has no business attempting to justify your perversion to me. > > "Skokkie" <glenton@hotmail.com> wrote in message > > > [quoted text clipped - 5 lines] > The idea never occurred to me, and I will not spend much time thinking about > it either. It's just as well, a denial would not have helped snip >You still don't see it you moron. >That shitty feel good toe the party line bullshit >gives you away every-time. As opposed to the way you goose step your party's line? > snip > >You still don't see it you moron. > >That shitty feel good toe the party line bullshit > >gives you away every-time. > > As opposed to the way you goose step your party's line? Correct. That idiot sKoKKie missed that. We all toe our own beliefs. It is the fool who denies it. > > snip > > >You still don't see it you moron. [quoted text clipped - 5 lines] > Correct. That idiot sKoKKie missed that. We all toe our own beliefs. > It is the fool who denies it. Listen you Merkin twit, why do you not come out of the closet and admit your homosexuality instead of constantly reflecting it at everyone. Clearly you are a fool for denying it "We all toe our own beliefs" - ey that is an euphemistic description of a bigot if ever I heard one! Have you ever thought of a cranial liposuction to get rid of useless fat? - no because in your case it is an enema that should be applied to the area which should hold a brain. You are sad, really sad!. "Skokkie" <glenton@hotmail.com> lisped in message > Listen you Merkin twit, why do you not come out of the closet and admit your > homosexuality That didn't take long. It generally takes a faggot a week to start the ole )you are a faggot too( bullshit. Grow up sKoKKie, you are just another lame faggot with the same ole song from the *faggot book of rote* > "Skokkie" <glenton@hotmail.com> lisped in message > > [quoted text clipped - 6 lines] > Grow up sKoKKie, you are just another lame faggot > with the same ole song from the *faggot book of rote* Ayish! - This preoccupation with homosexuality along with the admission that it is so bad that other people have been recognising it too. When are you going to listen, when will you come to terms with this thing. Stop dismissing it as a problem in other people, learn to deal with your anger. You are a sad git. >> "Skokkie" <glenton@hotmail.com> lisped in message >>> [quoted text clipped - 16 lines] > > You are a sad git. haha....good one skokkie....he needs to know his place.:) "Mike" <Mike@home.com> wrote in message > haha....good one skokkie....he needs to know his place.:) I know it isn't on my knees sucking a males sh.t covered dick. I know it isn't on my knees taking another males dick up my a.s. So tell me smiley, do you know your place, down on your knees? >"Mike" <Mike@home.com> wrote in message >> >> haha....good one skokkie....he needs to know his place.:) >> >I know it isn't on my knees sucking a males sh.t covered dick. Nobody really cares WHAT you do, if anything, for sex, dear. Perhaps you're sucking the sh.t of the cock of the bull in the back fields. Or perhaps your dog's cock or pussy? It's of no interest, really. Yes, heterosexuals do engage in anal sex! LOL....have you bought your latest supply of oxycodone? "GMCarter" <fiar@verizon.net> wrote in message > Nobody really cares WHAT you do, if anything, for sex, ... Exactly. I have never said. I have stated for the record what I don't do. I know, you are confused. >"GMCarter" <fiar@verizon.net> wrote in message >> >> Nobody really cares WHAT you do, if anything, for sex, ... > >Exactly. I have never said. So you DO f.ck animals! LOL...figures "GMCarter" <fiar@verizon.net> wrote in message > So you DO f.ck animals! > > LOL...figures Some of those chicks are real foxes but I'd never call them animals. No wonder you have to go to the local sh.t-house to get a date, and a dude to boot, lol. > "Mike" <Mike@home.com> wrote in message > > > > haha....good one skokkie....he needs to know his place.:) > > > I know it isn't on my knees sucking a males sh.t covered dick. > I know it isn't on my knees taking another males dick up my a.s. but you persist with these fantasies - why? You are really sad "Skokkie" <glenton@hotmail.com> wrote in message > but you persist with these fantasies - why? How about being more specific. Three examples will do fine. You can do that, yes? > "Skokkie" <glenton@hotmail.com> wrote in message > > [quoted text clipped - 4 lines] > > You can do that, yes? Enough of this inanity generated by a tiresome and unimaginative sad git - Killfiled! > " Death" <Death@yourdoor.net> wrote in message > > [quoted text clipped - 9 lines] > Enough of this inanity generated by a tiresome and unimaginative sad git - > Killfiled! Damn and I only asked for 3 examples of my so-called fantasies. Had I'd known you were going to cry, I would have asked for 2. Does K-mart sell those kill-files? Does the ATF require a permit? Well heck no, they are an illusion for the insane. > "Mike" <Mike@home.com> wrote in message >> [quoted text clipped - 6 lines] > > down on your knees? I think that is where you prefer to be - down on your knees with a mouthful of dick, as you seem obsessed with dicks "Mike" <Mike@home.com> wrote in message > I think that is where you prefer to be - down on your knees with a mouthful > of dick, as you seem obsessed with dicks I'm obsessed with laughing at aids infected faggots who allowed an aids infected dick into their a.shole. So tell me smiley when did you become infected? snip... >Ayish! - This preoccupation with homosexuality along with the admission that >it is so bad that other people have been recognising it too. LOL....see below Adams HE; Wright LW Jr; Lohr BA. Is homophobia associated with homosexual arousal? J Abnorm Psychol 1996 Aug;105(3):440-445. Department of Psychology, University of Georgia, Athens 30602-3013, USA. The authors investigated the role of homosexual arousal in exclusively heterosexual men who admitted negative affect toward homosexual individuals. Participants consisted of a group of homophobic men (n = 35) and a group of nonhomophobic men (n = 29); they were assigned to groups on the basis of their scores on the Index of Homophobia (W. W. Hudson & W. A. Ricketts, 1980). The men were exposed to sexually explicit erotic stimuli consisting of heterosexual, male homosexual, and lesbian videotapes, and changes in penile circumference were monitored. They also completed an Aggression Questionnaire (A. H. Buss & M. Perry, 1992). Both groups exhibited increases in penile circumference to the heterosexual and female homosexual videos. Only the homophobic men showed an increase in penile erection to male homosexual stimuli. The groups did not differ in aggression. Homophobia is apparently associated with homosexual arousal that the homophobic individual is either unaware of or denies. "GMCarter" <fiar@verizon.net> wrote in message > Department of Psychology, University of Georgia, Athens 30602-3013, > USA. > The men were exposed to sexually > explicit erotic stimuli consisting of heterosexual, male homosexual, > and lesbian videotapes, and changes in penile circumference were > monitored. Lets see, that is a video ... > They also completed an Aggression Questionnaire (A. H. Buss > & M. Perry, 1992). Both groups exhibited increases in penile > circumference to the heterosexual and female homosexual videos. ... and this is a questionnaire, oh great >"GMCarter" <fiar@verizon.net> wrote in message > [quoted text clipped - 6 lines] > >Lets see, that is a video ... Yes, you should watch that video. They also measured their cock size as they watched two guys getting it on. Getting a wee lil woody, their, anonymous fellow? > >"GMCarter" <fiar@verizon.net> wrote in message > > [quoted text clipped - 11 lines] > They also measured their cock size as they watched two guys getting it > on. Getting a wee lil woody, their, anonymous fellow? One does not have to conduct scientific experiments to gain a definite conclusion about this sad git who is projecting his sexual fantasies onto other people, with such imaginative detail nogal. Like he seriously revels in the description and has become very hard assed about the perceptions about him that it gives to other people. Truly A Sad Git. Send a shrink as all of the rejection that he suffers could make him a sewerage pipe candidate. "Skokkie" <glenton@hotmail.com> wrote in message > Send a shrink as all of the rejection that he suffers could make him a > sewerage pipe candidate. hahahahaha, come on, do try harder faggie. As you can see, I generate attention. Move away people, nothing to see but faggot whining here. "GMCarter" <fiar@verizon.net> wrote in message > Yes, you should watch that video. I'd rather watch a public hanging of faggots that infected others. > They also measured their cock size as they watched two guys getting it > on. Getting a wee lil woody, their, anonymous fellow? Nah, I'll pass on the filthy perverted faggot sex show. Now if have some spare rope lying around ... snip >Nah, I'll pass on the filthy perverted faggot sex show. LOL...the little woody wiggles in your pants. "GMCarter" <fiar@verizon.net> wrote in message > " Death" <Death@yourdoor.net> > > > >Nah, I'll pass on the filthy perverted faggot sex show. > > LOL...the little woody wiggles in your pants. I see you passed on the rope trick. Too bad you didn't pass on the sh.t-house trick. You could have saved your-self a sore ass-hole and the $3.00 it charged you. > >Hey Carter > > [quoted text clipped - 8 lines] > > George M. Carter Okay sorry I was a bit vague in my presentation, but I thought that as nobody actually believes the kak that the SA government spews out that the sarcasm or Irony would be obvious. How's this one. Jacob Zuma has nothing to do with the arms corruption and the ANC are not using this and other front companies to fund their activities. . snip... >How's this one. >Jacob Zuma has nothing to do with the arms corruption and the ANC are not >using this and other front companies to fund their activities. . I can't really comment on that one. However, it makes me think about how wonderfully honest and decent companies like Halliburton and Bechtel are and what a wonderful and brave job they are doing in Iraq, a just and noble war the US started for lots of excellent reasons and that has resulted in no death or suffering, the liberation of its now happy people and the end of injustice worldwide! There seems to be a glitch in the news programme's software that reposts the very same message (with the very same message ID) several times. Alex: Ii couldn't agree more> /dh > There seems to be a glitch in the news programme's software > that reposts the very same message (with the very same message > ID) several times. Alex Ii couldn't agree more /d > There seems to be a glitch in the news programme's softwar > that reposts the very same message (with the very same messag > ID) several times There seems to be a glitch in the news programme's softwar that reposts the very same message (with the very same messag ID) several times >There seems to be a glitch in the news programme's software >that reposts the very same message (with the very same message >ID) several times. So there does, but you haven't answered the question once. SignatureSteve Hayes from Tshwane, South Africa Web: http://hayesfam.bravehost.com/stevesig.htm E-mail - see web page, or parse: shayes at dunelm full stop org full stop uk > >There seems to be a glitch in the news programme's software > >that reposts the very same message (with the very same message > >ID) several times. > > So there does, but you haven't answered the question once. Which question? You asked who the "them" are. I replied: "Steve Hayes" <hayesmstw@hotmail.com> schreef in bericht news:repost.71903.j4aas2909695r8drjjvpd8eibfn3qqi88f@4ax.com... > >It took them a quarter of a century to state the obvious. > >And the exceptionalist reasoning for Africa is laughable, [quoted text clipped - 5 lines] > > What "exceptionalist reasoning"? The idea that things in Africa are different from the rest of the world. The idea that there is no heterosexual HIV/AIDS epidemic anywhere except Africa. The idea that Africans 'have sex differently', revived as the 'dry sex', 'baby sex', etc. myths. The idea that Africans 'have sex more often'. The idea that in Africa, HIV is spread by mosquitos, recently revived as the idea that malaria is a vector for vulnerability to HIV infection and transmission. Note that none of these ideas are never confirmed by statistically sound research whether from specialists in the relevant fields or not. The truth is that the cheap tests (ELISA) used for both surveys and diagnosis in Africa are hypersensitive, and are basically unconfirmed, when in the West they are only used to guard the blood supply, for which a hypersensitive test is actually useful. It is used in surveys, but never used on it's own in diagnosis of HIV infection in individual patients. ELISA is too sensitive to be used on it's own in Africa. That is the truth no one is yet willing to own up to. HIV/AIDS figures in Africa will _always_ be overstated, as long as surveys depend on these tests. Alex By the way, dr. Chin had some interesting things to say about HIV, and the downward revision of HIV statistics in Africa. The difference made here, is the switch from Antenatal Clinic Surveys (of small numbers of pregnant women at antenatalc clinics) to DHS surveys (Demographic and Health Surveys), which take about 10,000 people who are statistically representative for the general population (age, gender, income, region, etc.). And what a difference that makes. Read on... BOSTON GLOBE: Estimates on HIV called too high New data cut rates for many nations By John Donnelly, Globe Staff | June 20, 2004 http://www.boston.com/news/world/articles/2004/06/20/estimates_on_hiv_called_too _high/ Washington Post Essentially the same article, two years later (April 2006) http://www.washingtonpost.com/wp-dyn/content/article/2006/04/05/AR2006040502517. html?sub=new Just for some levity, http://www.sciencedaily.com/releases/2005/09/050930080923.htm Frog Peptides Block HIV In Lab Study A new weapon in the battle against HIV may come from an unusual source -- a small tropical frog. Frog Venom Could Be Vital Weapon In Combatting Cancer And Heart Disease (September 21, 2001) -- Researchers at the University of Ulster have uncovered a vital weapon in the fight against killer conditions like cancer and heart On the claims that it is heterosexual sex which spreads HIV in Africa, and that this must be because Africans are 'doing something different', check this out. 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 On Mon, 5 Feb 2007 00:33:45 +0100, "Alex" <avdeelen.REMOFETHIS1@wanadoo.nl wrote >There seems to be a glitch in the news programme's softwar >that reposts the very same message (with the very same messag >ID) several times So there does, but you haven't answered the question once -- Steve Hayes from Tshwane, South Afric Web: http://hayesfam.bravehost.com/stevesig.ht E-mail - see web page, or parse: shayes at dunelm full stop org full stop u 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 vector for transmission in the west, why should it b in Africa The truth is, there is no epidemic, and that is that http://news.bbc.co.uk/2/hi/health/6321683.st Expert doubts widespread HIV ris Intravenous drug use Intravenous drug users are a key high-risk grou 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 Afric are unlikely to contract HIV/Aids, as it is restricted to certain high-risk groups Campaigners have promoted a message of safer sex which involve the use of condoms for protection UK experts said Dr Chin's views were inaccurate, and misrepresente current thinking among HIV/Aids bodies 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 Dr Chin says it is only in sub-Saharan Africa, where unprotected sex outsid 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 se with other men, intravenous drug users and female sex workers And he says that, unless the clients or partners of people in these group 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" b UNAids and Aids activists because it is "politically and socially mor acceptable" to say HIV risk behaviours are present in all populations Writing in "The Aids Pandemic", Dr Chin says: "These activists do not wan to further stigmatise persons or population groups who have such high ris levels of HIV risk behaviours and who are already marginalised "By refusing to accept the fact that HIV is very difficult to transmit sexuall without the highest levels of sexual risk behaviours, Aids programmes hav avoided labelling some populations as being more promiscuous than others "It is a much more socially and politically correct public health message t say that sexual promiscuity exists in all populations and thus the risk o epidemic heterosexual HIV transmission to the general public, or t ordinary people can be prevented only by aggressive programme directed at the general population, and especially to youth. He cited studies which showed the risk of someone in the genera population of contracting HIV from any single sexual act was, a the highest estimate, one in 1,000 And he says the failure to recognise this means that scarce public healt resources in countries where HIV prevalence is low are being waste on prevention programmes being targeted at the public, when it is th high-risk groups who should be targeted 'Disservice Dr Purnima Mane, director of policy evidence and partnerships at UNAid said: "Without having access to the full text of the book, it is very difficul for UNAids to comment on it. But she said: "The Aids response has always invited a high-level of debat and discussion. UNAids welcomes this debate and stands by its scientifi approach "Twenty-five years into the Aids epidemic has shown the world how th 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 sai Dr Chin's views may have been accurate 10 to 15 years ago, bu were not true now "He is overstating his case. Sub-Saharan Africa is not the only plac to have heterosexual epidemics and most AIDS activists no longe 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. > The truth is, there is no epidemic, and that is that. Oh yeah then what are all of these people dying of? I think that either Alex is quite young or maybe is afraid of being tested himself. >> The truth is, there is no epidemic, and that is that. > > Oh yeah then what are all of these people dying of? I think that either Alex is quite young or maybe is afraid of being tested himself >> The truth is, there is no epidemic, and that is that > Oh yeah then what are all of these people dying of Great - er Doug we use the convention of bottom posting here on scsa as it makes the sequence more understandable and easy to follow. (Yeah and I know that a lot of people post out of their bottoms) Alex wrote... > HIV/Aids campaigners are circulating "misconceptions" about who is at risk, > a former World Health Organization expert has warned. Back in the 1980s the HIV/AIDS campaigners demanded that governments spend trillions of dollars on propaganda claiming that "everyone" was at risk of HIV. Several trillion dollars later, those same HIV/AIDS campaigners claim that only a few groups are at risk, and demanding that several more trillion dollars be spent on propaganda targeting them specifically. Naturally, the trillions of dollars should be administered by groups controlled by the HIV/AIDS campaigners. "Alex" <avdeelen.REMOFETHIS1@wanadoo.nl> wrote in message > 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. The same song I have sung for years. Again I'll sing, poverty does not cause aids. 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 vector for transmission in the west, why should it b in Africa The truth is, there is no epidemic, and that is that http://news.bbc.co.uk/2/hi/health/6321683.st Expert doubts widespread HIV ris Intravenous drug use Intravenous drug users are a key high-risk grou 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 Afric are unlikely to contract HIV/Aids, as it is restricted to certain high-risk groups Campaigners have promoted a message of safer sex which involve the use of condoms for protection UK experts said Dr Chin's views were inaccurate, and misrepresente current thinking among HIV/Aids bodies 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 Dr Chin says it is only in sub-Saharan Africa, where unprotected sex outsid 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 se with other men, intravenous drug users and female sex workers And he says that, unless the clients or partners of people in these group 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" b UNAids and Aids activists because it is "politically and socially mor acceptable" to say HIV risk behaviours are present in all populations Writing in "The Aids Pandemic", Dr Chin says: "These activists do not wan to further stigmatise persons or population groups who have such high ris levels of HIV risk behaviours and who are already marginalised "By refusing to accept the fact that HIV is very difficult to transmit sexuall without the highest levels of sexual risk behaviours, Aids programmes hav avoided labelling some populations as being more promiscuous than others "It is a much more socially and politically correct public health message t say that sexual promiscuity exists in all populations and thus the risk o epidemic heterosexual HIV transmission to the general public, or t ordinary people can be prevented only by aggressive programme directed at the general population, and especially to youth. He cited studies which showed the risk of someone in the genera population of contracting HIV from any single sexual act was, a the highest estimate, one in 1,000 And he says the failure to recognise this means that scarce public healt resources in countries where HIV prevalence is low are being waste on prevention programmes being targeted at the public, when it is th high-risk groups who should be targeted 'Disservice Dr Purnima Mane, director of policy evidence and partnerships at UNAid said: "Without having access to the full text of the book, it is very difficul for UNAids to comment on it. But she said: "The Aids response has always invited a high-level of debat and discussion. UNAids welcomes this debate and stands by its scientifi approach "Twenty-five years into the Aids epidemic has shown the world how th 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 sai Dr Chin's views may have been accurate 10 to 15 years ago, bu were not true now "He is overstating his case. Sub-Saharan Africa is not the only plac to have heterosexual epidemics and most AIDS activists no longe 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. There seems to be a glitch in the news programme's softwar that reposts the very same message (with the very same messag ID) several times There seems to be a glitch in the news programme's softwar that reposts the very same message (with the very same messag ID) several times 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 vector for transmission in the west, why should it b in Africa The truth is, there is no epidemic, and that is that http://news.bbc.co.uk/2/hi/health/6321683.st Expert doubts widespread HIV ris Intravenous drug use Intravenous drug users are a key high-risk grou 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 Afric are unlikely to contract HIV/Aids, as it is restricted to certain high-risk groups Campaigners have promoted a message of safer sex which involve the use of condoms for protection UK experts said Dr Chin's views were inaccurate, and misrepresente current thinking among HIV/Aids bodies 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 Dr Chin says it is only in sub-Saharan Africa, where unprotected sex outsid 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 se with other men, intravenous drug users and female sex workers And he says that, unless the clients or partners of people in these group 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" b UNAids and Aids activists because it is "politically and socially mor acceptable" to say HIV risk behaviours are present in all populations Writing in "The Aids Pandemic", Dr Chin says: "These activists do not wan to further stigmatise persons or population groups who have such high ris levels of HIV risk behaviours and who are already marginalised "By refusing to accept the fact that HIV is very difficult to transmit sexuall without the highest levels of sexual risk behaviours, Aids programmes hav avoided labelling some populations as being more promiscuous than others "It is a much more socially and politically correct public health message t say that sexual promiscuity exists in all populations and thus the risk o epidemic heterosexual HIV transmission to the general public, or t ordinary people can be prevented only by aggressive programme directed at the general population, and especially to youth. He cited studies which showed the risk of someone in the genera population of contracting HIV from any single sexual act was, a the highest estimate, one in 1,000 And he says the failure to recognise this means that scarce public healt resources in countries where HIV prevalence is low are being waste on prevention programmes being targeted at the public, when it is th high-risk groups who should be targeted 'Disservice Dr Purnima Mane, director of policy evidence and partnerships at UNAid said: "Without having access to the full text of the book, it is very difficul for UNAids to comment on it. But she said: "The Aids response has always invited a high-level of debat and discussion. UNAids welcomes this debate and stands by its scientifi approach "Twenty-five years into the Aids epidemic has shown the world how th 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 sai Dr Chin's views may have been accurate 10 to 15 years ago, bu were not true now "He is overstating his case. Sub-Saharan Africa is not the only plac to have heterosexual epidemics and most AIDS activists no longe 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. 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 Unfortunately, public education in this regard wouldn't make us the bigges potential market for .. anything As everyone that's at all informed knows, lesion-causing virus-permeabl condoms, extremely deadly poisons and unlikely abstinence are the entir 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 b made. Invest in big pharm. Place a bet on who manages to pull off a P campaign to force their vaccines on schoolchildren. Maybe one of them ca convince us that with 100000000000 of us getting infected every minute o so, we'd better just buy all their stocks of AZT and put it in our wate supply. Big money Love, however it look -- Rahasy nospam_rahasya@meditate.co.z 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 vector for transmission in the west, why should it b in Africa The truth is, there is no epidemic, and that is that http://news.bbc.co.uk/2/hi/health/6321683.st Expert doubts widespread HIV ris Intravenous drug use Intravenous drug users are a key high-risk grou 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 Afric are unlikely to contract HIV/Aids, as it is restricted to certain high-risk groups Campaigners have promoted a message of safer sex which involve the use of condoms for protection UK experts said Dr Chin's views were inaccurate, and misrepresente current thinking among HIV/Aids bodies 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 Dr Chin says it is only in sub-Saharan Africa, where unprotected sex outsid 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 se with other men, intravenous drug users and female sex workers And he says that, unless the clients or partners of people in these group 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" b UNAids and Aids activists because it is "politically and socially mor acceptable" to say HIV risk behaviours are present in all populations Writing in "The Aids Pandemic", Dr Chin says: "These activists do not wan to further stigmatise persons or population groups who have such high ris levels of HIV risk behaviours and who are already marginalised "By refusing to accept the fact that HIV is very difficult to transmit sexuall without the highest levels of sexual risk behaviours, Aids programmes hav avoided labelling some populations as being more promiscuous than others "It is a much more socially and politically correct public health message t say that sexual promiscuity exists in all populations and thus the risk o epidemic heterosexual HIV transmission to the general public, or t ordinary people can be prevented only by aggressive programme directed at the general population, and especially to youth. He cited studies which showed the risk of someone in the genera population of contracting HIV from any single sexual act was, a the highest estimate, one in 1,000 And he says the failure to recognise this means that scarce public healt resources in countries where HIV prevalence is low are being waste on prevention programmes being targeted at the public, when it is th high-risk groups who should be targeted 'Disservice Dr Purnima Mane, director of policy evidence and partnerships at UNAid said: "Without having access to the full text of the book, it is very difficul for UNAids to comment on it. But she said: "The Aids response has always invited a high-level of debat and discussion. UNAids welcomes this debate and stands by its scientifi approach "Twenty-five years into the Aids epidemic has shown the world how th 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 sai Dr Chin's views may have been accurate 10 to 15 years ago, bu were not true now "He is overstating his case. Sub-Saharan Africa is not the only plac to have heterosexual epidemics and most AIDS activists no longe 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. There seems to be a glitch in the news programme's softwar that reposts the very same message (with the very same messag ID) several times 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 Unfortunately, public education in this regard wouldn't make us the bigges potential market for .. anything As everyone that's at all informed knows, lesion-causing virus-permeabl condoms, extremely deadly poisons and unlikely abstinence are the entir 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 b made. Invest in big pharm. Place a bet on who manages to pull off a P campaign to force their vaccines on schoolchildren. Maybe one of them ca convince us that with 100000000000 of us getting infected every minute o so, we'd better just buy all their stocks of AZT and put it in our wate supply. Big money Love, however it look -- Rahasy nospam_rahasya@meditate.co.z There seems to be a glitch in the news programme's softwar that reposts the very same message (with the very same messag ID) several times 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 vector for transmission in the west, why should it b in Africa The truth is, there is no epidemic, and that is that http://news.bbc.co.uk/2/hi/health/6321683.st Expert doubts widespread HIV ris Intravenous drug use Intravenous drug users are a key high-risk grou 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 Afric are unlikely to contract HIV/Aids, as it is restricted to certain high-risk groups Campaigners have promoted a message of safer sex which involve the use of condoms for protection UK experts said Dr Chin's views were inaccurate, and misrepresente current thinking among HIV/Aids bodies 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 Dr Chin says it is only in sub-Saharan Africa, where unprotected sex outsid 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 se with other men, intravenous drug users and female sex workers And he says that, unless the clients or partners of people in these group 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" b UNAids and Aids activists because it is "politically and socially mor acceptable" to say HIV risk behaviours are present in all populations Writing in "The Aids Pandemic", Dr Chin says: "These activists do not wan to further stigmatise persons or population groups who have such high ris levels of HIV risk behaviours and who are already marginalised "By refusing to accept the fact that HIV is very difficult to transmit sexuall without the highest levels of sexual risk behaviours, Aids programmes hav avoided labelling some populations as being more promiscuous than others "It is a much more socially and politically correct public health message t say that sexual promiscuity exists in all populations and thus the risk o epidemic heterosexual HIV transmission to the general public, or t ordinary people can be prevented only by aggressive programme directed at the general population, and especially to youth. He cited studies which showed the risk of someone in the genera population of contracting HIV from any single sexual act was, a the highest estimate, one in 1,000 And he says the failure to recognise this means that scarce public healt resources in countries where HIV prevalence is low are being waste on prevention programmes being targeted at the public, when it is th high-risk groups who should be targeted 'Disservice Dr Purnima Mane, director of policy evidence and partnerships at UNAid said: "Without having access to the full text of the book, it is very difficul for UNAids to comment on it. But she said: "The Aids response has always invited a high-level of debat and discussion. UNAids welcomes this debate and stands by its scientifi approach "Twenty-five years into the Aids epidemic has shown the world how th 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 sai Dr Chin's views may have been accurate 10 to 15 years ago, bu were not true now "He is overstating his case. Sub-Saharan Africa is not the only plac to have heterosexual epidemics and most AIDS activists no longe 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. 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 Unfortunately, public education in this regard wouldn't make us the bigges potential market for .. anything As everyone that's at all informed knows, lesion-causing virus-permeabl condoms, extremely deadly poisons and unlikely abstinence are the entir 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 b made. Invest in big pharm. Place a bet on who manages to pull off a P campaign to force their vaccines on schoolchildren. Maybe one of them ca convince us that with 100000000000 of us getting infected every minute o so, we'd better just buy all their stocks of AZT and put it in our wate supply. Big money Love, however it look -- Rahasy nospam_rahasya@meditate.co.z 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 vector for transmission in the west, why should it b in Africa The truth is, there is no epidemic, and that is that http://news.bbc.co.uk/2/hi/health/6321683.st Expert doubts widespread HIV ris Intravenous drug use Intravenous drug users are a key high-risk grou 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 Afric are unlikely to contract HIV/Aids, as it is restricted to certain high-risk groups Campaigners have promoted a message of safer sex which involve the use of condoms for protection UK experts said Dr Chin's views were inaccurate, and misrepresente current thinking among HIV/Aids bodies 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 Dr Chin says it is only in sub-Saharan Africa, where unprotected sex outsid 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 se with other men, intravenous drug users and female sex workers And he says that, unless the clients or partners of people in these group 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" b UNAids and Aids activists because it is "politically and socially mor acceptable" to say HIV risk behaviours are present in all populations Writing in "The Aids Pandemic", Dr Chin says: "These activists do not wan to further stigmatise persons or population groups who have such high ris levels of HIV risk behaviours and who are already marginalised "By refusing to accept the fact that HIV is very difficult to transmit sexuall without the highest levels of sexual risk behaviours, Aids programmes hav avoided labelling some populations as being more promiscuous than others "It is a much more socially and politically correct public health message t say that sexual promiscuity exists in all populations and thus the risk o epidemic heterosexual HIV transmission to the general public, or t ordinary people can be prevented only by aggressive programme directed at the general population, and especially to youth. He cited studies which showed the risk of someone in the genera population of contracting HIV from any single sexual act was, a the highest estimate, one in 1,000 And he says the failure to recognise this means that scarce public healt resources in countries where HIV prevalence is low are being waste on prevention programmes being targeted at the public, when it is th high-risk groups who should be targeted 'Disservice Dr Purnima Mane, director of policy evidence and partnerships at UNAid said: "Without having access to the full text of the book, it is very difficul for UNAids to comment on it. But she said: "The Aids response has always invited a high-level of debat and discussion. UNAids welcomes this debate and stands by its scientifi approach "Twenty-five years into the Aids epidemic has shown the world how th 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 sai Dr Chin's views may have been accurate 10 to 15 years ago, bu were not true now "He is overstating his case. Sub-Saharan Africa is not the only plac to have heterosexual epidemics and most AIDS activists no longe 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. There seems to be a glitch in the news programme's softwar that reposts the very same message (with the very same messag ID) several times 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 Unfortunately, public education in this regard wouldn't make us the bigges potential market for .. anything As everyone that's at all informed knows, lesion-causing virus-permeabl condoms, extremely deadly poisons and unlikely abstinence are the entir 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 b made. Invest in big pharm. Place a bet on who manages to pull off a P campaign to force their vaccines on schoolchildren. Maybe one of them ca convince us that with 100000000000 of us getting infected every minute o so, we'd better just buy all their stocks of AZT and put it in our wate supply. Big money Love, however it look -- Rahasy nospam_rahasya@meditate.co.z There seems to be a glitch in the news programme's softwar that reposts the very same message (with the very same messag ID) several times 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 vector for transmission in the west, why should it b in Africa The truth is, there is no epidemic, and that is that http://news.bbc.co.uk/2/hi/health/6321683.st Expert doubts widespread HIV ris Intravenous drug use Intravenous drug users are a key high-risk grou 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 Afric are unlikely to contract HIV/Aids, as it is restricted to certain high-risk groups Campaigners have promoted a message of safer sex which involve the use of condoms for protection UK experts said Dr Chin's views were inaccurate, and misrepresente current thinking among HIV/Aids bodies 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 Dr Chin says it is only in sub-Saharan Africa, where unprotected sex outsid 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 se with other men, intravenous drug users and female sex workers And he says that, unless the clients or partners of people in these group 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" b UNAids and Aids activists because it is "politically and socially mor acceptable" to say HIV risk behaviours are present in all populations Writing in "The Aids Pandemic", Dr Chin says: "These activists do not wan to further stigmatise persons or population groups who have such high ris levels of HIV risk behaviours and who are already marginalised "By refusing to accept the fact that HIV is very difficult to transmit sexuall without the highest levels of sexual risk behaviours, Aids programmes hav avoided labelling some populations as being more promiscuous than others "It is a much more socially and politically correct public health message t say that sexual promiscuity exists in all populations and thus the risk o epidemic heterosexual HIV transmission to the general public, or t ordinary people can be prevented only by aggressive programme directed at the general population, and especially to youth. He cited studies which showed the risk of someone in the genera population of contracting HIV from any single sexual act was, a the highest estimate, one in 1,000 And he says the failure to recognise this means that scarce public healt resources in countries where HIV prevalence is low are being waste on prevention programmes being targeted at the public, when it is th high-risk groups who should be targeted 'Disservice Dr Purnima Mane, director of policy evidence and partnerships at UNAid said: "Without having access to the full text of the book, it is very difficul for UNAids to comment on it. But she said: "The Aids response has always invited a high-level of debat and discussion. UNAids welcomes this debate and stands by its scientifi approach "Twenty-five years into the Aids epidemic has shown the world how th 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 sai Dr Chin's views may have been accurate 10 to 15 years ago, bu were not true now "He is overstating his case. Sub-Saharan Africa is not the only plac to have heterosexual epidemics and most AIDS activists no longe 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. 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 Unfortunately, public education in this regard wouldn't make us the bigges potential market for .. anything As everyone that's at all informed knows, lesion-causing virus-permeabl condoms, extremely deadly poisons and unlikely abstinence are the entir 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 b made. Invest in big pharm. Place a bet on who manages to pull off a P campaign to force their vaccines on schoolchildren. Maybe one of them ca convince us that with 100000000000 of us getting infected every minute o so, we'd better just buy all their stocks of AZT and put it in our wate supply. Big money Love, however it look -- Rahasy nospam_rahasya@meditate.co.z 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 Unfortunately, public education in this regard wouldn't make us the bigges potential market for .. anything As everyone that's at all informed knows, lesion-causing virus-permeabl condoms, extremely deadly poisons and unlikely abstinence are the entir 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 b made. Invest in big pharm. Place a bet on who manages to pull off a P campaign to force their vaccines on schoolchildren. Maybe one of them ca convince us that with 100000000000 of us getting infected every minute o so, we'd better just buy all their stocks of AZT and put it in our wate supply. Big money Love, however it look -- Rahasy nospam_rahasya@meditate.co.z 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 vector for transmission in the west, why should it b in Africa The truth is, there is no epidemic, and that is that http://news.bbc.co.uk/2/hi/health/6321683.st Expert doubts widespread HIV ris Intravenous drug use Intravenous drug users are a key high-risk grou 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 Afric are unlikely to contract HIV/Aids, as it is restricted to certain high-risk groups Campaigners have promoted a message of safer sex which involve the use of condoms for protection UK experts said Dr Chin's views were inaccurate, and misrepresente current thinking among HIV/Aids bodies 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 Dr Chin says it is only in sub-Saharan Africa, where unprotected sex outsid 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 se with other men, intravenous drug users and female sex workers And he says that, unless the clients or partners of people in these group 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" b UNAids and Aids activists because it is "politically and socially mor acceptable" to say HIV risk behaviours are present in all populations Writing in "The Aids Pandemic", Dr Chin says: "These activists do not wan to further stigmatise persons or population groups who have such high ris levels of HIV risk behaviours and who are already marginalised "By refusing to accept the fact that HIV is very difficult to transmit sexuall without the highest levels of sexual risk behaviours, Aids programmes hav avoided labelling some populations as being more promiscuous than others "It is a much more socially and politically correct public health message t say that sexual promiscuity exists in all populations and thus the risk o epidemic heterosexual HIV transmission to the general public, or t ordinary people can be prevented only by aggressive programme directed at the general population, and especially to youth. He cited studies which showed the risk of someone in the genera population of contracting HIV from any single sexual act was, a the highest estimate, one in 1,000 And he says the failure to recognise this means that scarce public healt resources in countries where HIV prevalence is low are being waste on prevention programmes being targeted at the public, when it is th high-risk groups who should be targeted 'Disservice Dr Purnima Mane, director of policy evidence and partnerships at UNAid said: "Without having access to the full text of the book, it is very difficul for UNAids to comment on it. But she said: "The Aids response has always invited a high-level of debat and discussion. UNAids welcomes this debate and stands by its scientifi approach "Twenty-five years into the Aids epidemic has shown the world how th 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 sai Dr Chin's views may have been accurate 10 to 15 years ago, bu were not true now "He is overstating his case. Sub-Saharan Africa is not the only plac to have heterosexual epidemics and most AIDS activists no longe 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, [quoted text clipped - 11 lines] >> >>/Doug "Doug Houge" <d_houge@charter.net> wrote in message > >>The main way AIDs is spread in Africa is through Heterosexual sex. Ritual scaring and tattooing also plays a role in the spread. In our haste lets not forget the rape of children by infected males as a means to cure AIDS. Then there is the rape of women by the down low faggots. The sharing of needles in (hospitals). Their blood-banks are alive with HIV and who knows what else. But then, that is why Christ wasn't born in Africa, no virgin or 3 wise men could be found. > "Doug Houge" <d_houge@charter.net> wrote in message >> >> [quoted text clipped - 13 lines] >> >>/Doug "Doug Houge" <d_houge@charter.net> wrote in message > >>Aha, you are Christian? Well then why don't you act like one. I've read Giant but that doesn't make me Edna Ferber. There seems to be a glitch in the news programme's softwar that reposts the very same message (with the very same messag ID) several times Well then I guess I wouldn't use it, idiot. /Doug > There seems to be a glitch in the news programme's software > that reposts the very same message (with the very same message > ID) several times. 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 Unfortunately, public education in this regard wouldn't make us the bigges potential market for .. anything As everyone that's at all informed knows, lesion-causing virus-permeabl condoms, extremely deadly poisons and unlikely abstinence are the entir 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 b made. Invest in big pharm. Place a bet on who manages to pull off a P campaign to force their vaccines on schoolchildren. Maybe one of them ca convince us that with 100000000000 of us getting infected every minute o so, we'd better just buy all their stocks of AZT and put it in our wate supply. Big money Love, however it look -- Rahasy nospam_rahasya@meditate.co.z Doug sez: All I know is that AZT has been helping to keep me alive for twenty years and that can be proven. /Doug >> Dr Chin says HIV prevalence is low in most populations throughout the >> world [quoted text clipped - 26 lines] > > Love, however it looks "Doug Houge" <d_houge@charter.net> wrote in message > All I know is that AZT has been helping to keep me alive for twenty years > and that can be proven. OK, go ahead and prove you would be dead other-wise. > "Doug Houge" <d_houge@charter.net> wrote in message >> [quoted text clipped - 7 lines] >> >>/Doug > > "Doug Houge" <d_houge@charter.net> wrote in message > >> [quoted text clipped - 5 lines] > >>Coming from someone so ignorant and has not read many of my previous posts > >>to other groups, that is about the most stupid thing I have ever heard. That is the evasion I sought. I just wanted you on record as running from, ...and that can be proven, lol. >> > "Doug Houge" <d_houge@charter.net> wrote in message >> >> [quoted text clipped - 14 lines] >want to.... >. "Doug Houge" <d_houge@charter.net> wrote in message > >> >> All I know is that AZT has been helping to keep me alive for twenty > >> >> > >I know not why I waste my breath on this numbskull. It's really quite > >simple, I have been taken with some sort of illness that really makes me > >want to.... > >. Melt? > "Doug Houge" <d_houge@charter.net> wrote in message >> >> >> [quoted text clipped - 9 lines] > >FART? > "Doug Houge" <d_houge@charter.net> wrote in message >> >> All I know is that AZT has been helping to keep me alive for twenty years >> and that can be proven. >> > OK, go ahead and prove you would be dead other-wise. Why would I bother to let someone like you see my medical charts? You wouldn't understand them anyway. /DH "Doug Houge" <d_houge@charter.net> wrote in message > " Death" <Death@yourdoor.net> wrote in message > > [quoted text clipped - 7 lines] > Why would I bother to let someone like you see my medical charts? > You wouldn't understand them anyway. Another dodge from Dougie. He says he can prove his statement then runs away. Your medical chart will not prove azt kept you alive. It will only show you are alive. > Doug sez: > [quoted text clipped - 34 lines] >> >> Love, however it looks lol. "Dry Sex" no w that even sounds funny 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 vector for transmission in the west, why should it b in Africa The truth is, there is no epidemic, and that is that http://news.bbc.co.uk/2/hi/health/6321683.st Expert doubts widespread HIV ris Intravenous drug use Intravenous drug users are a key high-risk grou 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 Afric are unlikely to contract HIV/Aids, as it is restricted to certain high-risk groups Campaigners have promoted a message of safer sex which involve the use of condoms for protection UK experts said Dr Chin's views were inaccurate, and misrepresente current thinking among HIV/Aids bodies 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 Dr Chin says it is only in sub-Saharan Africa, where unprotected sex outsid 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 se with other men, intravenous drug users and female sex workers And he says that, unless the clients or partners of people in these group 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" b UNAids and Aids activists because it is "politically and socially mor acceptable" to say HIV risk behaviours are present in all populations Writing in "The Aids Pandemic", Dr Chin says: "These activists do not wan to further stigmatise persons or population groups who have such high ris levels of HIV risk behaviours and who are already marginalised "By refusing to accept the fact that HIV is very difficult to transmit sexuall without the highest levels of sexual risk behaviours, Aids programmes hav avoided labelling some populations as being more promiscuous than others "It is a much more socially and politically correct public health message t say that sexual promiscuity exists in all populations and thus the risk o epidemic heterosexual HIV transmission to the general public, or t ordinary people can be prevented only by aggressive programme directed at the general population, and especially to youth. He cited studies which showed the risk of someone in the genera population of contracting HIV from any single sexual act was, a the highest estimate, one in 1,000 And he says the failure to recognise this means that scarce public healt resources in countries where HIV prevalence is low are being waste on prevention programmes being targeted at the public, when it is th high-risk groups who should be targeted 'Disservice Dr Purnima Mane, director of policy evidence and partnerships at UNAid said: "Without having access to the full text of the book, it is very difficul for UNAids to comment on it. But she said: "The Aids response has always invited a high-level of debat and discussion. UNAids welcomes this debate and stands by its scientifi approach "Twenty-five years into the Aids epidemic has shown the world how th 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 sai Dr Chin's views may have been accurate 10 to 15 years ago, bu were not true now "He is overstating his case. Sub-Saharan Africa is not the only plac to have heterosexual epidemics and most AIDS activists no longe 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. 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 Unfortunately, public education in this regard wouldn't make us the bigges potential market for .. anything As everyone that's at all informed knows, lesion-causing virus-permeabl condoms, extremely deadly poisons and unlikely abstinence are the entir 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 b made. Invest in big pharm. Place a bet on who manages to pull off a P campaign to force their vaccines on schoolchildren. Maybe one of them ca convince us that with 100000000000 of us getting infected every minute o so, we'd better just buy all their stocks of AZT and put it in our wate supply. Big money Love, however it look -- Rahasy nospam_rahasya@meditate.co.z |
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