Monday, January 16, 2012

Pandemic HIV: Not as Perfect a Storm as we Have Been Led to Believe

In his review of Jacques Pepin's 'The Origins of AIDS', Peter Piot (Science 334 (6063):1642-1643, 2011) claims to have been "fascinated by the sometimes devastating consequences of medical injections" since the mid 1970s, following the Ebola virus outbreak in the Democratic Republic of Congo. That's strange, because I've never been able to detect that fascination in his papers. Perhaps his fascination is dormant, a bit like one of the HIV virus strains Pepin describes, which never get beyond infecting one or a handful of people.

Anyhow, now that Pepin has described the role of healthcare in spreading HIV, especially in the decades before the virus was recognized, maybe Piot will develop all those thoughts which never quite became papers. Perhaps his ideas will 'go viral', mobilize UNAIDS and the entire AIDS industry to relinquish their more evident fascination with the sexual behavior of Africans, and perhaps result in thorough investigations of the many suspected cases of healthcare transmission of HIV that have been ignored for so long.

But like Pepin himself, Piot jumps from high rates of HIV transmission as a result of unsafe healthcare to high rates of HIV transmission as a result of 'unsafe' sexual behavior, as if unsafe healthcare completely died out in the 1980s and ceased to play any significant role over the last twenty years or so. HIV transmission from unsafe healthcare did begin to reduce shortly after it was recognized as playing a part in spreading the virus. And in countries where healthcare practices were modified to avoid HIV transmission, HIV incidence, and eventually prevalence, began to drop.

But the massive increase in unsafe sexual behavior that was said to follow urbanization and various other (often rather vaguely described) changes in the 1970s and 1980s may never have happened, or may never have played as big a role in HIV transmission as the industry claims. Of course, sexual transmission of HIV occurred, and still occurs. But with healthcare producing large enough populations of HIV positive people, relatively normal (for human beings) levels of sexual behavior would have resulted in additional infections, much as sexual behavior continues to contribute to epidemics now, albeit far more modestly than is sometimes claimed.

The idea that healthcare related infections no longer occur, or hardly ever occur, is a matter for investigation. Piot and Pepin may be right, or even somewhat right; but there is a lot of empirical work to be done. The need for empirical enquiry into the possible extent of healthcare transmission has been obvious for many years, many people have called for the work to be done. But all that people like Piot have done is supported UNAIDS and the industry in denying a role for anything except sex.

Glass syringes are no longer used and disposable syringes, presumably, are not reused (very often). But how does the industry feel so confident that there are no practices in healthcare facilities which, if carried out without proper care, risk transmitting HIV and other bloodborne diseases? The 'perfect storm' metaphor that Pepin mentions and Piot echoes, one that is currently so beloved by journalists and other commentators, doesn't appear to be appropriate here. They both refer to a series of events that gave rise to the HIV pandemic, rather than concurrent events.


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