Monday, March 5, 2012

Timberg and Halperin's Tinderbox: a Veritable Candle on a Sunny Day

The authors of another book on the putative origins of HIV has been published by journalist Craig Timberg and academic (and ardent circumcision enthusiast) Daniel Halperin. There's a lengthy article plugging the book by the authors in the Washington Post, for whom Timberg works. Few know how to plug the latest pot-boiler like a journalist, especially one who wrote the book. But the article is a bit of a damp squib after Jacques Pepin's 'Origins of AIDS'. Timberg and Co. don't really deliver the goods, having promised something explosive.

While Pepin argues that the epidemic would never have got going without widespread colonial healthcare programs, and even with them it still took some decades, Timberg and Co. relegate everything about unsafe healthcare to a parenthetical comment. And though Pepin's argument becomes flakey when he claims that sexual behavior alone wouldn't have been enough to give rise to a serious epidemic, yet that it was enough to ensure that prevalence reached massive levels at some point, Timberg and Co. argue "it’s clear that colonial commerce created massive new networks of sexual interactions — and massive new transmissions of infections."

For them, it's quite simple: a hunter was infected by a chimp through a cut and went on to infect a sexual partner. As far as they are concerned, it was just a matter of there being a "population large enough to sustain an outbreak and a sexual culture in which people often have more than one partner, creating networks of interaction that propel the virus onward." For them, Kinshasa was that place. But while that city has been identified as the place where some of the earliest large scale transmission occurred, this does not mean all transmission, or even most transmission, was through heterosexual intercourse.

There is a problem with Kinshasa as a candidate for high levels of 'unsafe' sexual behavior: syphilis, the sexually transmitted infection (STI) that didn't bite. In 1958, nearly 100,000 men, all the men in the city, were screened for STIs; only 44 possibly had syphilis (and there were a few hundred with other STIs). Even some of those who possibly had syphilis may equally have been infected with the non-sexually transmitted yaws, which was too similar to distinguish.

Timberg and Co. are not too generous with dates in their article, so it could be argued that sexual behavior in Kinshasa changed after independence; this is what Pepin argues, albeit unconvincingly. But patterns of syphilis transmission just don't resemble patterns of HIV transmission. Males and females, urban and rural dwellers are infected with syphilis in fairly similar proportions, whereas HIV transmission is far higher among females and urban dwellers. And whereas HIV tends to infect wealthier people who have higher levels of education, syphilis tends to infect poorer people with less education.

In fact, trends in syphilis rates in many areas have gone in the opposite direction to trends in HIV prevalence. But syphilis rates do testify to at least two things; unprotected sex and poor sexual health facilities. In the few years before HIV was identified, these two factors came together in countries like Kenya, Tanzania and others in ways that may suggest when and where the real 'explosion' occurred. The highest HIV prevalence figures found in African countries were among sex workers, many of whom had been targetted by STI treatment and vaccination. Such rates have not since been found among this group. Significantly, in several non-African countries, HIV rates are not particularly high among sex workers unless they are also intravenous drug users.

Timberg and Halperin's argument doesn't work. HIV can be transmitted sexually but, as they and Pepin point out, it usually isn't. Pepin demonstrates very convincingly how unsafe healthcare programs, even ones that he himself was involved in, were required to enable the virus to infect huge numbers of people in a short space of time, something sexual transmission alone could not have done. But while Pepin doesn't successfully demonstrate how sexual behavior could take over from unsafe healthcare, Timberg and Halperin don't appear to demonstrate anything worth writing a whole book about.

The authors blame 'The Scramble for Africa', but without shedding any light on how various colonial maneuvers did, and continue to do, so much damage in former colonies. They and Pepin point a finger at 'urbanization', which is common in the HIV literature. But what, in particular, is it about colonization and urbanization that influence how a virus that is difficult to transmit sexually becomes a pandemic, and one driven primarily by sexual behavior if the HIV orthodoxy is to be believed? This is not merely a problem for historians: if the HIV industry continues to behave as if the virus is almost always heterosexually transmitted, non-sexual transmission will not be addressed, as it so urgently needs to be.

[This blog post is about Timberg and Halpern's article plugging their book, not on the book itself, which may take some time to acquire in East Africa. For more about non-sexually transmitted HIV, see the Don't Get Stuck With HIV site.



Anonymous said...

Please allow me to quote a blogger. If you're offended by his language, I apologize.

"It’s really hard to get HIV from fucking a woman’s pussy if you’re the guy. It’s possible, probably more likely if she is on her period because there is bleeding and your dick contacts the blood, which has tons of HIV in it. Vaginal secretions have HIV, but only a small amount. It’s hard to transmit HIV from a vagina to someone else.

Objections have been raised to this, pointing out that HIV from straight sex is common in India, Thailand and Africa. However, in Thailand and Africa at least, there are completely different forms of HIV than the types of HIV found in the West. Those types seem to be easily transmitted heterosexually, but the type in West seems to be hard to transmit heterosexually."

What are your thoughts on the 2nd paragraph?

Simon said...

Thank you for your comment. There are some interesting links on transmission probabilities for heterosexual sex in the following article:

However, there are many factors involved in sexual transmission that might increase the probability. But the blogger you cite is right about one thing; in Western countries, it is unusual for women to transmit HIV to men through heterosexual sex where no major additional risks are involved.

The claim that HIV from heterosexual sex is common in India, Thailand and Africa is the very one being contested because people are generally not asked about their non-sexual risks. Here's a short article where it is acknowledged that HIV through unsafe healthcare in India has been ignored:,%202011/62-65.pdf

In Africa, non-sexual risks are generally ignored because it is assumed, not demonstrated, that almost all HIV transmission is through heterosexual sex.

Higher and lower infectiousness of different subtypes has been demonstrated but that is unlikely, on its own, to explain the differences between high and low prevalence zones globally.

But remember, you're concentrating on heterosexual transmission, which is inefficient for all HIV subtypes. I'm interested in non-sexual transmission, which can be very efficient when it occurs in healthcare settings; it is probably very efficient for all subtypes.