The panel set up by South African President Thabo Mbeki to advise his government on dealing with Acquired Immune Deficiency Syndrome stands divided on the cause and nature of the disease.
THE 13th international biennial conference on Acquired Immune Deficiency Syndrome, or AIDS, in Durban in July last kickstarted a parallel debate on the causality of the disease (Frontline, August 18, 2000). That the debate is far from over is clear from the interim report of the Presidential Advisory Panel on AIDS, which was released in March. There are different sets of recommendations, which are based on different perceptions of what the cause of the disease is. The panel, comprising 32 eminent scientists from across the world (15 South Africans were included in it later), was set up by President Thabo Mbeki in April 2000 as part of his South African government's decision to respond to the AIDS catastrophe in an urgent and comprehensive manner. Within a decade from 1985, AIDS, which was initially thought to be confined to the homosexual population, had spread across the African continent. According to the World Health Organisation (WHO), of the 5.6 million people infected with the human immunodeficiency virus (HIV) in 1999, 3.8 million lived in sub-Saharan Africa, and 85 per cent of all HIV-related deaths occurred in the same region.
Addressing the conference in Durban, Mbeki had talked about finding an "African solution to an African problem". He questioned the finding that HIV was the cause of AIDS, but there were few takers for this theory, and Mbeki was attacked by several speakers in the plenary sessions. But the country's black majority threw its weight behind the President. Although access to treatment formed the leitmotif of the conference, the issue of whether it was HIV that caused AIDS was also deliberated upon.
The South African government had raised questions, among other things, about the accuracy of the tests conducted to diagnose HIV infection and the relationship between HIV infection and diseases such as tuberculosis, malaria and hepatitis that are endemic to Africa. The government learnt that there were divergent views on the existence, detection and action of HIV, the "primary" aetiological agent of AIDS. The terms of reference of the panel included looking at the causes of immune deficiency that led to death from AIDS and the most efficacious response to these causes, why HIV was being heterosexually transmitted in sub-Saharan Africa while in Western countries it was said to be (primarily) homosexually transmitted, the role of therapeutic interventions in developing countries, and so on.
The panelists were largely divided on the question of the cause of AIDS. While one section, representing the scientific orthodoxy, maintained that HIV caused AIDS, another rejected this theory, saying that problems such as poverty and malnutrition caused the disease. There was also a section that questioned the very existence of AIDS.
One of the panelists, Roberto Giraldo, was convinced that the extent of AIDS epidemic was actually worse than what the supporters of the HIV theory believed. Along with Etienne de Harven, another panelist, Giraldo had visited India prior to the Durban conference on an invitation from the Joint Action Council, which has been in the forefront of the campaign based on scepticism regarding HIV. According to him, the levels of immune deficiency in Africa have been increasing since 1974-1975, that is, about 10 years before AIDS was recognised as a disease. He said that the preoccupation of politicians and governments with the theory that HIV caused AIDS had masked the enormity of the threat of AIDS and prevented them from dealing with the real causes of the disease. The opponents of the theory that HIV caused AIDS maintain that the virus had never been purified and that electron micrographs of the virus needed to be published.
Several panelists supported the "chemical AIDS hypothesis", which implied that exposure to toxins (such as recreational drugs, irradiation and Azidothymidine, or AZT) and possible vitamin deficiency caused AIDS in the United States and Europe. Roberto Giraldo propounded the theory that immunosuppression is caused by stressors. Five groups of stressors - chemical, physical, biological, mental and nutritional - were listed as instrumental in destroying the immune system. The immunosuppression caused by these stressors could lead to AIDS even in people who were HIV-negative, he said.
Notably, the report says that even scientists who subscribe to the HIV theory accepted Giraldo's proposition.
The term co-factor or risk factors in AIDS was strongly opposed by a section of the panelists that has been identified as the Perth Group, which argued that this presupposed the existence of a primary factor, that is, HIV. Professor Luc Montagnier, a leading scientist who is convinced that HIV played a central role in causing AIDS, could not explain why the epidemic was restricted to gays and intravenous drug-users in the U.S. and Europe but had a heterosexual profile in the countries of the South.
Dr. Joe Sonnabend, a proponent of the theory that HIV causes AIDS, held that poverty and malnutrition played a more important role in the development of AIDS than was acknowledged by the scientific establishment. Therefore it did not come as a surprise that in the interim report this group did not recommend eradication of poverty or the reduction of inequities as a means to deal with AIDS.
There was agreement among the panelists on the need to maintain a National Register of AIDS deaths as AIDS was still not a notifiable condition in South Africa. There were others who disputed the estimate of the size of the "AIDS epidemic" in the country. Dr. Peter Duesberg stated that even if the WHO's estimate of 75,000 AIDS deaths in Africa annually were true, the figure still represented only 0.5 per cent of the continent's total mortality rate. He wondered whether the magnitude of the epidemic had been determined by South Africans themselves or by external agents.
Doubts were expressed by some panelists over the sexual transmission of AIDS. One African panelist went to the extent of commenting that the data presented could be interpreted as suggesting that the HIV was highly selective in terms of race. He said that the high prevalence of HIV positivity among the blacks of South Africa would suggest that they were more promiscuous than the whites but there was no evidence to support such a conclusion.
The panel was also divided on the issue of mother-to-child transmission through breast-feeding. Dr. David Rasnick quoted a paper which showed that formula-fed HIV negative babies had contracted HIV. The possibility of contracting AIDS through occupational exposure and blood-borne transmission was questioned by some panelists who claimed that both in Africa and the West very few doctors and healthcare workers working with "so-called" AIDS patients daily were infected with HIV.
There was division of opinion on HIV testing and the epidemiology of transmission. Professor Duesberg argued that microbial and viral infections were self-limiting and seasonal and that the epidemiology of microbial epidemic was typically random with no discrimination between heterosexuals and homosexuals or men and women.
There was general agreement on surveillance as a necessary tool to understand the AIDS epidemic. But opinion was divided on the risk factors. While one school of thought argued that poor economic status was a risk factor in itself, another held that poverty only contributed to circumstances that would increase the risk of contracting AIDS. The broad division among the panelists led to two sets of general recommendations in the report. Those who oppose the HIV theory have suggested that the South African government suspend the dissemination of the "psychologically destructive" message that HIV infection is fatal and, instead, help reduce the hysteria surrounding HIV and AIDS. This group has also suggested the suspension of all HIV testing until its relevance is proved in the African context.
In contrast, the group supporting the mainstream approach recommended, among other things, the strengthening of the surveillance of risk factors and HIV prevalence.
One key issue on which there was near consensus was the need to make the existing mechanisms for HIV testing reliable. There was also consensus on the need to provide the infrastructure and expertise that are necessary to develop a database on the magnitude of the incidence of AIDS in South Africa. The report has recommended that a trans-disciplinary team be constituted to undertake an in-depth study of AIDS mortality trends in the country.
As the question of the aetiology of AIDS divided the panel, the commonality of views on health policy and public policy got ignored. The split, noted the concluding part of the report, was based on a fundamental disagreement on the interpretation of scientific and clinical data and evidence on the cause and progression of AIDS. Scientific research had not yet generated answers to many legitimate questions, it said. The last word on AIDS in South Africa is yet to be heard and the panel is expected to work on the areas of consensus.