30 October 2012

Africa: HIV/Aids - the Facts and the Fiction

book review

Although short on solutions, biologist Chris Jennings persuasively argues that AIDS did not originate in Africa and that its spread is vastly overestimated.

When a book's statement of purpose is to "reconfigure the conceptual paradigm of the HIV/AIDS epidemic, such that resource allocations and health care interventions better serve the populations at need - both those with and without HIV/AIDS - worldwide", expectations are high. Although successful in making waves within the realm of HIV/AIDS research, Jennings' efforts largely fail to step outside this research paradigm and address the issue of resource allocation and healthcare priorities.

Nevertheless, the overall message Chris Jennings is trying to convey is never lost, despite the Harvard-educated biologist's attempts at writing for laypeople being sometimes overshadowed by large sections of scientific jargon.

HIV/AIDS: The Facts and The Fiction argues that the AIDS epidemic first began in New York City, that the HIV virus was not discovered in an African green monkey, and that the media alongside international and national bodies have grossly overestimated how many AIDS victims there have been.

Jennings's accompanying book, HIV/AIDS in South Africa: The Facts and the Fiction further highlights the dangers of estimating the number of HIV/AIDS victims in the country reported to be home to the largest HIV/AIDS epidemic in the world.

Where did it all begin?

Contrary to the widely held belief that AIDS originated in Africa, Jennings makes a convincing case that the first 'legitimate' cases of AIDS were in the United States - specifically New York City, then in Los Angeles. 72% of these first one thousand victims were gay men. And, although the first ever AIDS victim in the US was an African-American man, Jennings is quick to point out that the next 25 victims were Caucasian.

Jennings goes on to argue that the first connection between Africa and AIDS was made shortly after its initial outbreak in the US. One third of early sufferers were also infected with Kaposi's sarcoma, an opportunistic virus which takes advantage of the weakened immune system. And in 1981 - just two years after the first ever AIDS patient was diagnosed in New York City - the Morbidity and Mortality Week Report published an article stating that although Kaposi's sarcoma was very rare in the US, it accounted "for up to 9% of all cancers" in an " endemic belt" across equatorial Africa. Jennings asserts that the reiteration of this point by the New York Times planted the seed for future misconceptions about the links between Africa and AIDS.

The spread of AIDS

Jennings's portrayal of how AIDS spread to become a global epidemic is also unorthodox. Contrary to the widely held assumption that AIDS travelled from the African jungle to urban centres from which it permeated the Western world, Jennings argues that the spread of AIDS exemplifies his theory that "disease follows trade routes". He claims the first cases of AIDS were seen in the US, before the disease appeared throughout Europe, with the majority of the early victims having had homosexual relations in the US or with an American citizen. Jennings also highlights the fact that the first two confirmed AIDS victims in South Africa were two gay men who had travelled to the US.

Nevertheless, throughout this section of the book, Jennings fails to properly investigate the possibility that the virus existed in Africa but was not widely acknowledged for reasons such as traditional medical practices, the lack of central HIV reporting databases, and the possibility of diseases common to developing countries including tuberculosis, being diagnosed in place of the AIDS virus.

This shortcoming aside, his argument that the disease followed trade routes carries some weight. The fact that, as the virus began to ripple through the Caribbean and Europe, there was a virtual absence of the disease in Cuba and the Soviet Union, seems to confirm linkages between disease and trade routes, or a lack thereof, during the Cold War era.

Monkey business

Further to Jennings's version of the spread of AIDS, he goes on to clarify that an AIDS-like virus was not in fact located in an African green monkey in 1985, as initially reported by a group of researchers from the School of Public Health at Harvard. He explains that the scientists' findings came as a result of lab contamination and suggests that the lack of media coverage surrounding the researchers' retraction of their initial findings was just another incident of the media propagating a one-sided story that AIDS originated in Africa.

Indeed, the role of the media in supporting what Jennings refers to as the 'African fallacy' is a common theme throughout the book. On numerous occasions, Jennings refers to specific newspaper headlines to give examples of the media both propagating and inflating the idea of AIDS originating from, and decimating, the African continent. New York Times headlines such as "AIDS in Africa: A Killer Rages On" and "AIDS Is Everywhere, but Africa Looks Away" are provided as examples of such alarmist journalism. While Jennings makes mention of similar coverage appearing on the BBC and the Chicago Tribune, his overarching focus on the New York Times (a whole page of the book is dedicated to listing the publication's headlines) is quite puzzling and skewed at times.

Statistical searching

Jennings's investigation into the statistics that surround HIV/AIDS prevalence in Africa is nothing short of alarming. In particular, HIV/AIDS in South Africa provides a provocative and compelling analysis into a country he believes is the "principal exemplar of the discrepancy between modelled HIV/AIDS estimates, surveillance data, and death counts". His analysis questions both the methods used for diagnosing HIV/AIDS and the validity of country-wide estimates made by international organisations and South Africa's Department of Health.

Jennings is quick to point out the belief that South Africa has "the largest [HIV/AIDS epidemic] in the world" is based on estimates, not actual data. Before 1996, South Africa calculated the number of people living with HIV/AIDS using actual surveillance data. 12,825 cases were reported in 1996.

In estimates for 1997, however, the World Health Organisation (WHO) published figures suggesting there were 2.9 million people living with HIV/AIDS in South Africa and that 140,000 had died from the disease in 1997 - a marked difference from the 6,235 deaths reported.

In 1992, African countries reported 211,032 cumulative AIDS cases; WHO's estimate was 7.5 million. Throughout his statistical review, Jennings gives adequate weight to potential reasons for underreporting, but claims this alone cannot justify such an extreme difference in the data. Throughout HIV/AIDS in South Africa, Jennings provides an interesting and well-presented statistical summary that will leave readers questioning the validity of internationally-approved estimates.

Jennings also argues that the rate of false-positive HIV/AIDS tests in South Africa is absurdly high. The inappropriate use of diagnostic assays used to confirm cases of HIV/AIDS in a patient exhibiting signs of suffering from an opportunistic infection are being used on larger populations to test for the disease. Jennings asserts that this method of testing can be highly inaccurate, saying: "it is generally understood that medical assays are likely to generate more false-positives than true-positives in a large healthy asymptomatic population". As testing mechanisms become more sensitive, they are also more susceptible to producing false-positive readings.

Who is tested is also of concern. Instead of using the highly sensitive diagnostic assays on a random sample of the population, South African estimates are based on a survey of approximately 30,000 women who are pregnant for the first time; a group not representative of the population at large.

Jennings argues that such high rates of incorrect readings can be detrimental to fighting curable diseases because a large portion of health budgets in African countries is being spent on treating HIV/AIDS, when many presumed to suffer from the disease may in fact have other, more easily combated, illnesses.

An insight into AIDS

HIV/AIDS: The Facts and The Fiction and HIV/AIDS in South Africa: The Facts and The Fiction provide interesting insights into the myths and realities of the origins and scale of the HIV/AIDS epidemic. Jennings's discussion surrounding the origins of the disease is controversial, yet quite plausible. Although his analysis of the media coverage may be slightly flawed, his overall argument never wavers. When read one after the other, the two books can become quite repetitive, but his country specific analysis on South Africa effectively reinforces Jennings's hypothesis and is persuasively argued.

However, besides fleeting references to the fact that government budgets to treat HIV/AIDS patients in African countries dwarf those to treat curable diseases such as malaria and tuberculosis, Jennings does not succeed in providing alternatives. A discussion into more appropriate resource allocation would have both broadened the scope of his studies and enhanced their practical purposes.

Anna Rabin has a Masters in African Politics from the School of Oriental and African Studies. She has a particular interest in East Africa and demography.

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