Sam WP Mhlongo,
Head of Department Family Medicine & Primary Health Care, Medunsa
Medical University of Southern Africa, 0204 RSA
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Although the title "The politics of AIDS in South Africa: beyond the controversies" (Fassin & Schneider BMJ Vol. 326, March 1st 2003) is eye-catching, the piece has a number of disturbing inaccuracies, polemics and has failed to live up to the title. The article remains firmly rooted in the controversy and invitingly implores the question: what is the cause of AIDS in Africa? The authors have clearly made up their minds and without any shadow of doubt that HIV is the cause of AIDS in Africa and that heterosexual transmission is the dominant mode in the infection process. It s hardly surprising that they have failed to go beyond the controversies - hence HIV appears no less than 22 times in their article.
In their first paragraph, Fassin and Schneider claim that President Mbeki sent a letter to world leaders expressing his doubts that HIV was the exclusive cause of AIDS '.1 There is no reference for this 'letter' of Mbeki's to these anonymous world leaders. Fassin and Schneider deliberately mislead by misrepresentation of President Mbeki's position of 1999. As far as the facts stand at the moment, there is no evidence whatsoever to suggest that Mbeki has changed from his 1999 position. He still has the same questions, which are: Why is AIDS in Africa so vastly different from AIDS in Western Europe and North America? why is the mode of transmission predominantly heterosexual in Africa? How safe is the drug Zidovudine? When Mbeki failed to get a response to these questions from his scientists, he sought advice from outside South Africa from both orthodox and dissident scientists. This is how The Presidential AIDS Advisory Panel was formed in April 2000 consisting of 20 orthodox and 13 dissident scientists. 2 Mbeki's view is that science cannot be reconciled with national boundaries hence, the international nature of The Presidential AIDS Advisory Panel. Another misrepresentation in this article is that in April 2002, 'Mbeki formally distanced himself from "the AIDS dissidents". We are not given the evidence for this statement. The fact is: Mbeki has neither declared he was distancing himself from dissident nor orthodox positions on the subject of HIV/AIDS.
Slowly but inexorably evidence casting doubt on the orthodox assumption that in Africa, AIDS is overwhelmingly due to heterosexual transmission of HIV is emerging. Interestingly this evidence comes not from dissident but non-dissident scientists. The following from peer reviewed papers will illustrate this point:
a) Devon D. Brewer and his colleagues stated in their 2003 paper: '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 ...... Dispassionate assessment of our conclusions admitted depends on a willing suspension of disbelief, since the current paradigm is deeply embedded......Finally, Africans deserve scientifically sound information on the epidemiological determinants of their calamitous AIDS epidemic'. 3
b) With regard to sexual or vertical transmission, David Gisselquist et al have thrown wide open the discussion regarding the cause(s) of AIDS in Africa and concluded that: "The recognition that significant proportions of HIV in African adults and children cannot be explained on the basis of current knowledge about sexual and vertical transmission leaves open several transmission hypotheses" 4 In short, this must necessarily mean re-examination of the current hypothesis and assumption that the mode of HIV transmission in Africa is largely heterosexual activity. In addition the validity of the tests for HIV antibodies need to be questioned in addition to questioning poor hygiene practices in African health care services.
c) To date, the longest epidemiological study questioning heterosexual transmission is that of Nancy Padian and colleagues over a period of ten years. In their paper (Heterosexual Transmission of Human Immunodeficiency Virus (HIV) in Northern California: Results from a Ten- Year Study, Padian and her colleagues concluded that with regard to male to female transmission (0.0009 per contact), it would take 770 or 3333 sexual contacts respectively to reach a 50% or 95% probability of becoming infected. Based on Padian's estimate of female-to-male transmission, it would require 6200 and 27000 contacts and a period of 51 and 222 years respectively. 5
Fassin's and Schneider's reference to The Constitutional Court judgement on the provision of antiretrovirals has an air of triumphalism about it. It can be argued that this was not a judgement on science but a judgement dictated to by populism and national emotions about HIV/AIDS. In the midst of all this, physicians and medical scientists should rise above emotions and populist pursuits so that the public is made aware that the improvements in the health status of Western Europe and North America had very little to do with the provision of drugs. In the last two centuries the decline in the incidence of tuberculosis in these countries was not largely due to chemotherapy, but rather due to improved living conditions, sanitation, nutrition, employment and reduced family size- see figure showing mean annual death rates from TB in England and Wales. 6
Prof. Sam MHLONGO MBBS, MSc, LRCP, MRCS (London), MRCGP(UK)
1. Didier Fassin, Helen Schneider: The politics f AIDS IN South Africa: beyond the controversies: BMJ VOLUME 326 1 March 2003:495-497
2. Sam MHLONGO: HIV BLAMED FOR POVERTY: La medicina la psicanalisi la vita (PUBLISHED BY: SPIRALI/VEL 2000-MILAN)
3. Devon D Brewer et al: Mounting anomalies in the epidemiology of HIV in Africa: cry the beloved paradigm: International Journal of STD and AIDS 2003; 14:144-147
4. Gisselquist, Richard Rothenberg, John Potterat; Ernest Drucker. HIV infections in sub-Saharan African not explained by sexual or vertial transmission: International Journal of STD & AIDS 2002;13:657-666.
5. Padian NS et al (1997) Heterosexual Transmission of Human Immunodeficiency Virus (HIV) in Northern California: Results from a Ten- Year Study. American Journal of Epidemiology 1997;14:350-357.
6. Thomas Mckeown: The role of Medicine: Dream, Mirage or Nemesis: 92 - 96: Basil Blackwell: Oxford 1979)
Competing interests: None declared