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Comment on the Presidential Aids Advisory Panel Report from South Africa

from 

Christian Fiala, Etiene de Harven, Peter Duesberg, 
Claus Koehnlein, Heinz Spranger

 

Aetiology and transmission of Aids   
Surveillance
 
HIV tests and their accuracy 
 
Treatment of Aids
 
Preventive and Prophylactic Measures
 
Conclusion
:
 
- Lack of reliable data
 
- Lack of data concerning the reliability of HIV-testing 
- Lack of a reliable definition for Aids

 

April 05, 2001

In 2000, the President of South Africa invited a number of scientists of different backgrounds and different views to serve on a panel to discuss HIV/Aids. The panel met on two occasions in May and July in South Africa and exchanged views in an Internet discussion during the two months in between. A total of 52 scientists participated in these discussions.

The main questions raised were:

  • What causes the immune deficiency that leads to death from AIDS?
  • What is the most efficacious response to this cause or causes?
  • Why is HIV/AIDS in sub-Saharan Africa heterosexually transmitted while in the western world it is said to be largely homosexually transmitted?
  • What is the role of therapeutic interventions in the context of developing countries?

The discussions above should be underpinned by considerations of the social and economic context, especially poverty and other prevalent co-existing diseases and the infrastructural realities of developing countries.

The report released on 4 April 2001 summed up the interventions and discussions that took place.
The most striking aspect during all discussions was a division into two groups:
- Those scientists who put forward arguments in favour of HIV as being necessary and sufficient to cause Aids. Aids, in turn, leads necessarily to death and therefore has to be treated with antiretroviral drugs.
- Those scientists who put forward arguments for HIV not being the cause of Aids, for Aids being an artificial list of old, well known and treatable diseases and anti-retrovirals as being toxic and in part responsible for people suffering and dying from what is called Aids.

It was the first time in the history of HIV/Aids that scientists from different views were invited with the intention of finding common ground.
The individual interventions and arguments will not be repeated in this summary as they have been published already. Instead, the recommendations and conclusions will be cited together with a short analysis.

Aetiology and transmission of Aids

Arguments and views were totally divided and no common conclusion could be reached.

Surveillance

A surprising "General recommendationis" given at the end of this chapter: "There was general consensus on the need for the case definition of AIDS to be standardised for clinical practice in South Africa." This recommendation was necessary because no clinical guideline for the diagnosis of Aids in South Africa was presented to the panel. Only the Health Ministryıs reporting form for Aids cases was available. Aids is defined in this form on the basis of unspecific criteria like fever, diarrhoea and weight loss. An HIV-test is only optional. (This definition is based on the so-called Bangui-definition of WHO.)

Another surprising aspect was the lack of data. Or as the report puts it: "The deliberations of the panel were at all times bedevilled by the absence of accurate and reliable data and statistics on the magnitude of the AIDS problem or even HIV prevalence in South Africa. Repeated requests for such data and statistics, particularly by panellists who refuted the causal link between HIV and AIDS, failed to result in the provision of such data by either South African panellists or the officials of the Department of Health."
Therefore the following general recommendation was given: "to collect the data and develop reliable and up-to-date statistics on the magnitude of AIDS and prevalence of HIV in South Africa".
A good example of the underlying problem is given in the report itself. At the end of the last meeting, Dr. Makgoba presented statistics on mortality in SA from 1990 to 1999. These data showed a steady and linear increase of mortality, especially in the age-group 20-60 years. A parallel increase of HIV-positive results in the antenatal screening was observed during the same period. Dr. Makgoba presented these data as proof of an Aids-epidemic ­ but his interpretation ignores the widely believed concept of an average incubation period of 8-10 years. If anything, these data would indicate that HIV cannot be made responsible for an increased mortality during that period. Unfortunately there was no discussion on these data as they were not made available to the other members of the panel and were presented only at the end of the last meeting.
Dr Makgobaıs interpretation on this very basic subject is further complicated by comments from Statistics South Africa, which said: " Stats SA has several problems with this interpretation". It concluded on the age-specific mortality that "the 1999 profile is not a drastically new profile as portrayed."
However, Statistics South Africa is well aware of the real problems in the country: "the largest proportion of causes of death among males was unnatural causes. The breakdown shows that 27% of South African males die of accidents and violent deaths."
Statistics South Africa argued that the data from 1990 cannot be compared with 1999, as dramatic changes had taken place during that period. (i.e. Former Homelands were included in the statistics only after 1994 and the age distribution of the population had changed over time being demographically younger now.)

HIV tests and their accuracy

The report writes: "The key issue that came under focus was the reliability of the ELISA testing. ... A major recommendation arising from the two meetings was to apply a series of HIV tests of increasing stringency in order to establish the validity, veracity, rigour, reliability and concordance of ELISA, PCR and viral isolation."
It seems surprising to start studies on the reliability on HIV-test when they have been used for more than 15 years. Therefore it is safe to conclude that the decision to conduct studies to investigate the reliability was made because they had not yet been done.
(All predictions on HIV and Aids in South Africa are based on a sentinel screening in public antenatal clinics. One single ELISA test is used in this screening to diagnose HIV-infection.)

Treatment of Aids

The views were strongly divided on the need and danger of so-called anti-retroviral drugs. Nevertheless the report concludes: "The toxicity of anti-retroviral drugs was not in dispute from any of the panellists."

Preventive and Prophylactic Measures

Any recommendation on this subject is based on the understanding of the aetiology and the understanding of the nature of HIV and Aids. The views and arguments on both sides were diametrically opposed. No general conclusion could be reached on this subject.


Conclusion:

The panel was invited to discuss possible reasons and the magnitude of the HIV/Aids epidemic in South Africa ­ and to make recommendations on how to combat it.
General agreement was reached however on the following major problems:

- Lack of reliable data
Neither the SA health authorities nor the South African panel members presented data which indicated an increased mortality, not to mention an Aids epidemic.

- Lack of data concerning the reliability of HIV-testing
It was decided to undertake studies to assess the reliability of the HIV-tests, especially the ELISA test, because it is the most frequently used test in SA. (All predictions on HIV and Aids in South Africa are based on a sentinel screening in public antenatal clinics. One single ELISA test is used in this screening to diagnose HIV-infection.)

- Lack of a reliable definition for Aids
Three symptoms out of a list of unspecific clinical symptoms are used in the Ministry of Healthıs reporting form for Aids. (I.e. Fever, diarrhoea, weight loss, general itching, coughing etc. An HIV-test is optional in the diagnosis of Aids. This definition is known as the Bangui definition and was accepted by WHO in 1985.) No other document was presented to the panel showing the definition of Aids used by doctors in South Africa. The following recommendation was therefore approved: "There was general consensus on the need for the case definition of AIDS to be standardised for clinical practice in South Africa."

Therefore any recommendation concerning treatment or prevention has to be discussed on the basis of a complete lack of basic data. The panel was not provided with any reliable data whether there is a problem at all and if so of what magnitude. This is especially worrisome when it comes to the use of so-called antiretroviral drugs. It should be recalled that the report writes: "The toxicity of anti-retroviral drugs was not in dispute from any of the panellists."

The following questions arise after reading the report: Why is it that we ask these very basic questions only after almost 20 years of Aids-hysteria? And what did we do during this time when we fought against "HIV/Aids"?

Christian Fiala, MD, christian.fiala@aon.at
Department of Obstetrics and Gynaecology, General Public Hospital Korneuburg, Austria
Etiene de Harven, Prof. emerit (Pathology), pitou.deharven@wanadoo.fr
Univ. of Toronto, Canada 
Peter Duesberg, Prof., duesberg@uclink4.berkeley.edu
Dept. Mol. & Cell Biol. Stanley Hall UC Berkeley
Claus Koehnlein, MD, Koehnlein-Kiel@t-online.de
Specialist in Interne Medicine, Kiel, Germany 
Heinz Spranger, Univ.-Prof.a.D.Dr.Dr.h.c., IPOM.Spranger@t-online.de
German Association of medical and non-medical health Practitioners (Aktions-Kreis Heilberufe in Deutschland).

All are invited members of the South African Presidential Aids Advisory Panel

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