Michel D Kazatchkine and Didier Fassin
The controversy generated by President Thabo Mbeki’s statements on the role of HIV as the causal agent of Aids has led some investigators to question their participation in the forthcoming 13th international conference on Aids to be held in Durban in the second week of July.
In a letter to the secretary general of the United Nations and United States President Bill Clinton, Mbeki, after reiterating the commitment of South Africa to the fight against HIV/Aids and calling for specific African solutions to control the pandemic, questioned whether Aids was indeed caused by HIV. In this respect, Mbeki relied on old theses originally put forward by Peter Duisberg and David Rasnick that have been unanimously rejected by the scientific community.
By raising this discredited issue again at a gathering of international experts to discuss these matters, the president has provided the dissident scientists with an unexpected forum and taken the risk of increasing doubt in the general population of South Africa about facts that should not be called into question.
The fact that the virus is found in every patient with Aids, the chronological link between infection and the occurrence of the disease, the beneficial effect of anti- retroviral drugs on disease manifestations, the information gained from animal models and many other experimental lines of evidence have all led the scientists to unreservedly recognise the virus as the cause of Aids.
Beyond this controversy, one may, however, discern in Mbeki’s statements deep concern over the disarray that African countries have in the face of the pandemic, and his worry about the inability of the international community to intervene in an appropriate and effective manner. Indeed, the terms of his letter raise a number of issues of a historical, social, ethical and political nature that need to be taken into consideration.
More than two-thirds of the world’s 34- million HIV-seropositive people live in sub-Saharan Africa, which itself only represents one-tenth of the world population. Aids has become the number one infectious killer in this part of the world.
In South Africa it is estimated that more than four million people are infected with HIV. In some of the largest cities in the region up to one in four people are infected with the virus. Aids is now a threat to the life expectancy of the population, to the stability of families and communities, and also to the national economy and development.
Given the growth rate of the epidemic and the current lack of access to care, it is difficult to imagine that the situation will improve in the coming years. It is in this context that Mbeki’s letter calls for answers.
Even if HIV Type C, which is the predominant type of virus circulating in South Africa, were to be more infectious than other strains, a number of other factors would still have to be considered to explain the rapid progression of the epidemic and the high prevalence of HIV infection in the country.
The emergence and initial spread of the disease occurred at a time in South Africa’s history which was marked by decades of segregation and apartheid. An accelerated growth of the epidemic coincided with a period of instability at the end of this era. Similar phenomena were observed in other countries subjected to comparable regimes, such as Namibia.
An increased risk of infection with HIV and other sexually transmitted diseases is strongly linked with poverty, vulnerability and social and sexual violence. Such risk is also associated with migration of labour far from home, inherited from the systems of the bantustans, or else with alcohol consumption that started in the mining economy and is perpetuated through unemployment.
Examples from other regions of the world, such as previously Soviet countries, demonstrate that the end of long periods of social and political turmoil is associated with an increased susceptibility to infectious epidemics. This, we believe, is what Mbeki is saying, when discussing apartheid and the distinct epidemiological context of HIV infection in South Africa and in the region in his letter.
The president’s remarks also refer to the inability of the international community to put forward appropriate answers to the Aids pandemic. According to UNAIDS, $165-million is spent each year for prevention in Africa where 70% of infected people in the world live, whereas $3-billion is spent on anti- retroviral drugs for the richest countries that represent 10% of infected individuals worldwide.
Prevention programmes may only be effective, from a public health perspective, if they are implemented in the context of programmes aimed at reducing inequalities and violence and of actions aimed at improving access to care.
If the Security Council of the UN, the World Bank and the G8 are now putting these issues on the political agenda, and if some hope has been generated by the recent agreements passed between UNAIDS and some of the major pharmaceutical companies marketing anti-retroviral drugs, the moves are still too slow and too limited, and certainly not adapted to the scale of the epidemic that South Africa is facing. This is also in Mbeki’s statement and is the context in which one should interpret the controversy that recently followed the observation of adverse effects in therapeutic trials in South Africa.
The International Conference on Aids is held every second year. In 1996, at the time when much hope was generated by the first reports of the results obtained with triple-combination therapy, the conference slogan was global and full of enthusiasm: “One world, one hope”. Two years later, in Geneva, the message was still one of hope: “Bridge the gap”. This year in Durban, the conference emphasises the anxiety of the international community and the need for telling the truth: “Break the silence”.
We thus hope that Mbeki’s statements, rather than being limited to a useless controversy, will generate the necessary discussions between scientists and politicians. If HIV is undoubtedly the cause of Aids, the control of the pandemic will require that social, economic and political issues are addressed appropriately from a public health perspective. These are reasons for us to go to Durban and for “breaking the silence”.
Michel D Kazatchkine is professor of medicine at the University of Paris and director of the National Agency for Research on Aids in France. Didier Fassin is professor of sociology at the University of Paris and director of the Centre for Research on Public Health Issues