April 24, 2003
Volume 5/ Number 12
The need for effective AIDS relief in Africa, as called for by President Bush, is tragically self-evident. But before we throw $15 billion at the problem, we must understand that past programs have failed. Even more importantly, we must understand why past HIV/AIDS programs in Africa have failed. It is not because they lacked resources, but because they were based on a false—and deadly—premise of reckless promiscuity among Africans. Many AIDS experts have long maintained that heterosexual activity accounts for 90% or more of HIV infections in African adults. This is why family planning programs have been ratcheted up to include HIV prevention. But a series of studies published in the March 2003 issue of a respected peer-reviewed journal, the International Journal of STD & AIDS, suggests that the chief culprit may be medical transmission.(1) Infected needles and infected blood, in others words.
This mistake, driven by a fixation on reducing African populations and failed programs that actually spread HIV/AIDS, has cost millions of lives.
Steven W. Mosher
Are Africans Promiscuous Unto Death?
A newly published meta-analysis of African AIDS studies should be read by all concerned about the future of the African peoples. In the first part, Brewer and his colleagues propose that “existing data can no longer be reconciled with the received wisdom about the exceptional role of sex in the African AIDS epidemic.”(2) In the second, Gisselquist et al discuss “how health care transmission of AIDS in Africa was ignored” in previous
studies.(3) In the third, and final, article, Gisselquist and Potterat estimate the actual percentage of HIV/AIDS cases in Africa that was transmitted heterosexually, as opposed to medically.(4) These studies empirically demonstrate that unsafe injections and other medical exposures to contaminated blood may account for two-thirds or more of the new cases of HIV/AIDS. In this new view, sexual activity is responsible for one-third or less, perhaps much less, of the spread of HIV in Africa.
In the late eighties, influential AIDS experts reached the conclusion that heterosexual sex was playing an exceptional role in the African AIDS epidemic. In a prominent 1988 article in Science, Piot et al wrote that ‘Studies in Africa have demonstrated that HIV-1 is primarily a heterosexually transmitted disease and that the main risk factor for acquisition is the degree of sexual activity with multiple partners, not sexual orientation.’(5) Once this paradigm was firmly in place, it tended to be self-perpetuating. Epidemiological evidence of medical transmission of AIDS by unsafe injections and other medical exposures to contaminated blood was ignored or misrepresented. The World Health Organization (WHO) now claims that ”current estimates suggest that more than 99% of HIV infections prevalent in Africa in 2001 are attributable to unsafe sex.”(6) 99%!
But on what evidence were these sweeping conclusions based? Very little, as it turns out. As Gisselquist et al note, “We have been unable to locate any document—from the 1980s or later—that describes a process to estimate a 90% sexual contribution to Africa’s HIV epidemic from empirical studies of risk factors for HIV.”(7)
So where did the “consensus” come from?
In the very early stages of the African epidemic, AIDS was demographically associated with sexually active populations, principally prostitutes and their clients.(8) This association seems to have caught the attention of various interest groups which, for diverse ideological, political, and financial reasons, promoted the notion of heterosexual transmission in their publications, proposals, and press releases.
First, many in the foreign aid community shared the conviction that Africa was “overpopulated,” and that both the world and Africa would be a better place if fewer African babies were born.(9) In order to drive down the birth rate, ongoing population control programs relied upon the promotion and distribution of condoms and contraceptives. Those who supported or participated in these anti-natal programs were inclined to emphasize the role of sexual transmission in African HIV/AIDS as an additional argument for condom promotion and distribution.
Second, in 1984 USAID began piggybacking its HIV/AIDS programs onto preexisting family planning programs. Organizations which applied for and received funding for such “integrated” programs–so-called because they brought together HIV prevention and pregnancy prevention under the same roof—may have been inclined to emphasize sexual transmission of HIV in their grant proposals and reports. If “unprotected” sex was driving up both the birth rate and the HIV/AIDS rate, then their integrated HIV/SRH clinics were the answer to both crises.
Third, HIV/AIDS was identified in the Western mind with homosexuals (also called MSMs, or men who have sex with men) and injection drug users (IDUs). As Gisselquist et al write, “[I]t was in the interests of AIDS researchers in developed countries—where HIV seem stubbornly confined to MSMs, IDUs, and their partners—to present AIDS in Africa as a heterosexual
epidemic.”(10) Homosexual activist Randy Shilts writes in his account of AIDS in America that “Nothing captured the attention of editors and news directors like the talk of widespread heterosexual transmission of
Fourth, as Packard and Epstein have documented, “the role of sexual promiscuity in the spread of AIDS in Africa appears to have evolved out of prior assumptions about the sexuality of Africans.”(12) That is to say, Africans were imagined to have too much sex with too many partners in circumstances that were too risky. These assumptions have little basis in reality. As Brewer et al report, “Levels of sexual activity reported in a dozen general population surveys in Africa 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 behavior shown in these surveys and the epidemic trajectories observed in these countries.”(13)
Fifth, as Gisselquist et al notes, “health professionals in WHO and elsewhere worried that public discussion of HIV risks during health care might lead people to avoid immunizations. A 1990 letter to the Lancet, for example, speculated that “a health message—e.g., to avoid contaminated injection materials—will be misunderstood and that immunization programmes will be adversely affected.”(14)
In short, individuals and organizations read into the African situation their own biases (against people in general and Africans in particular), their own agenda (a heterosexual epidemic and immunizations at any cost). The result was what Gisselquist et al call the “ignoring and misinterpreting of epidemiologic evidence.” This is very, very strong language for a scientific journal to publish.
In their second study, Gisselquist, Potterat and their colleagues examined all the evidence on African AIDS transmission available through 1988, before what they call the “premature closure of the debate” led “researchers in Africa . . . [to] often assume sexual transmission without testing partners, without asking about health care exposures, and when conflicting evidence nevertheless emerges—such as infected adults who deny sexual exposures to HIV—routinely rejecting it.”(15) In all, they reviewed 22 separate studies. What they found is startling:
Injections were more highly associated with HIV than was sex. “Published epidemiological evidence from 1984-88 in Africa shows higher average crude PAFs [population attributable fractions, a measure of risk] associated with injections than with measures of sexual exposure.”(16)
Most of those infected with HIV were in a long-term monogamous relationship. “Although some adults may have under-reported numbers of sexual partners, the consistency of the evidence suggests a large majority of HIV infections in non-promiscuous adults, and little concentration in the general population according to sexual activity.”(17)
Those of higher socioeconomic status have higher rates of HIV than those of lower status. “Since [Sexually transmitted diseases] STD have long been associated with lower socioeconomic and educational attainment, it was at least equally plausible that associations between high status and HIV pointed to differences in health care rather than sexual behavior.”(18) That is to say, the more “health care” one was exposed to, the greater one’s risk of developing HIV.
Clinic attendance was associated with HIV. “Comparison of HIV prevalence and incidence in STD clinics with prevalence in general population studies suggests that risk for HIV infection was associated with clinic
Infants were medically infected with HIV. “High rates of HIV infections in children that could not reasonably be attributed to vertical [that is, mother-to-child] transmission.”(20)
They close this extraordinary indictment of health care in Africa by pleading with “public health managers [to] . . . be more willing to seek and respect evidence about the proportion of HIV in Africa from medical
In their third, and final, article, Gisselquist et al estimate the actual percentage of HIV/AIDS cases in Africa that were transmitted sexually. The figure they come up with—25 to 35%–is far below the 90% hypothesis customarily assumed by researchers.(22) This rate of sexual transmission is only a third of what would be necessary to sustain the rapidly expanding HIV/AIDS epidemic.
Gisselquist et al urge a new effort to assess the role of medical
transmission: “A growing body of evidence points to unsafe injections and other medical exposures to contaminated blood as pathways that have not yet been adequately addressed.”(23) The risk of infection with HIV from a contaminated medical injection is one in 30.(24) This risk is 33 times higher than the generally accepted probability of transmission for penile-vaginal sex (about one in 1000).(25)
Where do Africans experience such exposures, which have taken such a toll on African life? Often in family planning programs, where injectable contraceptives such as Depo-Provera, Norplant implantation, and abortion (called “post-abortion care”) by Manual Vacuum Aspirator (MVA) are the order of the day.
Next week we will estimate how many of the 22 million deaths from
AIDS,(26) and the 30 million HIV infections, are a direct and indirect consequence of U.S. and foreign-funded family planning programs in Africa.
1. David D. Brewer, Stuart Brody, Ernest Drucker, David Gisselquist, Stephen F. Minkin, John J. Potterat, Richard B. Rothernberg, and Francois Vachon, “Mounting Anomalies in the Epidemiology of HIV in Africa: Cry the Beloved Paradigm,” Int. J. of STD & AIDS 2003; 14:144-147. David Gisselquist, John J. Potterat, Stuart Brody, and Francois Vachon, “Let it be Sexual: how Health Care Transmission of AIDS in Africa was Ignored,” Int. J. of STD & AIDS 2003; 14:148-161. David Gisselquist and John J. Potterat, “Heterosexual Transmission of HIV in Africa: An Empiric Estimate,” Int. J. of STD & AIDS 2003; 14:162-173.
2. Brewer et al, p. 144.
3. Gisselquist, Potterat, Brody and Vachon, p. 148.
4. Gisselquist and Potterat.
5. Piot P. Plummer F.A, Mhalu F.S., Lamboray J-L, Chin J., Mann J.M.,
“AIDS: An International Perspective,” Science 1988; 239:573-9.
6. World Health Organization (WHO). “The World Health Report 2002: Reducing Risks, Promoting Healthy Life.” Geneva: WHO, 2002.
7. Gisselquist, “Heterosexual Transmission of HIV in Africa: An Empiric Estimate,” Int. J. of STD & AIDS 2003; 14:162-173, p. 162.
8. Quinn, T.C., Mann J. M., Curran, J.W., Piot, P., “AIDS in Africa: an Epidemiologic Paradigm.” Science 1986; 234:955-63. Van de Perre, P, Rouvroy, D., Lapage, P., et al. Acquired Immune Deficiency Syndromw in Rwanda. Lancet 1984; ii: 62-65.
9. Gisselquist, David, et al, International Journal of STD & AIDS 2003; 14:148-161, page 158.
10. Ibid., p. 158.
11. Randy Shilts, And the Band Played On: Politics, People, and the AIDS Epidemic (New York: St. Martin’s Press, 2000), p. 513.
12. Packard, R.M., Epstein, P., Epidemiologists, Social Scientists, and the Structure of Medical Researh on AIDS in Africa,” Soc Sci Med 1991; 33:771-83.
13. Brewer et al, “Mounting Anomalies in the Epidemiology of HIV in
Africa: Cry the Beloved Paradigm.” International Journal of STD & AIDS 2003; 14:144-147. p. 145.
14. Gisselquist et al, “Let it be Sexual,” p. 158.
15. Ibid., “Let it be Sexual,” p. 148.
16. Ibid., p. 154.
17. Ibid., p. 152.
18. Ibid., p. 153.
19. Ibid., p. 154.
20. Ibid., p. 153.
21. Gisselquist et al, “Discounting health Care in HIV Transmission,” p. 159.
22. Gisselquist et al, “Estimating sexual transmission of HIV,” p. 171.
23. Gisselquist, “Estimating . . .”, p. 171.
24. Drucker, E.M., Alcabes, P.G., Marx, P.A., “The Injection Century: Consequqnces of Massive Unsterilie Injecting for the Emergence of Human pathogens.” Lancet 2001; 358:1989092.
25. Royce, R.A., Sena, A., Cates. W. Jr., Cohen, M.S. “Sexual Transmission of HIV.” New England Journal of Medicine 1997: 336:1072-8.
26. UNAIDS, “AIDS Epidemic Update,” 2000-2002; World Health Organization, Fact Sheet 2, “The Global HIV/AIDS epidemic.”