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Elsevier issues ultimatum to Medical Hypotheses editor

Eduard Grebe — Thu, 11 Mar 2010 08:22:00 +0000

In a stunning indictment of the pseudoscience published in Medical Hypotheses, the journal's publisher has issued an ultimatum to the editor: implement peer review or resign. This comes after the retraction of two AIDS denialist papers that the journal published, which were unanimously rejected by five reviewers in a process managed by The Lancet. The papers, “HIV-AIDS hypothesis out of touch with South African AIDS: A new perspective” by Peter Duesberg and “AIDS denialism at the ministry of health” by Marco Ruggiero, caused great concern in the scientific community and several prominent AIDS researchers wrote to the publisher expressing their concern. The retractions and Elsevier's decision to implement peer review at the journal will no doubt be held up by denialists as evidence of "censorship," but in fact illustrates that "dissident science" does not stand up to the scrutiny of peer review. Medical Hypotheses does not conduct peer review and had under the leadership of its present editor, Bruce Charlton, become a haven for pseudoscience of various kinds, including AIDS denialism.

Below are two reports on the publisher's steps to reform Medical Hypotheses.

Zoë Corbyn writes in Times Higher Education:

The editor of the journal Medical Hypotheses has been given until 15 March either to implement changes to adopt a traditional peer-review system, or to resign.

He has also been told that even if he stays with the journal, his contract will not be renewed at the end of the year.

As Times Higher Education reported in January, publisher Elsevier is attempting to rein in its unorthodox journal, which publishes papers on the basis of how interesting or radical they are rather than using peer review, after it published a paper last July that denied the link between HIV and Aids.

The article prompted an outcry from Aids researchers, leading Elsevier to propose changes to both introduce peer review and exclude papers on certain controversial topics.

But Elsevier’s plans have been vehemently opposed by the journal’s editor, Bruce Charlton, its editorial advisory board and a large number of Medical Hypotheses’ authors, who have mounted a campaign to save the journal, believing it offers an important outlet for radical ideas.

Professor Charlton said: “Elsevier is asking me either to resign immediately, or else immediately to begin implementing changes that it has unilaterally and irrationally demanded. But my conscience will not allow me… I cannot do either of these things.”

The news comes as two controversial papers on the Aids virus that had been retracted from the journal following the outcry are “permanently withdrawn” after they failed to pass the test of peer review.

The papers in question are “HIV-AIDS hypothesis out of touch with South African AIDS: A new perspective” by Peter Duesberg, professor of molecular and cell biology at the University of California, Berkeley, and a paper published the same month, “AIDS denialism at the ministry of health” by Marco Ruggiero, professor of molecular biology at the University of Florence.

Both papers are being permanently withdrawn from the scientific record, even though the Ruggiero paper does not deny the link between HIV and Aids, but argues that the Italian Ministry of Health seemed not to believe that HIV is the “sole cause” of the Aids virus.

The papers were both rejected unanimously by five anonymous reviewers in a process managed by The Lancet, another Elsevier journal.

But Professor Charlton said he rejected both the process and outcome of this assessment, and accused Elsevier of running a “show trial” and making a “gross mistake”.

Read the full article.

ScienceInsider reports:

The editor of the journal Medical Hypotheses—an oddity in the world of scientific publishing because it does not practice peer review—is about to lose his job over the publication last summer of a paper that says HIV does not cause AIDS. Publishing powerhouse Elsevier today told editor Bruce Charlton that it won't renew his contract, which expires at the end of 2010, and it asked that Charlton resign immediately or implement a series of changes in his editorial policy, including putting a system of peer review in place. Charlton, who teaches evolutionary psychology at the University of Newcastle upon Tyne in the United Kingdom, says he will do neither, and some on the editorial advisory board say they may resign in protest if he is fired.

Elsevier's move is the latest in an 8-month battle over the journal; it comes after an anonymous panel convened by Elsevier recommended drastic changes to the journal's course, and five scientists reviewed the controversial paper and unanimously panned it.

Medical Hypotheses, which says it "will consider radical, speculative and non-mainstream scientific ideas provided they are coherently expressed," is the only Elsevier journal not to practice peer review. Scientist, entrepreneur, and author David Horrobin, who founded the journal in 1975, believed reviewers tend to dislike what lies outside the scientific mainstream and thus are reluctant to embrace new ideas, however promising. Charlton, who succeeded Horrobin in 2003, takes the same view: He decides what gets published himself—although he occasionally will consult another scientist—and manuscripts are edited only very lightly. As thejournal's Web site explains, "the editor sees his role as a 'chooser', not a 'changer.' "

It's a policy that leads to the occasional wild and wacky paper—a 2009 article for which the author studied his own navel lint became an instant classic—but the journal is also a "unique and excellent" venue for airing new and valuable ideas, says neuroscientist Vilayanur Ramachandran of the University of California (UC), San Diego, who published in the journal 15 times himself and sits on its editorial advisory board. "There are ideas that may seem implausible but which are very important if true," Ramachandran says. "This is the only place you can get them published."

...

Duesberg—who has not published anything on HIV the past decade except for one paper in a journal published by the Indian Academy of Sciences—says Elsevier's measures are the latest example of "censorship" imposed by the "AIDS establishment." But Medical Hypotheses' critics applaud the publisher’s latest step. "It seems clear that Elsevier has come to realize that there is a problem with Medical Hypotheses and that they are doing what they can to rectify it," says Moore.

Read the full article.

Debunking Delusions - New book by Nathan Geffen

Eduard Grebe — Wed, 10 Mar 2010 13:27:38 +0000

AidsTruth contributor and a leader of the Treatment Action Campaign, Nathan Geffen, has published a new book documenting AIDS denialism and the related quackery in South Africa titled Debunking Delusions: The Inside Story of the Treatment Action Campaign. We will publish a full review soon. More information can be found at the book's website. Below is the publisher's summary of the book.

Summary

One of the great, iconic struggles for social justice in the 21st century has been the campaign of the TAC against state-supported Aids denialism in South Africa. This struggle between activists, scientists and health workers, on the one hand, and a strange alliance of dissidents, quacks and political leaders, on the other, is here recounted in absorbing and dramatic detail for the first time by an insider. In his book Nathan Geffen, one of the TAC leaders, describes how early on in its life the organisation discovered that the greatest obstacle to AIDS treatment was in fact the South African government’s denialism. Not only did this extend to a reluctance to provide antiretroviral treatment to AIDS patients but also to support of a host of quacks and denialists who operated freely in the country to sow suspicion and confusion about the efficacy of standard medical treatment of AIDS. The most notorious of these were the German vitamin seller, Dr Matthias Rath, who along the way sued The Guardian of London and lost his case, and the Dutch nurse Tine van der Maas. It was the TAC that, as a result of a court case it brought against Rath, managed to stop his operations in South Africa; and it was the TAC, once again through legal means, that put pressure on the South African government to roll out an antiretroviral programme throughout the country. Geffen describes not only the TAC’s response to the puzzling intransigence of government and the spellbinding nonsense of dissidents, but the thought, strategy and discussion that lay behind the organisation’s major decisions. The story of the TAC’s campaign is one of the great triumphs of citizen activism for social justice and human rights.

About the Author

Nathan Geffen has been one of the leaders of TAC since 2000. His work has involved confronting the AIDS denialist policies of Thabo Mbeki and Manto Tshabalala-Msimang. He was also the editor of TAC’s magazine Equal Treatment. He has written extensively on AIDS and human rights. He previously co-authored two chapters in Edwin Cameron’s book Witness to Aids, winner of the Sunday Times Alan Paton Award. This is Geffen’s first full book.

“Between these covers you will find all the passion and intelligence Nathan Geffen devoted to the fight against quackery in South Africa. The Mbeki government’s march of folly is fully exposed here. One hopes that this book will serve, not only as a record, but as a lesson.” – Jonny Steinberg

“An intellectually incisive, engagingly written history of a policy calamity – and the courageous activism it unleashed – that has important implications for our country's understanding of its past, as well as its future course.” – Edwin Cameron

Junk Science Kills

Eduard Grebe — Tue, 09 Feb 2010 17:45:03 +0000

Elizabeth M. Whelan writes in the New York Post:

The media gave big headlines to this week's stories on a prestigious British medical publication's retraction of an article that had claimed to show a causal link between standard childhood vaccinations (measles, mumps and rubella) and autism.

Yet the coverage of the Lancet affair didn't truly convey the outrageousness of the original publication or the gravity of its consequences -- consequences long festering, since the paper was published not last week but 12 years ago.

Many of us in the scientific community recognized the "study" as junk when it appeared in 1998. Even before we learned of then-unknown ethical failings by its lead author, we knew the study was based on a tiny population of only 12 children. More, it relied on a novel methodology that assumed some bizarre, previously unheard of, association between children's autism and their manifestation of intestinal problems.

Nonetheless, the media back then seized on this story from a prestigious medical source -- and the scare picked up steam when TV appearances by actress Jenny McCarthy and a Rolling Stone article by Robert Kennedy Jr. blared word of the putative dangers of vaccines.

When criticism of the paper intensified in the days after publication, Lancet editor-in-chief Dr. Richard Horton defended his decision to publish what he acknowledged as an inferior study by claiming it would generate debate on the autism/vaccine issue. Even when 10 of the original 13 authors withdrew their names from the article, Horton still refused to withdraw the study.

Read the full piece in the New York Post.

Salon.com: The autism-vaccine lie that won't die

Eduard Grebe — Mon, 08 Feb 2010 15:42:12 +0000

Rahul K. Parikh, M.D. writes on Salon.com:

The media trumpeted an irresponsible study, ensuring that its nasty legacy thrives

Feb. 05, 2010

This week, Dr. Andrew Wakefield's now infamous study linking the MMR vaccine to autism was finally retracted by the prestigious Lancet medical journal. The move came days after medical officials in the United Kingdom found the doctor guilty of multiple ethics violations. For doctors, this is a victory -- but a bittersweet one.

As a pediatrician, I grapple daily with what Wakefield wrought: parents who are twisted in knots -- to the point of tears -- about whether to immunize their child. In the 12 years since the publication of Wakefield's study, 10 of his fellow co-authors have denounced him, and an unremitting series of revelations have exposed just how corrupt his motives and methods were. Most important, multiple studies verified there is no link between the MMR (or any other) vaccine and autism. Meanwhile, infectious diseases once confined to medical history have broken out in our communities. To say the retraction is criminally overdue is an understatement.

Further, even as Wakefield's research is expunged from the scientific record, what he spawned -- a well-funded, vocal, even rabid movement -- will remain. Without him, poster girl Jenny McCarthy would have been abandoned in the MTV archives instead of smugly crowing to Time magazine, "I do believe sadly it's going to take some diseases coming back to realize that we need to change and develop vaccines that are safe. If the vaccine companies are not listening to us, it's their f___ing fault that the diseases are coming back. They're making a product that's s___ ." And anti-vaccine darling David Kirby would split his time between running a P.R. firm and writing pithy articles about art and aircraft instead of turning speculation and rumor into a Kennedy-esque vaccine-autism conspiracy theory. Finally, Wakefield himself stands to be completely unaffected by both the U.K. medical community (which could revoke his license to practice there) and the Lancet's decision. He long ago settled here in the U.S. and successfully peddles his views through his Thoughtful House autism center in Texas.Still, while the media busily finger-wagged, blogged and tweeted about the damnation of Andrew Wakefield, I wondered whether it considered its own complicity in the whole sordid affair.

The anti-vaccine hysteria, after all, began like so many other big stories: with a press conference. That's where Andrew Wakefield first staked his claim that the MMR vaccine caused autism, according to Paul Offit's book, "Autism's False Prophets." Wakefield wasn't flanked by doctors or hospital officials but by P.R. folks he had hired himself. "One case of [autism] is too many," he said. "It's a moral issue for me, and I can't support the continued use of [the MMR vaccine] until this issue has been resolved."

The problem, of course, is that a news conference loads a gun that the media usually pulls the trigger on: Headlines like "Ban Three-in-One Jab, Doctors Urge" started rolling off the presses. While measles made a tragic resurgence, few reporters attempted to scrutinize Wakefield or his audacious claim. (Even Salon has its own history of bad reporting on the topic, in a controversial and inaccurate 2005 piece by Robert F. Kennedy Jr.)

Read the full article on Salon.com.

The Price of Denial: A documentary on the legacy of AIDS denialism in South Africa

Eduard Grebe — Sat, 30 Jan 2010 12:54:36 +0000

This documentary was produced by the non-profit health news agency Health-e and was recently broadcast on an independent television channel in South Africa.

View Part I:

(If you do not see the video above, your browser does not support HTML5 video playback. Download the video or visit this page in Firefox or Chrome.)
Download Part I in ogg/theora or in mp4.

Part II after the jump.

View Part II

Download Part II in ogg/theora or in mp4.

Wakefield, who linked MMR vaccine to autism, found to have shown "callous disregard" for children

Eduard Grebe — Thu, 28 Jan 2010 22:56:30 +0000

The anti-vaccine movement, which shares characteristics with AIDS denialism (both like to blame pharmaceutical conspiracies) and which was originally based on claims by British surgeon Andrew Wakefield, has been dealt a decisive blow by a finding against Wakefield by the General Medical Council. Caims that the MMR vaccine was linked to autism have since been shown to be baseless, but are still promoted by some, including by groups linked to AIDS denialism. The Guardian reports:

Dr Andrew Wakefield, the expert at the centre of the MMR controversy, "failed in his duties as a responsible consultant" and showed a "callous disregard" for the suffering of children involved in his research, the General Medical Council (GMC) has ruled.

Wakefield also acted dishonestly and was misleading and irresponsible in the way he described research that was later published in the Lancet medical journal, the GMC said. He had gone against the interests of children in his care, and his conduct brought the medical profession "into disrepute" after he took blood samples from youngsters at his son's birthday party in return for payments of £5.

The doctor, who was absent from today's GMC hearing, faces being struck off the medical register. The panel decided the allegations against him could amount to serious professional misconduct, an issue to be decided at a later date.

Continue reading at The Guardian.

Also see "From the Lancet to the GMC: how Dr Andrew Wakefield fell from grace".

DART results show majority of HAART benefits can be achieved even without routine laboratory monitoring

Eduard Grebe — Wed, 13 Jan 2010 22:07:25 +0000

The results from the DART trial, reported this week in The Lancet, provide important evidence for HAART programmes in resource-constrained settings. From commentary by Phillips & Oosterhout published alongside the results:

In much of sub-Saharan Africa, the scale-up of use of antiretroviral therapy has been so far achieved without routine laboratory monitoring of drug toxicity and efficacy. Until now, there has not been substantive evidence about the consequences of delivering antiretrovirals without such routine monitoring.

In The Lancet today, the DART Trial Team present the Development of AntiRetroviral Therapy in Africa (DART) trial. In DART at enrolment, all participants started triple-drug antiretroviral therapy and were randomised to clinically driven monitoring versus laboratory plus clinical monitoring for toxicity (haematology and biochemistry) and efficacy (CD4-cell counts). Over 5 years, the proportions who had one or more serious adverse events were almost identical, while there was a somewhat higher proportion in the group on clinically driven monitoring who had disease progression or death (28%, compared with 21% in the other group; hazard ratio 1·31, 95% CI 1·14—1·51). This benefit of laboratory plus clinical monitoring is probably due to the use of CD4 count rather than presence of clinical symptoms alone to decide on when to switch to a second-line regimen. This criterion for switching on the basis of CD4 count is just one of the CD4-count switch criteria recommended by WHO; the other criteria (on the basis of CD4-count change from baseline and from peak) are problematic to implement without a baseline CD4 count and frequent CD4 counts being available thereafter.

The other particularly striking result from DART is the 5-year survival in both groups: 87% for clinical monitoring and 90% for laboratory plus clinical monitoring. Such rates of survival are for people in whom the initial median CD4-cell count was 86 cells per μL. For comparison, the survival in the Entebbe cohort of untreated HIV-positive people in 5 years was below 10% (data presented in the DART report), which emphasises the huge clinical benefits of antiretroviral therapy. The DART Trial Team concluded from their results that antiretroviral therapy can be delivered safely with good-quality clinical care, which would allow treatment delivery to be decentralised, and that there is a role for CD4 testing from the second year on antiretrovirals to guide the switch to second-line therapy, which should encourage accelerated development of simpler and cheaper point-of-care CD4 tests. The DART investigators should be complimented for exceptional achievement by completing this important trial with such a low loss to follow-up (7%) in challenging circumstances, which shows that excellent trials can be done in Africa.

The results from DART are very important for antiretroviral programmes, no matter what their current level of routine laboratory monitoring. Programmes that currently deliver antiretrovirals without any laboratory monitoring can be reassured that the vast majority (but not all) of the potential survival benefit of such therapy can be realised with the use of such a simple approach (albeit with particularly intensive and high-quality clinical monitoring, which is a substantial challenge to achieve in routine settings throughout sub-Saharan Africa). Similarly, no antiretroviral programme should enhance laboratory monitoring at the expense of putting more people in need on these drugs. Those clinics that do use routine measurement of biochemistry and haematology can reduce their laboratory costs to enable spending on other aspects of the programme (which has already started in some programmes). Programmes that monitor people on antiretrovirals with CD4 counts should consider adopting the switch criterion used in DART of CD4 count below 100 cells per μL (ie, only this one of the WHO-recommended criteria, rather than all three), and apply this criterion to people who have been on therapy for at least 2 years. Such a delay should help to reduce the number of people in whom a switch is made when viral load is actually suppressed.

Read the commentary at The Lancet (open access; registration required)

Details on the main paper below:

The Lancet, Volume 375, Issue 9709, Pages 123 - 131, 9 January 2010

Routine versus clinically driven laboratory monitoring of HIV antiretroviral therapy in Africa (DART): a randomised non-inferiority trial

DART Trial Team

Summary

Background

HIV antiretroviral therapy (ART) is often managed without routine laboratory monitoring in Africa; however, the effect of this approach is unknown. This trial investigated whether routine toxicity and efficacy monitoring of HIV-infected patients receiving ART had an important long-term effect on clinical outcomes in Africa.

Methods

In this open, non-inferiority trial in three centres in Uganda and one in Zimbabwe, 3321 symptomatic, ART-naive, HIV-infected adults with CD4 counts less than 200 cells per μL starting ART were randomly assigned to laboratory and clinical monitoring (LCM; n=1659) or clinically driven monitoring (CDM; n=1662) by a computer-generated list. Haematology, biochemistry, and CD4-cell counts were done every 12 weeks. In the LCM group, results were available to clinicians; in the CDM group, results (apart from CD4-cell count) could be requested if clinically indicated and grade 4 toxicities were available. Participants switched to second-line ART after new or recurrent WHO stage 4 events in both groups, or CD4 count less than 100 cells per μL (LCM only). Co-primary endpoints were new WHO stage 4 HIV events or death, and serious adverse events. Non-inferiority was defined as the upper 95% confidence limit for the hazard ratio (HR) for new WHO stage 4 events or death being no greater than 1·18. Analyses were by intention to treat. This study is registered, number ISRCTN13968779.

Findings

Two participants assigned to CDM and three to LCM were excluded from analyses. 5-year survival was 87% (95% CI 85—88) in the CDM group and 90% (88—91) in the LCM group, and 122 (7%) and 112 (7%) participants, respectively, were lost to follow-up over median 4·9 years' follow-up. 459 (28%) participants receiving CDM versus 356 (21%) LCM had a new WHO stage 4 event or died (6·94 [95% CI 6·33—7·60] vs 5·24 [4·72—5·81] per 100 person-years; absolute difference 1·70 per 100 person-years [0·87—2·54]; HR 1·31 [1·14—1·51]; p=0·0001). Differences in disease progression occurred from the third year on ART, whereas higher rates of switch to second-line treatment occurred in LCM from the second year. 283 (17%) participants receiving CDM versus 260 (16%) LCM had a new serious adverse event (HR 1·12 [0·94—1·32]; p=0·19), with anaemia the most common (76 vs 61 cases).

Interpretation

ART can be delivered safely without routine laboratory monitoring for toxic effects, but differences in disease progression suggest a role for monitoring of CD4-cell count from the second year of ART to guide the switch to second-line treatment.

Funding

UK Medical Research Council, the UK Department for International Development, the Rockefeller Foundation, GlaxoSmithKline, Gilead Sciences, Boehringer-Ingelheim, and Abbott Laboratories.

Read the paper at The Lancet (open access; registration required)

Chigwedere & Essex refute AIDS denialist arguments in AIDS & Behavior

Eduard Grebe — Tue, 12 Jan 2010 22:46:18 +0000

Also see the comment piece Still Crazy After All These Years (open access) by Nicoli Nattrass that appears in the same issue of AIDS & Behavior.

Update (22/01/2010): See AIDS Denialism Under Fire From Researchers by Nora Proops in The AIDS Beacon.

AIDS & Behavior. 2010 Jan 8. [Epub ahead of print]

AIDS Denialism and Public Health Practice

Chigwedere P, Essex M.

In this paper, we respond to AIDS denialist arguments that HIV does not cause AIDS, that antiretroviral drugs are not useful, and that there is no evidence of large-scale deaths from AIDS, and discuss the key implications of the relationship between AIDS denialism and public health practice. We provide a brief history of how the cause of AIDS was investigated, of how HIV fulfills Koch's postulates and Sir Bradford Hill's criteria for causation, and of the inconsistencies in alternatives offered by denialists. We highlight clinical trials as the standard for assessing efficacy of drugs, rather than anecdotal cases or discussions of mechanism of action, and show the unanimous data demonstrating antiretroviral drug efficacy. We then show how statistics on mortality and indices such as crude death rate, life expectancy, child mortality, and population growth are consistent with the high mortality from AIDS, and expose the weakness of statistics from death notification, quoted by denialists. Last we emphasize that when denialism influences public health practice as in South Africa, the consequences are disastrous. We argue for accountability for the loss of hundreds of thousands of lives, the need to reform public health practice to include standards and accountability, and the particular need for honesty and peer review in situations that impact public health policy.

PMID: 20058063

Read the full article on SpringerLink (open access)

doi:10.1007/s10461-009-9654-7

New myth debunked: The fact that some HIV-positive people live in good health without treatment for many years proves that HIV is harmless

Eduard Grebe — Mon, 11 Jan 2010 16:12:51 +0000

Fact: A small percentage of people infected with HIV do live for many years without developing AIDS. They are often known as long-term non-progressors. But such individuals are rare: without proper medical care, including antiretroviral drugs when needed, most HIV-positive people will eventually develop AIDS.

As putative evidence that HIV is harmless, some HIV/AIDS denialists point to examples of HIV-infected people who survive for many years, even decades, without receiving antiretroviral treatment. HIV denialists often claim that these people survived because they avoided antiretroviral therapy, and that diet, exercise, nutritional supplements or herbal therapies, stress reduction, hypnosis, and other interventions prevent progression to AIDS. These claims are untrue and dangerous.

Read the full bebunking.

Declines in Mortality Rates and Changes in Causes of Death in HIV-1-Infected Children During the HAART Era

Eduard Grebe — Tue, 29 Dec 2009 13:11:02 +0000

J Acquir Immune Defic Syndr. 2010 Jan;53(1):86-94.

Brady MT, Oleske JM, Williams PL, Elgie C, Mofenson LM, Dankner WM, Van Dyke RB; for the Pediatric AIDS Clinical Trials Group219/219C Team.

CONTEXT: Introduction of highly active antiretroviral therapy has significantly decreased mortality in HIV-1-infected adults and children. Although an increase in non-HIV-related mortality has been noted in adults, data in children are limited.

OBJECTIVES:: To evaluate changes in causes and risk factors for death among HIV-1-infected children in Pediatric AIDS Clinical Trials Group 219/219C.

DESIGN, SETTING, AND PARTICIPANTS:: Multicenter, prospective cohort study designed to evaluate long-term outcomes in HIV-1-exposed and infected US children. There were 3553 HIV-1-infected children enrolled and followed up between April 1993 and December 2006, with primary cause of mortality identified in the 298 observed deaths.

MAIN OUTCOME MEASURES:: Mortality rates per 100 child-years overall and by demographic factors; survival estimates by birth cohort; and hazard ratios for mortality by various demographic, health, and antiretroviral treatment factors were determined.

RESULTS:: Among 3553 HIV-1-infected children followed up for a median of 5.3 years, 298 deaths occurred. Death rates significantly decreased between 1994 and 2000, from 7.2 to 0.8 per 100 person-years, and remained relatively stable through 2006. After adjustment for other covariates, increased risk of death was identified for those with low CD4 and AIDS-defining illness at entry. Decreased risks of mortality were identified for later birth cohorts, and for time-dependent initiation of highly active antiretroviral therapy (hazard ratio 0.54, P < 0.001). The most common causes of death were "End-stage AIDS" (N = 48, 16%) and pneumonia (N = 41, 14%). The proportion of deaths due to opportunistic infections (OIs) declined from 37% in 1994-1996 to 24% after 2000. All OI mortality declined during the study period. However, a greater decline was noted for deaths due to Mycobacterium avium complex and cryptosporidium. Deaths from "End-stage AIDS," sepsis and renal failure increased.

CONCLUSIONS:: Overall death rates declined from 1993 to 2000 but have since stabilized at rates about 30 times higher than for the general US pediatric population. Deaths due to OIs have declined, but non-AIDS-defining infections and multiorgan failure remain major causes of mortality in HIV-1-infected children.

PMID: 20035164.

Read at JAIDS.

Science: HIV Natural Resistance Field Finally Overcomes Resistance

Eduard Grebe — Tue, 29 Dec 2009 12:58:18 +0000

Science 11 December 2009: Vol. 326. no. 5959, pp. 1476 - 1477

Dozens of studies have been examining people who fend off HIV despite repeated exposures in an effort to find genetic or immunologic factors that can help guide AIDS vaccine research. But all too often the leads point in contradictory directions, in part because investigators use different assays to probe their samples, and there is little coordination among them. Many labs also use wildly varying criteria to decide who qualifies as HIV-resistant, making it difficult to sort out which study subjects were truly exposed and uninfected, were exposed and have an occult infection, or were never exposed in the first place. At the first-ever meeting on natural immunity to HIV, held from 15 to 17 November, researchers attempted to hammer out these and other issues.

Read the article at Science.

doi: 10.1126/science.326.5959.1476

The effect of combined antiretroviral therapy on the overall mortality of HIV-infected individuals

Eduard Grebe — Sun, 20 Dec 2009 19:30:32 +0000

AIDS. 2010 Jan 2;24(1):123-37.

HIV-CAUSAL Collaboration.

OBJECTIVE: To estimate the effect of combined antiretroviral therapy (cART) on mortality among HIV-infected individuals after appropriate adjustment for time-varying confounding by indication. DESIGN: A collaboration of 12 prospective cohort studies from Europe and the United States (the HIV-CAUSAL Collaboration) that includes 62 760 HIV-infected, therapy-naive individuals followed for an average of 3.3 years. Inverse probability weighting of marginal structural models was used to adjust for measured confounding by indication. RESULTS: Two thousand and thirty-nine individuals died during the follow-up. The mortality hazard ratio was 0.48 (95% confidence interval 0.41-0.57) for cART initiation versus no initiation. In analyses stratified by CD4 cell count at baseline, the corresponding hazard ratios were 0.29 (0.22-0.37) for less than 100 cells/microl, 0.33 (0.25-0.44) for 100 to less than 200 cells/microl, 0.38 (0.28-0.52) for 200 to less than 350 cells/microl, 0.55 (0.41-0.74) for 350 to less than 500 cells/microl, and 0.77 (0.58-1.01) for 500 cells/microl or more. The estimated hazard ratio varied with years since initiation of cART from 0.57 (0.49-0.67) for less than 1 year since initiation to 0.21 (0.14-0.31) for 5 years or more (P value for trend <0.001). CONCLUSION: We estimated that cART halved the average mortality rate in HIV-infected individuals. The mortality reduction was greater in those with worse prognosis at the start of follow-up.

PMID: 19770621

Survival of Children with HIV in the United States Has Improved Dramatically Since 1990s, New Analysis Shows

Eduard Grebe — Sun, 20 Dec 2009 18:31:08 +0000

Mortality Rate Still Higher Than for Children without HIV

The death rates of children with HIV have decreased ninefold since doctors started prescribing cocktails of antiretroviral drugs in the mid-1990s, concludes a large-scale study of the long-term outcomes of children and adolescents with HIV in the United States. In spite of this improvement, however, young people with HIV continue to die at 30 times the rate of youth of similar age who do not have HIV, found researchers from the National Institutes of Health and other institutions.

Earlier studies have shown that adults with HIV are living longer because of improved multi-drug antiretroviral regimens known as highly active antiretroviral therapy (HAART). However, limited information has existed about the effectiveness of HAART in improving the survival of children with HIV. The current analysis, published in the Dec. 15 issue of the Journal of Acquired Immune Deficiency Syndromes, delineates the effects of HAART on the rates and causes of death for HIV-infected children and adolescents.

Conducted by the Pediatric AIDS Clinical Trials Group, the study was co-funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) and the National Institute of Allergy and Infectious Diseases (NIAID), both part of NIH. The study’s first author is Michael T. Brady, M.D., of Nationwide Children’s Hospital in Columbus, Ohio.

In 1994, the mortality rate for HIV-infected children and youth younger than 21 years of age in the United States was 7.2 deaths per 100 person years (a rate based on the number of children in the study and the total number of years each child was followed). By 2000, that rate had plummeted to 0.8 deaths per 100 person years and remained stable through 2006. The mean age at death for HIV-infected youth in the study more than doubled from 8.9 years in 1994 to 18.2 years in 2006.

Although this represents a dramatic improvement in survival, the death rate for children with HIV is approximately 30 times higher than that of similarly aged U.S. children who do not have HIV. Multi-organ failure and kidney disease are now major causes of death for HIV-infected children and adolescents. Infections also continue to cause deaths in this group of patients. However, the type of infections has changed, from infections traditionally associated with AIDS to infections that are more common in children without HIV infection.

"The findings are very encouraging, but they still show a need for improvement," said Alan Guttmacher, M.D., acting director of NICHD. "For both adults and children, combination antiretroviral therapy is highly effective in preventing the opportunistic infections and other complications resulting from HIV infection. We must now better understand and pursue treatments for children and adolescents to address the other conditions resulting from HIV infection."

"Basic research and clinical studies funded by NIH beginning in the 1980s laid the foundation for the development of the more than two dozen drugs now available to fight HIV, enabling many children infected with the virus to live into adulthood,"said NIAID Director Anthony S. Fauci, M.D. "Now we face the challenge of effectively treating the consequences of long-term HIV infection in people who have been infected since childhood."

Between 1993 and 2006, the researchers tracked 3,553 U.S. children and adolescents infected with HIV. Of those children, 298 died. Growing numbers of children with HIV began receiving HAART between 1994 and 2000, and death rates declined annually during that period. Nearly 60 percent of all deaths in the study occurred before 1997, before the advent of HAART for the treatment of children; moreover, children who died were almost four times as likely to have never received HAART as those who survived.

"A wonderful change has occurred: Most HIV-infected children now reach adulthood," said Lynne Mofenson, M.D., an author of the paper and chief of the Pediatric, Adolescent and Maternal AIDS branch at NICHD. "Will these children have a normal lifespan? Unfortunately, we don’t have all the answers yet. Currently, we don’t have the means to prevent all the complications of HIV infection."

In the early years of the study, secondary infections killed more than one-third of the children who died, but from 2002 to 2006, that proportion fell to less than one-fourth. Over time, children and adolescents with HIV became more likely to die of kidney failure, stroke, or AIDS-induced multiple organ failure.

To try to prevent these deaths, another long-term study of children with HIV called the Pediatric HIV/AIDS Cohort Study is being funded by NICHD, NIAID, the National Institute on Drug Abuse, the National Institute on Deafness and Other Communication Disorders, the National Heart, Lung, and Blood Institute, and the National Institute of Mental Health. This study is monitoring how children and adolescents with the virus grow and develop, what complications they experience, and whether they experience side effects from their medication.

"To keep these children healthy, we need to learn more about how HIV and anti-HIV drugs affect their growing bodies," said Dr. Mofenson. "We took a big leap in our understanding with this study, and the next pediatric cohort study will lead to even more improvements in understanding HIV infection and its treatment in youth."

In addition to Drs. Brady and Mofenson, the other authors of the article are James M. Oleske, M.D., M.P.H., of the University of Medicine and Dentistry of New Jersey; Paige L. Williams, Ph.D., of the Harvard School of Public Health; Carol Elgie of Frontier Science Technology and Research Foundation; Wayne M. Dankner, M.D., of Parexel International and Duke University Medical Center, and Russell B. Van Dyke, M.D., of Tulane University.

The NICHD sponsors research on development, before and after birth; maternal, child, and family health; reproductive biology and population issues; and medical rehabilitation. For more information, visit the Institute’s Web site at http://www.nichd.nih.gov/.

NIAID conducts and supports research—at NIH, throughout the United States, and worldwide—to study the causes of infectious and immune-mediated diseases, and to develop better means of preventing, diagnosing and treating these illnesses. News releases, fact sheets and other NIAID-related materials are available on the NIAID Web site at http://www.niaid.nih.gov.

The National Institutes of Health (NIH) — The Nation's Medical Research Agency — includes 27 Institutes and Centers and is a component of the U.S. Department of Health and Human Services. It is the primary federal agency for conducting and supporting basic, clinical and translational medical research, and it investigates the causes, treatments, and cures for both common and rare diseases. For more information about NIH and its programs, visit www.nih.gov.

Six-month gain in weight, height, and CD4 predict subsequent antiretroviral treatment responses in HIV-infected South African children

Eduard Grebe — Sun, 20 Dec 2009 16:00:00 +0000

AIDS. 2010 Jan 2;24(1):139-46.

Yotebieng M, Van Rie A, Moultrie H, Meyers T.

OBJECTIVES: Construct percentile curves for 6-month gain in weight, height, CD4 cell count, and CD4 percentage (CD4%) in children initiating ART, and to assess the association between lower percentiles and subsequent ART responses. DESIGN: Cohort of 1394 HIV-infected children initiating ART between April 2004 and March 2008, Johannesburg, South Africa METHODS: The generalized additive model for location, scale, and shape was used to construct percentile curves for 6-month gain in weight, height, CD4 cell count, and CD4%. Cox proportional models were used to assess the association between lower percentiles of each distribution and death, virological suppression, and treatment failure between 6 to 36 months post-ART initiation. RESULTS: Lower percentiles for gain in weight, CD4, and CD4% count after 6 months of ART, but not height, were associated with poor subsequent treatment outcomes independent of baseline characteristics, with increasing strength of association as percentiles decreased. Age-specific 6-month post-ART weight gain in our cohort was substantially higher compared with 6-month weight gain in non-HIV-infected American children of the Fels Institute cohort and the attained weight-for-age at 6 months post-ART plotted on WHO weight-for-age growth charts were not associated with subsequent treatment outcomes. CONCLUSION: Gain in CD4% in the first 6 months of ART was the best predictor of poor subsequent ART outcomes. In areas with limited access to CD4%, weight gain post-ART using our newly developed reference distributions for HIV-infected children on ART is a good alternative to CD4%, and clearly superior to the commonly used 'Road-to-Health' weight-for-age charts.

PMID: 19940744

Another myth debunked: HIV is a harmless passenger virus

Eduard Grebe — Thu, 17 Dec 2009 16:17:18 +0000

Fact: Studies in vitro, ex vivo and in vivo all support HIV's ability to deplete CD4+ T-cells.

There are some denialists that argue that HIV does exist but that it is merely a harmless passenger virus and that no evidence exists to claim otherwise. In fact, there are thousands of studies that support the cytopathic properties of HIV. While some aspects of how HIV destroys cells that are not fully understood, that it does so it beyond doubt. This is not unique to HIV, of course, as the effects of many diseases are known despite the mechanisms not being completely elucidated. Some of what is known (and supporting evidence will be cited) is the documented here. Since there are literally thousands upon thousands of papers on HIV, a representative few are cited here. This is by no means an exhaustive list.

Evidence shows us that AIDS the CD4+ T-cell depletion is due to HIV. This can be observed 1) in vitro (in cell cultures), 2) ex vivo (in tissues removed from animal models or patients), and 3) in vivo both in animal models and in infected individuals.

Read the full debunking here.

View the list of myths we debunk here.

Conspiracy beliefs about HIV associated with lower adherence.

Eduard Grebe — Thu, 10 Dec 2009 19:03:22 +0000

A new study has found poorer adherence to antiretroviral therapy among African-American men with HIV who hold conspiracy beliefs, e.g. that HIV is a man-made virus designed to kill Africans.

JAIDS. 2009 Dec 09.

Conspiracy Beliefs About HIV Are Related to Antiretroviral Treatment Nonadherence Among African American Men With HIV

Bogart, Laura M PhD; Wagner, Glenn PhD; Galvan, Frank H PhD; Banks, Denedria MSW

Background: Medical mistrust is prevalent among African Americans and may influence health care behaviors such as treatment adherence. We examined whether a specific form of medical mistrust-HIV conspiracy beliefs (eg, HIV is genocide against African Americans)-was associated with antiretroviral treatment nonadherence among African American men with HIV.

Methods: On baseline surveys, 214 African American men with HIV reported their agreement with 9 conspiracy beliefs, sociodemographic characteristics, depression symptoms, substance use, disease characteristics, medical mistrust, and health care barriers. Antiretroviral medication adherence was monitored electronically for one month postbaseline among 177 men in the baseline sample.

Results: Confirmatory factor analysis revealed 2 distinct conspiracy belief subscales: genocidal beliefs (eg, HIV is manmade) and treatment-related beliefs (eg, people who take antiretroviral treatments are human guinea pigs for the government). Both subscales were related to nonadherence in bivariate tests. In a multivariate logistic regression, only treatment-related conspiracies were associated with a lower likelihood of optimal adherence at one-month follow-up (odds ratio = 0.60, 95% confidence interval = 0.37 to 0.96, P < 0.05).

Conclusions: HIV conspiracy beliefs, especially those related to treatment mistrust, can contribute to health disparities by discouraging appropriate treatment behavior. Adherence-promoting interventions targeting African Americans should openly address such beliefs.

doi: 10.1097/QAI.0b013e3181c57dbc

PMID: 19952767

ART halves overall mortality of HIV-infected individuals

Eduard Grebe — Tue, 08 Dec 2009 15:06:54 +0000

AIDS. 2010 Jan 2;24(1):123-37.

The effect of combined antiretroviral therapy on the overall mortality of HIV-infected individuals

The HIV-CAUSAL Collaboration

Abstract

Objective: To estimate the effect of combined antiretroviral therapy (cART) on mortality among HIV-infected individuals after appropriate adjustment for time-varying confounding by indication.

Design: A collaboration of 12 prospective cohort studies from Europe and the United States (the HIV-CAUSAL Collaboration) that includes 62 760 HIV-infected, therapy-naive individuals followed for an average of 3.3 years. Inverse probability weighting of marginal structural models was used to adjust for measured confounding by indication.

Results: Two thousand and thirty-nine individuals died during the follow-up. The mortality hazard ratio was 0.48 (95% confidence interval 0.41-0.57) for cART initiation versus no initiation. In analyses stratified by CD4 cell count at baseline, the corresponding hazard ratios were 0.29 (0.22-0.37) for less than 100 cells/μl, 0.33 (0.25-0.44) for 100 to less than 200 cells/μl, 0.38 (0.28-0.52) for 200 to less than 350 cells/μl, 0.55 (0.41-0.74) for 350 to less than 500 cells/μl, and 0.77 (0.58-1.01) for 500 cells/μl or more. The estimated hazard ratio varied with years since initiation of cART from 0.57 (0.49-0.67) for less than 1 year since initiation to 0.21 (0.14-0.31) for 5 years or more (P value for trend <0.001).

Conclusion: We estimated that cART halved the average mortality rate in HIV-infected individuals. The mortality reduction was greater in those with worse prognosis at the start of follow-up.

doi: 10.1097/QAD.0b013e3283324283

PMID: 19770621

Still Crazy After All These Years: The Challenge of AIDS Denialism for Science

Eduard Grebe — Mon, 07 Dec 2009 18:09:17 +0000

AIDSTruth contributor Nicoli Nattrass writes in AIDS and Behavior:

In his new book, Denying AIDS, Seth Kalichman observes that people are surprised by the persistence of AIDS denialists: “Are they still around?”[1, p. 1] he is often asked. And it is a good question. Given the large body of scientific and clinical evidence on HIV disease and treatment (expertly summarized by Chigwedere and Essex in this issue of AIDS and Behavior) it is indeed strange that Peter Duesberg and his followers still claim HIV is harmless and that antiretrovirals cause rather than treat AIDS. While such dissident views were intellectually respectable in the 1980s when HIV science was new, they make little sense today. Thus Joseph Sonnabend, a doctor who treated some of the earliest AIDS cases in New York and was well known for arguing that environmental factors may be more important than a virus in driving AIDS, was quick to change his mind once antiretroviral treatment was shown to act against HIV and transform the health of his patients [2, p. 25]. Peter Duesberg, by contrast, refused to accept the evidence, thereby earning the label ‘denialist’ rather than ‘dissident’ [1, 2].

Duesberg may be pathologically contrarian in this respect, but he has an enduring appeal. Kalichman [1] argues that this is in large part because his claim that HIV is harmless reinforces the normal process of denial most people undergo when faced with traumatizing information—such as a positive HIV test result. Another reason is that Duesberg’s views are promoted in books, on denialist websites and blogs and by a persistent trickle of ‘Duesberg-as-oppressed-hero-scientist’ stories from independent film-makers and journalists. It is precisely because he holds a post at Berkeley and is an elected member of the National Academy of Sciences, that Duesberg has been able to build the media profile that sustains him. As Epstein argues, by ‘using his scientific credentials to buy him popular support, then using the popular support to push for recognition by his colleagues—Duesberg gained staying power’ [3, p. 142].

This has resulted in HIV science being represented as fundamentally contested in ways which it actually is not. And because of the threat AIDS denialism poses both to public health and to the authority of HIV science itself, scientists have found it necessary, time and time again, to respond to Duesberg’s claims, despite their long having been demolished [see e.g. 4–8]. Chigwedere and Essex’s paper in this issue is one more such refutation in a long line of refutations. What makes their paper different is that in addition to marshalling the key evidence in support of the scientific consensus on HIV, they criticize Duesberg for inspiring South Africa’s ex-President Mbeki AIDS policies (thereby causing hundreds of thousands of unnecessary deaths) and they take him to task for suggesting (in a co-authored paper initially published in Medical Hypotheses but subsequently withdrawn by the publisher) that the African AIDS epidemic does not exist.

Chigwedere and Essex are clearly angry—the emotion is evident on every page. This is not merely because of the dangers Duesberg’s intransigence poses for public health but because of his refusal to change his views when the evidence demands it. This has long been a source of frustration for HIV scientists. For example, Robert Gallo, the co-discoverer of HIV, has described him as ‘like a little dog that won’t let go’ [in 6, p. 1644] and John Moore [9], an eminent virologist at Weill Cornell Medical School, has likened Duesberg to Monty Python’s black knight who keeps fighting despite having all of his limbs cut off by his opponent. And the problem is far more than intellectual because disregarding evidence not only undermines scientific progress, but it threatens the social basis which makes such progress possible. Respect for the evidence and for the people who generate it is a core value in the scientific community—and it is precisely this that Duesberg flouts. Warren Winkelstein, one of the early HIV epidemiologists, recalls how, at a meeting of the National Academy of Sciences in Washington to discuss Duesberg’s theories, Duesberg would frequently get up, wander around the room and start talking to reporters. In his view, Duesberg simply ‘wasn’t listening to what was being said’ [in 10, p. 131). The message Duesberg was broadcasting then, and in all his statements on AIDS, is loud and clear: he alone is correct and the work of others is not worth considering.

Read the full article on SpringerLink.

doi:10.1007/s10461-009-9641-z

The Lancet: a new South Africa takes responsibility

Eduard Grebe — Mon, 07 Dec 2009 14:56:40 +0000

The Lancet has hailed the new approach evident in South Africa in which the government has decisively turned away from the AIDS denialism associated with former President Thabo Mbeki.

The Lancet, Volume 374, Issue 9705, Page 1867, 5 December 2009

HIV/AIDS: a new South Africa takes responsibility

On Dec 1 the usual activities surrounding World AIDS Day will take on a special significance for South Africans. In a high-profile event in Pretoria, the South African National AIDS Council (SANAC) is bringing together people who work in HIV/AIDS, those who have been affected by HIV, and government officials, including President Jacob Zuma, Deputy President and SANAC Chair Kgalema Motlanthe, and the Minister of Health Aaron Motsoaledi. Zuma will give a televised address on HIV/AIDS to the nation. Under the motto “I am responsible, we are responsible, South Africa is taking responsibility”, a new era in the country's response to HIV/AIDS is being publicly heralded. In a key-messages booklet, SANAC calls on everyone to know their HIV status by frequent testing; on communities to stop stigma and discrimination against people living with HIV; and on itself to ensure that the government is taking responsibility for people to receive counselling, provide condoms, and give access to treatment for tuberculosis and HIV.

Already on Oct 29, in what has been widely praised as a landmark speech, Zuma left no doubt about the decisive departure from the previous government's stance of denialism and indifference: “South Africa must work harder to implement the national strategy to tackle HIV/AIDS…all South Africans need to know their HIV status and be informed of the treatment options available to them…there should be no shame, no discriminations, and no recriminations”. The non-governmental organisation Treatment Action Campaign called Zuma's speech, which came almost 10 years after Thabo Mbeki made his HIV/AIDS denial clear before the same National Council of Provinces, as “one of the most important speeches in the history of AIDS in South Africa”.

This extremely welcome and long-awaited change in attitude, and its appropriate urgency, is accompanied by a burst of behind-the-scene activities at the Department of Health and SANAC. In a press conference last month, Motsoaledi explained that there are moves ahead to integrate health facilities for tuberculosis and HIV/AIDS, that antiretroviral treatment (ART) guidelines are being revised to initiate treatment for those with a CD4-cell count below 350 cells per μL, and that there are plans for comprehensive integrated antenatal care, which include prevention of mother-to-child transmission—all actions that were called for in The Lancet's recent South Africa Series. The revised ART treatment discussions even came ahead of new WHO recommendations, published on Nov 30. South Africa's National Strategic Plan for HIV/AIDS and sexually transmitted diseases aims to reduce the rate of infections by 50% and cover 80% of the people who need ART by 2011. In October, Cabinet committed to accelerate the response to meet these targets by 2011.

Additionally, Motsoaledi and others in his department are busy identifying and rectifying managerial and attitudinal deficiencies in district-level health-care facilities and have created an expert group to advance the National Health Insurance agenda.

This integrated multilevel approach to tackle the long-neglected burden of HIV/AIDS—based on, and emboldened by, scientific assessment—is a refreshing and brave shake up by a politician. It raises hope and excitement, especially among scientists, academics, and clinicians, who have been ignored and alienated for far too long. However, the task is enormous. South Africa remains the country with the largest HIV-positive population, 5·7 million, according to 2008 UNAIDS figures. Average antenatal prevalence is 29·3% but four districts record a prevalence above 40%, and 79% of maternal deaths tested for HIV were HIV-positive. What is needed to make these ambitious plans a reality is adequate resources, both financial and human, and buy-in by all involved. The South African World AIDS Day motto rightly asks for everyone to take responsibility and play his or her part.

When we asked for serious discussions and decisive actions in a Comment accompanying the launch of The Lancet Series, we could not have hoped for a swifter indication of serious engagement. And although the ultimate test will be in the actual delivery of preventive efforts and treatment for all, and evidence of an effect on new infections and mortality, a first very important and encouraging step towards these goals has been made. South Africa has shown how science and policy working together make the best advocates for change—change for a healthier future.

Article reproduced by permission of Elsevier.

doi:10.1016/S0140-6736(09)62065-1

In Memoriam, Lambros Papantoniou

Eduard Grebe — Wed, 02 Dec 2009 16:38:17 +0000

by George N. Pavlakis, Rockville, MD USA

What do you do about someone who claims to be an expert, serving up half-truths, twisting the facts in credible-sounding sentences and misleading a patient? There must be some rules that apply to someone who professes to be an expert and induces patients to stop their doctor-prescribed medication. These must be applied to prevent harm to more patients. And what if these actions lead to the patient’s death?

Such is the case of Lambros Papantoniou, a journalist living in Washington, a diplomatic correspondent for several Greek media institutions for more than 30 years and a man loved by all who met him. Even in the higher political echelons of Washington, he was affectionately known as “Mr Lambros”.

During a hospital stay approximately ten years ago, Lambros was diagnosed with AIDS and given anti-retroviral therapy. Following this, his interest in the AIDS problem skyrocketed, and he sought information on it. Although he was a diplomatic correspondent, he reported on AIDS issues several times.

Unfortunately, Lambros attracted the attention of Andrew Maniotis, a scientist and self-proclaimed expert on many fields, and AIDS denialist. Dr. Maniotis is not a medical doctor, nor a pathologist, as he occasionally describes himself. He is not a tenured professor, nor a tenure-track candidate for a higher academic career. At times he denies he is an “AIDS denialist,” but this term accurately describes public opinions. He does not shy away from controversy and publicizes naïve opinions that contradict the established knowledge and medical science, trying to nullify the medical gains of generations of researchers and doctors.

Maniotis claims that Lambros was like a brother to him. With such brothers, who needs enemies? The two men became friends, and Maniotis visited Lambros often in the last few years, his influence growing stronger and stronger, ultimately convincing him that HIV did not exist. Lambros stopped taking his medication and the result was devastating. After his death, Lambros’s family and friends found his medication in his refrigerator, untouched since 2007. Instead of his life-saving doctor prescribed medicine, Lambros was convinced to consume Maniotis-promoted vitamins.

During 2007, increasingly influenced by Maniotis, Lambros became more aggressive in interrogating scientists and government officials about AIDS. In his attempts to discredit Dr. Robert Gallo, Maniotis urged Lambros to seek an interview with Gallo, hoping to confront him with an AIDS denialist agenda and publish articles containing slander and misinformation.

Dr. Gallo took the bait and spoke with Lambros openly and frankly. To his credit, Lambros published a series of articles in which he reported on the issue ethically and to the best of his ability. Undaunted by this failure, Maniotis intensified his efforts to convince Lambros of his outlandish ideas on AIDS. Lambros was finally convinced and published an extensive interview, in which Maniotis disputes all scientific facts about HIV and AIDS, advising HIV positive people, like Lambros himself, to stop taking their doctor-prescribed medication and to rely on vitamins and other unproven methods.

Unfortunately, Lambros’ non-scientific background and his personal vulnerability as an HIV positive person got the best of him, and he became more and more a spokesperson of the AIDS denialists, putting his complete trust in Maniotis.

This trust eventually cost him his life. He simply stopped taking his medication. Already hospitalized once, Lambros’s health depended on blocking HIV through anti-retroviral drugs. Without this protection, the virus continues to damage the immune system, until the patient becomes vulnerable to a multitude of common infectious agents, which would ordinarily be blocked by a functioning immune system. With the medication, he likely would have lived a longer and healthier life.

Having finally succumbed to Maniotis’ 'freindship', at several White House and State Department briefings in Washington, Lambros asked hostile nonsensical questions repeating the statements of Maniotis verbatim. He asked whether anyone had actually seen the virus. He accused the medical profession of poisoning the “so-called AIDS” patients with drugs.

In retrospect, Lambros’ increasingly erratic behavior can be partially explained by his deteriorating health. HIV ultimately landed him at Howard University Hospital under unclear circumstances. The most likely scenario is that he was found confused and disoriented and was taken to the closest emergency room. He had developed encephalitis, a common outcome of end-stage HIV infection. He was later transferred to Georgetown Hospital, where he died of encephalitis. During his more lucid moments at the hospital, Lambros told his friends he was dying of AIDS.

In the meantime, Maniotis, having the trust of Lambros’s family, was calling both hospitals and arguing about prescribed treatments, accusing medical personnel of trying to kill Lambros, all while denying the existence of AIDS. The doctors found the situation highly distracting and asked that Maniotis does not contact them. The Greek Embassy had to intervene and tell Maniotis to back off.

During this last period of his life, Lambros was clearly very sick and confused, making several statements reflecting this confusion. To their shame, AIDS denialists are promoting these statements on the Internet in order to build up their own agenda, disrespecting the memory of a sick and confused man, and, of course, not acknowledging their part in his death.

"Nobody really knows why he's gone," claims Maniotis. But in the end, Lambros knew, and so do we. He died of encephalitis following the collapse of his immune system, an outcome of HIV infection. We know from millions of other cases that, had he taken his anti-retroviral medicine and prevented further damage by HIV, he could have had many more productive years.

Some of us who knew him also feel a bit guilty at times about not being able to protect him more from predators like Maniotis.

Consequently, we feel that along with celebrating his contributions, his achievements, his life of giving, of helping many people in his community, we also need to tell his true story. Lambros was a defender of our democratic ideals, a stalwart defender of the truth, a man who gave freely of himself, his time and the limited money he had, helping countless people in his neighborhood in Washington, in cities throughout the U.S. and in Greece. He is missed even by those he criticized.

We must honor him by not allowing his death to be used to hurt others. We must not be silent, as silence did not become Lambros himself.

As a generation of AIDS activists realized some time ago, Silence = Death.

Rian Malan still getting AIDS stats wrong

Eduard Grebe — Tue, 01 Dec 2009 13:09:43 +0000

by Nathan Geffen, 1 December 2009

Substantially updated by the author on 7 December 2009

In a piece published in Rapport newspaper and on politicsweb, Rian Malan claims:

[D]on't trust anything the Aids bwanas say - especially not Nathan Geffen of TAC. Earlier this week, he informed the world that Zuma's mistake "was of little consequence," because other data showed that SA's death rate has doubled since l997. Hmmm. It is true that annual death registrations rose from 316,000 in 1997 to around 600,000 in 2007, but it is absurd to claim, as Geffen did, that this was almost entirely the result of Aids.

Over the same period, completeness of registration rose from around 67 percent to 81 percent, according to Stats SA, while our population rose by close on seven million. If you adjust the raw numbers accordingly, Geffen's apparent doubling shrinks to an increase of around 15 to 20 percent.

He then published a correction:

Correction: I am informed that my mathematical skills leave much to be desired. If you run the numbers in the penultimate paragraph correctly, the real increase in SA death registrations since l997 comes out at around 30 percent - still a tragedy by any reckoning, but still way short of the doubling claimed by Geffen.

First let's deal with the numbers. Malan continues to get it wrong, even in his correction. AIDS deaths have conservatively increased 6-fold since 1997, from approximately 50,000 to well over 300,000 in 2006 as well as 2007 and maybe even over 350,000, meaning the real increase in deaths -which is way more than 30%- recorded or otherwise, was mainly due to AIDS. The ASSA2003 interventions model calculates under 150,000 AIDS deaths in 2000 and about 360,000 in 2007. Approximately 45% of deaths in 2006 and 2007 were due to AIDS. The model probably overestimates AIDS deaths but not substantially enough to give any material support to Malan's argument. But even a 30% increase in mortality, as Malan acknowledges, is a tragedy.

Far more knowledgeable people than either Malan or myself work on the ASSA model. They take into account all the available data: recorded deaths, improved registration, population growth and much else. Of course, as with any model, there is a good deal of uncertainty, but it is the best we have to go on - and far better than Malan, who admits his mathematical skills leave much to be desired.

In Malan's Rolling Stone article in 2001, his arguments were based on outright AIDS denialism, in which he confused the different types of testing algorithms needed for diagnosis of an individual patient versus epidemiological surveys. His articles in 2003 in Spectator and Noseweek continued in the same vein. But with each subsequent article he has come closer and closer to admitting the massive scale of the HIV epidemic. His latest acknowledgement that AIDS is responsible for a 30% increase in mortality is almost mainstream. Yet his writing style remains unrepentant and he brushes off as a triviality the realisation that he is not mathematically competent to do this work.

He also misrepresents me. Nowhere did I write that real deaths had doubled in my recent article that he appears to be referring to. I wrote, accurately, that recorded deaths increased over 90% in a decade. I also wrote, "Improved death registration and population growth can account for only a small portion of this increase. The vast majority of additional deaths are due to the HIV epidemic."

This was also accurate. Only a careless reading of my wording would imply that total deaths (i.e. recorded plus unrecorded) have doubled due to AIDS. This might seem a minor "He said, I said" spat, but it demonstrates a lack of integrity in public engagement. Despite our overall success, I am sure there is much fair criticism that can be directed at TAC about our actions over the last decade, but manipulating AIDS statistics is not one of them.

Without any sense of irony, Malan concludes, "we should just ignore those who try to manipulate us with numbers and support Zuma's common-sense plan to stamp out the disease." Actually, it is because of the people who Malan falsely accuses of manipulation that we finally have a common-sense AIDS plan. While we were fighting for it, Malan was supporting Mbeki on AIDS.

Some of my colleagues have been weary about me responding to Malan. They have warned me that he is being a contrarian so that he can promote his new book and that a response is exactly what he wants. But I think Malan is a talented wordsmith whose writing style convinces some people; it is them I aim my articles at. But being clever with words does not imply competence and Malan's articles on AIDS are littered with errors.

According to Wikipedia Malan stated, "I get a kick out of it when the Treatment Action Campaign attacks me; it's like sport." I do not know if he really said this, but it does appear to be sport for him.

For TAC and me, it is a waste of precious time and aggravating. Many people find AIDS statistics impersonal. But I do not; they remind me of Christopher Moraka, who testified before Parliament in 2000 that he could not get medicines to treat his systemic thrush. He died a couple of months later. Or Edward Mabunda, TAC's late firebrand poet. And Ronald Louw, a close friend and brilliant lawyer based at UKZN who died a few years ago of AIDS. No, this debate is not sport for TAC or me.

Killer syndrome: The Aids denialists

Eduard Grebe — Tue, 01 Dec 2009 12:48:40 +0000

Rob Sharp reports in The Independent on the presistence of AIDS denialism

A middle-aged man walks into an East London café and apologises for being late. With his clipped hair and bus-driver's uniform of thick overcoat, shirt, and branded tie, he looks like any other public service employee. But soon he delivers a speech of startling ferocity against the medical establishment.

Mike explains that he runs a London-based health website on which he posts articles and links to information that questions whether HIV causes Aids, disputes the existence of HIV, and denies the fact that unprotected sex helps to spread it. He offers support for those who, he says, are "negotiating with medical authorities over taking a different approach to dealing with their circumstances." He claims to get thousands of hits on his site and has helped advise several people who have been diagnosed with HIV and are launching legal action against their local health authorities, in the belief that they have been unfairly treated by the doctors who are trying to help them.

Mike is an Aids denialist. He shares the view of a global network of academics and campaigners that follow the proclamations of Peter Duesberg, a cell biologist at the University of California, Berkeley, who believes HIV does not cause Aids. And, alarmingly, 2009 has been a good year for the denialist community.

In the first week of November, a record number of Aids denialists from 28 countries, including Britain, attended the Rethinking Aids conference in Oakland, California. One of the main draws of the conference was a screening of a controversial new documentary by Canadian-born director Brent Leung, House of Numbers, which gives a platform to denialist theories.

Over the last two months it has been screened at the Cambridge and Raindance Film Festivals - decisions that provoked a storm of criticism online. The Spectator was forced to cancel a debate and screening of the film on 28 October after some of the participating speakers pulled out. And yet despite widespread outrage, the film has undoubtedly encouraged those who espouse denialist theories in the UK.

So who are the Aids deniers and what do they believe? According to Seth Kalichman, a psychologist at the University of Connecticut, whose exposé of the movement, Denying Aids, was published in March, denialists anywhere in the world generally share several common beliefs. They say that the "myth" that HIV causes Aids is the product of conspiracies between governments and the pharmaceutical industry; that antiretroviral medication is toxic; and that one day the orthodox medical theories on HIV will crumble.

So far, so typically crackpot. But the movement has gained some damaging traction - and the propagation of denialist theories can have deadly repercussions. Aids charities warn that reading material which argues that HIV does not cause Aids can dissuade potential sufferers from getting tested for HIV, and even lead HIV-infected people to ignore HIV-positive results and cause them to reject antiretroviral therapies.

"Denying the link between HIV and Aids is scientific illiteracy," says Yusef Azad, director of policy and campaigns at the National Aids Trust, Britain's leading HIV/Aids charity. "But worse than that, it is profoundly dangerous and has caused countless unnecessary deaths. Just because something is on the internet does not mean it is even remotely true. More than two decades of peer-reviewed scientific research demonstrates in some detail how HIV attacks the immune system and causes Aids if left untreated."

Read the full article on The Independent's website.

McGill Daily on the dangers of denialism

Eduard Grebe — Fri, 27 Nov 2009 00:14:33 +0000

Stephanie Law writes in the McGill Daily:

Christina Maggiore died of an AIDS-related illness on December 27, 2008. She was a successful businesswoman who started a multimillion-dollar import/export clothing company, and a freelance consultant for U.S. government export programs. Maggiore is most notorious for her role as an HIV-positive activist who promoted the idea that HIV is not the real cause of AIDS. She was an HIV-denialist.

Maggiore was diagnosed with HIV in 1992. In 1994, she met Peter Duesberg, a molecular biology professor at the University of California at Berkley. Duesberg convinced Maggiore that HIV does not lead to AIDS. A year later, Maggiore started one of the largest networks of HIV-denialists and skeptics, called Alive & Well AIDS Alternatives.

Maggiore refused antiretroviral treatment for HIV because she did not think HIV would lead to AIDS and AIDS-related illnesses. She did not take the recommended treatment for pregnant HIV-positive women to prevent mother-to-child transmission. Her child died at the age of three from Pneumocystis jirovecii pneumonia. The Los Angeles County coroner and various other independent pathology experts concluded that the death was a direct result of her untreated HIV that had progressed into AIDS.

W hen asked about Maggiore, Mark Wainberg, director of the McGill University AIDS Centre, becomes enraged: “Christina Maggiore and her daughter died because they didn’t get treated…. Their story is tragic, but the reality is, Christina Maggiore was so misguided in believing this concoction of bullshit, that it cost not only her life, which is her business, but also the life of her three-year-old kid, and that is everybody’s business.”

Maggiore and her daughter’s deaths are only two of many that result from denying the causal link between HIV and AIDS.

Read the full article.

Constantine and Weiss pinpoint misrepresentations

Eduard Grebe — Thu, 26 Nov 2009 20:22:29 +0000

Statements by Professor Niel Constantine and Professor Robin Weiss about the Misrepresentation of their Interviews in “House of Numbers.”

Posted November 23, 2009, to HouseofNumbers.org

The sections on HIV antibody tests in “House of Numbers” contain fragments of interviews with a number of different people, put together in a way that confuses viewers rather than clarifying what HIV testing protocols are and how they work. The editing of the interviews to try to create doubts about the worth of HIV diagnostic assays is surely intentional. Questioning HIV diagnostics is one of the main tactics of HIV denialism.

The talking heads in these sections of the video include an eager-to-please but inexpert woman working in a temporary testing tent in a South African mall, several legitimate scientists, and HIV denialist Liam Scheff and filmmaker Brent Leung. The section jumbles together bits of speech about the use of HIV antibody testing for different purposes—for screening the blood supply, for screening individuals for HIV infection and confirmatory testing, for diagnosis and for prognosis. It also scrambles remarks about different generations of tests; about tests of different qualities—those manufactured under FDA oversight and those produced in uncontrolled conditions; about different types of HIV antibody tests—conventional and rapid tests, ELISA and Western Blot; and about the use of these tests under different countries’ government protocols—Germany, South Africa, Britain, the USA. The resulting mess of words creates confusion – as it was intended to.

The history, variety, and protocols of HIV antibody testing can be confusing to non-experts. Leung and his team have exploited this in the film. But any of the legitimate scientists or clinicians in the film, asked a clear question by an ethical interviewer who would try to present their views accurately, could easily explain how HIV antibody testing works, what protocols are used to maximize accuracy in different places and at different times, the distinctions between screening and diagnostic assays, the differences between ELISAs and Western Blots, and so on. But Brent Leung sought to confuse, not clarify. He wanted to make it seem like the tests are unreliable and that the scientists he interviewed didn’t know disagreed with each other about HIV tests. The reality is very different. HIV antibody tests are extremely accurate, and various confirming protocols (two or three different types of tests) are used in different places.

Two scientists who were interviewed by Leung, then edited to appear as if they held antagonistic views, are Niel Constantine, Professor of Pathology at the University of Maryland, and Robin Weiss, Professor of Viral Oncology in the Division of Infection and Immunity at University College, London. Professors Constantine and Weiss both say that their interview footage as edited misrepresented what they know and what they said. In fact, contrary to the impression created in “House of Numbers”, they agree with one another about the nature, value, and accuracy of HIV antibody tests. Here are their statements.

Dr. Constantine's Statement

“What Mr. Leung has done is take our statements completely out of context. For example, he and I were discussing the use of rapid HIV tests and their accuracy. I explained that the tests were excellent, but that some individuals were assembling rapid HIV tests from individually purchased components and making these tests in their garages for sale. Such tests, that had not been subjected to the quality assurance measures required by organizations such as the FDA, were inferior and should not be used. That is, only tests that were approved by expert organizations should be used. Hence, my statement in the film "Now if I tell you that the test you took was lousy and didn't mean a thing." Mr. Leung used this to imply that I was stating that HIV tests were useless.”

-- Niel T. Constantine, Ph.D., Professor of Pathology, University of Maryland School of Medicine

Dr. Weiss's Statement

“The sound bites were extracted out of quite a long interview with me and presented out of context. In my recollection (I don't have a tape of the interview) Leung was pressing me about HIV antibody tests in reference to screening blood donations. When I said ‘I don't think the Western Blot is a useful diagnostic test; I don't think it's worth doing’, I was referring to relatively high throughput screening for blood banks, and in the mid 1980s we did not yet have commercial dip stick Western Blot kits available. In retrospect, it would have been better for me to say: ‘I don't think the Western Blot was a useful primary screening test’.

“I also cited what I regarded as a dogma that a Western Blot test was essential as a confirmatory test; ELISA tests made by two different manufacturers can also provide a confirmed result. For instance, in some UK labs the Wellcozyme ELISA using a competition format was used for primary screening and was then followed up with a confirmatory assay using the Abbott standard direct-binding ELISA instead of a Western Blot.

“It strikes me that similar false contrast and out of context quotes have been crafted together throughout the programme. Furthermore, Leung doesn't seem to understand or acknowledge that doubts about the precision or reliability of tests that were devised as research tools in 1984 (the first year in which we could grow HIV in reasonable amounts in the lab) really have little relevance to the reliability of subsequent mass produced commercial tests, which had to go through extensive quality control before they were marketed or used in clinics and blood banks. It's rather like saying that Roentgen's original fuzzy X-ray pictures are a valid reason for debunking today's radiological imaging systems for hospital diagnosis.”

-- Robin A Weiss, Ph.D., Professor of Viral Oncology, Division of Infection and Immunity, University College London

The following text is an annotated transcript of the sections of the video about HIV antibody testing, to provide a context for Professor Constantine’s and Professor Weiss’ statements. Annotations in italics.

Scene: Brent Leung is getting an HIV test in a South African mall.

African woman tester: “We always say to our clients: even if you have tested here, you can go to other centers and go and verify your test. We cannot say you’re 100%. Because you find clients going from area to area doing these tests, and they come with stories that I was negative at a certain area and positive with you.” She seems to be talking about people who are HIV+ testing repeatedly at different sites in hopes of getting negative results.

Leung: “And how do they decide if they are positive or negative?”

Tester: “We cannot tell, because we are using a rapid test.” This answer doesn’t mean the rapid test is useless, but that it requires confirmation.

Audio: Sinister background music.

Leung, narrating to impose a particular interpretation on the interview snippets: “It occurred to me that perhaps the HIV epidemic is reported to be so widespread in South Africa and other poor nations simply because they use these inaccurate tests.”

Image: flooded African shantytown.

James Chin, MD, MPH- Chief of Global HIV Surveillance World Health Organization 1987-92: “There’s the saying that if you knew how sausages, what sausages are made of, most people would hesitate to sort of eat them because they wouldn’t like what’s in it; and if you knew how HIV numbers are cooked, uh.. or made up, you would use them with extreme caution.”

This is a completely different topic—how HIV statistics are estimated—but the insertion of this sentence here makes it seem that Chin is discussing HIV tests.

Caption: London, England. View of London, Thames from above.

Leung: “I decided to investigate HIV testing protocols used throughout the developed world.”

Harold Jaffe MD, Director, CDC AIDS Division 1992-95 Head of Public Health Dept. Oxford 2004- Present: “When we are testing people for HIV, the first thing we do is a screening test and it’s usually a test called the “ELISA” Jaffe’s sentence is cut off here.

Niel T. Constantine PhD- Director, Clinical Immunology Institute of Human Virology: “But there are also now available rapid assays that can be used as screening methods.”

Liam Scheff, HIV denialist: “Because they’re faster, and we all know, faster and cheaper is more efficient.”

And people don’t need to wait two weeks for highly accurate results. Is this bad?

Claudia Kücherer, MD, Molecular Biologist, Robert Koch Institute, Germany: “If an ELISA is positive, it does not mean that the patient is HIV positive. So that’s a problem.” But what did she then go on to say as an explanation of this statement? We are not shown, as Leung only manipulates sound bites.

Robin Weiss PhD- Professor of Viral Oncology University College London: “If we’re using antibodies as a screening test to tell who is infected or not, uh, very occasionally you can get false positives.”

Niel T. Constantine: “So screening tests by themselves should not be used as a definitive measure of infection; that’s why we use a screening test to pick up all the cases, but we use a confirmatory test to eliminate any false positives.

Back to the South African testing booth:

Tester: “Take it easy… I’ll pierce at the site.” She pricks Leung’s finger.

*Leung [voice over]: “It should be emphasized that most of the developing world uses only screening tests to confirm an HIV diagnosis; there are not confirmatory tests.” Leung is presumably referring to the use a second ELISA test from a different manufacturer, in contrast to a Western Blot, for confirmation. This is a highly accurate protocol and necessary where resources are limited.

Robert C. Gallo: “This has a margin of error done properly that’s extremely low. In other words, it’s one of medicine’s better tests.”

Robin Weiss: “I don’t think the Western Blot is a useful diagnostic test; I don’t think it’s worth doing.” See Dr. Weiss’s explanation of this sentence.

Niel T. Constantine: “Did he give a reason? You know anybody can say anything, I think it’s stupid to drive a car. But come on you gotta give a reason!”

In the background, Leung starts to say, “He said…”

Robin Weiss: “It’s a useful prognostic test. Once you know that someone is infected, then you can follow their antibody responses well with Western Blots.” This is a true, accurate statement.

Niel T. Constantine: “I’d say he’s absolutely wrong, it has a complete usefulness.” With what statement is Professor Constantine disagreeing here? The film doesn’t show

Footage pans backs and forth between the two men in a blurred, swinging motion, juxtaposing them to impose a sense of concurrency and argument.

Robin Weiss: “You don’t need a Western Blot! And it’s become a dogma in HIV research that you need one ELISA followed by a western; you don’t. You need two different kinds of ELISAs made in two different formats.” Professor Weiss here emphasizes the need for using two independent tests to obtain confirmation of HIV status. Most countries still use an ELISA followed by a Western Blot, a long established and highly reliable procedure. Professor Weiss simply says that there is an alternative method that could now be used and expresses his opinion that using two ELISAs is the better option.

Leung: “Would you ever want to confirm somebody is positive using just ELISAs? “

Claudia Koshered: “No. Never. It’s not…It’s against the rules, it’s against the recommendations.” In Germany, that is true, but not everywhere. Different nations make different decisions on many aspects of health care all the time.

Liam Scheff: “It’s a turbulent sea of argument about how can we use this test, when can we use this test, why does this test have no standard?” Tests made by different manufacturers are slightly different, and are read differently. However, all approved tests are very accurate. It is a profound logical error to say that if screening or measuring tests vary, the thing they screen for or measure does not exist

Niel T. Constantine: “Now if I tell you that the test you took was lousy and didn’t mean a thing, would that make any difference for everybody to hear?” See Dr. Constantine’s statement about the proper context for this comment: he is referring to bootleg tests that are not reliable.

Leung: “It’ll make a difference for me.”

Niel T. Constantine: “Yeah I know.”

Science, pseudoscience and professional responsibility

Eduard Grebe — Thu, 26 Nov 2009 15:05:04 +0000

by Dr John Moore, PhD (Originally published by health-e)

Surveys have consistently shown that over 40% of Americans do not believe in evolution. It is not surprising, then, that our society is vulnerable to being fooled by people who misrepresent scientific or historical facts.

We are now all too familiar with the crazed activities of the 'Birthers', an ad hoc, right wing political group refusing to accept President Obama was born in the United States. Earlier this year, we saw media coverage of the insane views of a clique that refuses to accept American astronauts walked on the moon 40 years ago. The "9/11 Truth Movement" flourishes on the internet, arguing that the World Trade Center and the Pentagon were not hit by hijacked jetliners, but were blown up by the CIA at the behest of Israeli intelligence. Conspiracy groups like these usually do little real damage to society, although the activities of the "9/11 Truth Movement" foster anti-Semitism and insult the memories of the nearly 3000 Americans who died on 9/11. Unfortunately, other equally bizarre and factually unfounded, internet-based conspiracy groups can, and do, harm, even kill, significant numbers of people. This is not just an American problem, as the ripple effects of conspiracy theories spread worldwide via the internet. Indeed, the most serious consequences of one such group’s actions have been felt in Africa.

A small group of misguided and, in some cases malicious, individuals have long promoted the view that HIV does not cause AIDS or, in an even more bizarre twist of the truth, that HIV does not even exist. An even nastier variation of the theme is that HIV was created by the US government as a device to kill "undesirables", such as people with black skins or who are gay. None of these opinions is true, and there is not a shred of credible scientific or historic evidence to support them. Unfortunately, the Mbeki administration in South Africa put in place policies based around the premises that HIV is harmless but anti-retroviral drugs are dangerous. This decision caused over 330,000 unnecessary deaths during the first half of this decade. And yet the "AIDS Denialists" even question this death toll, a tactic no different from Holocaust Deniers asking "Did six million really die". Many Americans and Europeans have also died, persuaded by the "AIDS Denialists" that they did not need to take anti-retroviral drugs to treat their HIV infections. Distrust of the federal government and the medical establishment among African American communities has adversely affected AIDS prevention and treatment programs in the USA, in no small measure due to the crazy belief that HIV was created as a weapon of selective genocide. Indeed, this particular rumor even re-surfaced in the last Presidential election campaign. Real people die real deaths as a direct result of the pseudo-science promoted by the "AIDS Denialists".

In a similar vein, groups that claim vaccination is harmful have harmed global immunization programs, and thereby caused avoidable deaths worldwide. A conspiracy theory group often called "The Mercuries" has been particularly vociferous in its argument that a mercury-containing preservative found in some vaccines causes autism. There is less mercury in a vaccine shot than in a tuna fish sandwich, and the mercury present in the fish is in a more dangerous chemical form. Overall, a now vast body of solid scientific evidence has proven that autism has no connection whatsoever to any vaccine or vaccine component. This is now settled science within the professional community, which understands that the cause of autism is based in human genetics. But despite the facts, the distrust of vaccines that has been created by “The Mercuries” and other anti-vaccine conspiracy groups is now damaging efforts to counter swine flu by vaccination, both in America and, increasingly, elsewhere. The polio vaccine eradication campaign has been harmed, notably in Nigeria, by rumors that the vaccine is contaminated with dangerous chemicals, or even with HIV, or that it was designed by “white people to sterilize black people”. As a result, this dangerous infection has still not been eradicated from Africa, where it lingers on, killing and paralyzing yet more people.

The mindsets of the "AIDS Denialists" and "The Mercuries" are similar to each other. Both groups are irrational on the science, twisting the facts to a perverse extent and stubbornly ignoring and rejecting all the evidence that speaks against their views. Each group is bolstered by a very small number of scientists whose paper qualifications provide them with a superficial, wafer-thin veneer of academic credibility. The two conspiracy groups contain individuals who will resort to threats of violence and who harass those who dare to speak up against them. A common tactic of both groups is to smear scientists and physicians who recommend AIDS drugs or the use of vaccines as being nothing more than paid tools of the pharmaceutical industry. Yet both the "AIDS Denialists" and "The Mercuries" are supported by promoters of “alternative (i.e., quack) therapies" who have a financial interest in damning approved anti-HIV drugs or licensed vaccines. “Ambulance-chasing” lawyers have also been heavily involved with the anti-vaccine groups, fostering the hopes of grieving parents that they (and the lawyers) might receive a payout from a scientifically ill-informed jury.

The conspiracy theory groups also receive the support of a small, but noisy, subset of media professionals who seem attracted to the personalities involved, smelling stories in the controversies. This has been particularly problematic recently in the anti-vaccine arena, where some American chat shows and right wing news programs have given undue attention to “The Mercuries”. Bizarre as it may seem, the views of medically unqualified Hollywood celebrities are given equal, or even greater, weight on these shows than those of expert physicians and scientists. Science and pseudoscience should never be “balanced” in this way. To make an analogy: if a film star claimed that we should not fly on a jetliner because mercury contamination could make the wings fall off, we would simply laugh, preferring to listen to the views of qualified aeronautical engineers and metallurgists (and to our own experience as travelers). Yet, nowadays, film stars’ views on vaccine composition are given huge weight by some chat show hosts.

The "AIDS Denialists" and "The Mercuries" are no different from the "Birthers", the moon-landing hoaxers, the "9/11 Truth" members and the Holocaust Deniers in the irrationality of their views and their belief in government conspiracies and cover-ups. Indeed, some members of the various groups flit from one conspiracy-themed web site to another, seeking and finding solace in a variant form of irrationality. One of the very few academic supporters of the" AIDS Denialism" movement also investigates the Loch Ness Monster, Alien Crop Circles and other such fringe or paranormal themes. It would be funny if it were not so tragic.

What can be done about dispelling this kind of damaging nonsense? America has a strong tradition of free speech, so dangerous views will continue to be promoted, however harmful they are to public health and the best interests of society. The internet is the territory of the conspiracist, and it is likely to remain so. But media professionals should not be so unquestioning of the science when they provide airtime or column inches to those with fringe views. Controversy may help sell advertising, but at what cost?

A particular concern is that the ideas that HIV is harmless and that vaccines cause autism have been underpinned by a very few academics or physicians working in American or European universities or hospitals. These “thought leaders” for the conspiracy groups should now be made to face the professional consequences of their scientifically unsupportable actions. Is academic freedom such a precious concept that scientists can hide behind it while betraying the public so blatantly? When the facts are so solidly against views that kill people, there must be a price to pay. Post-tenure review of the progress of academic careers is something the university system could put in place if it chose to. How can bona fide universities justify their employees teaching students, even medical students, that HIV is harmless? How can academic and medical institutions still employ people whose views lead to the deaths of over 330,000 South Africans? Shielding the proponents of pseudoscience by doing nothing is a dereliction of a duty to the public. It is also moral cowardice. It is now time for Africa to speak out and demand action against those who have been responsible for so many deaths on this continent.

Call for Mandatory Disclosure of Pharmaceutical Industry-Funded Events for Health Professionals

Eduard Grebe — Thu, 26 Nov 2009 13:52:56 +0000

We endorse this call for mandatory disclosure.

Mandatory Disclosure of Pharmaceutical Industry-Funded Events for Health Professionals

Robertson J, Moynihan R, Walkom E, Bero L, Henry D (2009) PLoS Med 6(11): e1000128. doi:10.1371/journal.pmed.1000128

Summary Points

There are moves internationally to ensure greater disclosure of gifts and educational events for doctors paid for by pharmaceutical manufacturers. However, there is no agreement on appropriate standards of disclosure. In Australia, since mid-2007, there has been mandatory reporting of details of every industry-sponsored event, including the costs of any hospitality provided.
Examination of the Australian data shows that although expenditure at individual events is often modest, cumulative expenditure is high, particularly in the case of medical specialists prescribing high cost drugs—oncologists, endocrinologists, and cardiologists.
Although a significant advance, the new Australian reporting standards do not allow assessment of the educational value of sponsored events, and do not include details of speakers or educational content for most events. However, doctors in training are often present at these events.
At present, the standards of disclosure are inadequate and should not be tied to an arbitrary monetary value of gifts or sponsorship. Reporting standards should require the names of the speakers presenting, whether sponsors played a role in suggestion or selection of speakers or the development of the content of presentations, and the nature of any direct or indirect financial ties between the speakers and the sponsors.

For boxes, tables and figures, visit the original article on Plos Medicine.

Background

We are in a period of unprecedented scrutiny of the relationships between the pharmaceutical industry and doctors [1]–[4]. Legislators are now considering how they might become involved in the regulation of these practices. This is a telling comment on the perceived failure of the medical profession to regulate itself and of self-regulation by industry. But reliable and comprehensive data on the nature and extent of industry sponsorship are rare. Several states in the US have mandatory disclosure laws for physician payments, but these data have proved difficult to access and analyse [5]. The US Congress is considering new mechanisms for revealing industry–professional interactions (the so-called “Sunshine” Acts) [6],[7].

One of the first countries to move towards greater transparency was Australia. The pharmaceutical industry representative body, Medicines Australia, has a self-regulatory Code of Conduct that sets standards for the ethical marketing and promotion of prescription pharmaceutical products for its member companies. In addition to monitoring of promotional activities, a Code of Conduct Committee adjudicates on complaints regarding pharmaceutical company activities [8]. In 2007, the Australian Competition Tribunal placed disclosure requirements on Medicines Australia. It approved that body's Code of Conduct for industry–professional relationships on the condition that details of every sponsored event, including the costs of any hospitality, were posted on their website [9],[10]. Reporting commenced in July 2007 and data are updated six monthly [8].

In this Policy Forum we examine the Australian data and argue that although a definite advance, the Australian disclosure requirements fall short of what is required. We propose more comprehensive reporting standards, which should have application to other settings and jurisdictions.

Australian Experience of Pharmaceutical Company Disclosures

In Australia, the emphasis in disclosure is on monitoring the level and type of sponsorship of educational events rather than documenting the dollar value of gifts and other payments to physicians. Since 2007 pharmaceutical companies have been required to report all functions (educational events) provided or sponsored for health professionals. They are required to disclose the following: the venue; the professional status of attendees; a description of the function and duration of the educational content of events; the nature of the hospitality; the total cost of hospitality; the numbers of attendees; and the total cost of the function [11].

The first report, covering the period July to December 2007, provided details of 14,649 events (Table 1) [12]. This total is equivalent to almost 600 events per week nationally, at a cost of around AUD$1 million/week (US$879,074.00). Put another way, the pharmaceutical industry spends, on average, around AUD$1,000 annually on each doctor through sponsorship of such events. The top five companies in terms of the numbers of sponsored events were Astra Zeneca, Pfizer, Sanofi Aventis, Janssen Cilag, and Eli Lilly (Table 1). The most generous of the active companies (those with >100 functions in 6 months) was Bristol Myers Squibb, with an average cost per head of AUD$95.26. In contrast, Alphapharm (a generics manufacturer) sponsored 441 events (mostly in professional rooms with a sandwich lunch) at an average cost per head of AUD$18.24 (Table 1).

Hospitality (food, beverages, travel, accommodation) accounted for around AUD$17 million of the total of AUD$31 million spent on functions. Thirty-five percent of sponsored events (n = 5,174) were held in restaurants, hotels, or function centres. The average cost per head was much higher when the venue was a restaurant (AUD$71.35) than in a hospital (AUD$12.11). In 7.2% of cases (n = 1,062) expenditure exceeded AUD$100 per head (examples are given in Box 1). There were 74 events (0.5%) with total outlays per head on hospitality in excess of AUD$500.

Medical specialists were present at 62% (n = 9,018) of events, family physicians at 30% (n = 4,437), nurses at 26% (n = 3,820), and pharmacists at less than 5% (n = 621) of events. Registrars (medical specialists in training) were present at 19% (n = 2,827) of events; in 179 instances they were the only attendees. The medical subspecialties most often featured were psychiatry (17.9%), and oncology (15.2%), who received industry hospitality roughly three times as often as any other subspeciality (Table 2). The largest per head expenditure was directed at endocrinologists, oncologists, and cardiologists (Table 2). Companies spent considerably more on restaurant meals for doctors (AUD$76.73) than for nurses (AUD$48.78).

Companies reported no responsibility for the educational content in only 9% of events (n = 1,287). Likewise, continuing medical education (CME)/continuing professional development (CPD) points were allocated to 9% of events (n = 1,270). Just over 20% of all events were described as “journal club” or “grand rounds” (n = 3,035), mostly conducted in hospitals. The majority of events (n = 10,723, 73.2%) were a mix of meetings of various kinds, including workshops and in-service training activities; only 4% (n = 591) were described as “conferences.” Table 3 shows the topics discussed, the most common being cardiology, diabetes, oncology, psychiatry, and respiratory medicine. The most common specific topics were hypertension, osteoporosis, breast cancer, type-2 diabetes, and depression. All represent large and important markets for pharmaceutical products. Topic descriptions, where provided, often matched the product portfolio of the sponsor, although there were few mentions of specific drug names (n = 582, 4%).

Importantly, Australian companies are not required to disclose the names of the speakers, whether sponsors played a role in their selection or in the choice of the content of presentations. They are also not required to disclose the nature of any financial ties between their companies and the speakers.

Why Do We Need Better Disclosure?

The information provided by Medicines Australia points to a high level of contact between pharmaceutical manufacturers and health professionals, particularly doctors. The per-person expenditure was greatest for medical specialists who prescribe high cost drugs—oncologists, endocrinologists, and cardiologists. Generally, expenditure at individual events was modest; however the cumulative expenditure and the overall level of contact was high. The available information suggests that companies exert influence over the educational content of events in most cases, and doctors in training are often present at these functions. There is substantial evidence that attendance at company-sponsored events modifies prescribing practices [13]–[15]. The presence of doctors in training and students (in hospital-based sessions) may lead to a process of enculturation whereby they come to regard repeated contact with pharmaceutical companies as a normal and acceptable part of their professional practice. The data reviewed here indicate that, from a company perspective, it is cheap and easy to sponsor meetings in hospitals and health centres, and the return on this “investment” is likely to be high. Equally, it is straightforward for administrators to limit sponsorship of such activities, should they choose to do so. It is difficult to see a role for pharmaceutical companies at hospital grand rounds.

The evidence from this analysis of Australian data suggests that disclosure requirements should not stipulate thresholds—set dollar amounts below which disclosure is not required. Physician-reporting requirements such as those in Vermont and Minnesota in the US, which exempt payments of less than US$100, could obscure the broad cumulative influence of a number of smaller payments [5],[16]. The literature indicates that it is not only the size of the gift that matters—it is the sense of reciprocity that it engenders [17].

The types of activities described here need to be viewed within the broader context of other forms of pharmaceutical industry interaction with doctors, including face-to-face contact with representatives, advertising in medical journals, consultancies, membership of advisory boards, and stock holding [18]–[20]. While lavish gifts and generous travel support have been a focus of attention in the past, these have been progressively discouraged by industry and professional guidelines. It is likely that the frequent, more modest, sponsored educational events will become increasingly important and influential, and the principal form of contact between industry and health professionals.

There are a number of organisations that will benefit from more comprehensive disclosure of these activities. Professional organisations and accreditation bodies will have accurate data on the level and type of contact their members have with pharmaceutical companies. This will enable them to counter the undesirable effects of such relationships through the development of guidelines, or the evolution of practice standards or disciplinary codes. They will benefit from sequential data to determine if practices are changing over time. The public, the media, and consumer groups will have access to reliable data on which to base their judgements about industry-health professional contact and, when appropriate, to lobby for change. Individual health professionals could have access to information on which to judge their own practices against those of their peers. If legislation is thought necessary, governments will have data on which to monitor its impact.

Proposals for Greater Transparency

The Australian reporting standards are deficient in not including details that enable a judgement about the educational value of company sponsored events. We believe that reporting schemes should require the following details: the names of the speakers presenting, whether sponsors played a role in suggestion or selection of speakers or the development of the content of presentations, and the nature of any direct or indirect financial ties between the speakers and the sponsors. This type of information is routinely requested by professional journals; so there are ample precedents and it is particularly relevant when judging the appropriateness of educational events.

We experienced considerable difficulty in accessing the Australian data, which are compiled in portable document format (pdf). As suggested in the US Sunshine Acts it is important that summary reports listing each function are accessible to the public in a searchable, downloadable, and analysable format [5]–[7].

Whether there should be a central register or database that identifies attendees at company-sponsored functions is more controversial. The data could be compiled from the records of names collected by the pharmaceutical companies. Reports could be provided to health professionals, which would enable them to compare their practices with their peers. We are not here advocating public disclosure of this information, but individuals could be asked to provide reports in particular circumstances—for instance when ethics committees are considering the industry ties of an investigator.

In Box 2 we have summarised the main data elements that we think should be included in disclosure programs. What we suggest is consistent with the recent Institute of Medicine (IOM) Report on conflicts of interest [21]. This report recommended that the US Congress create a national program requiring companies and their foundations to publicly report payments to physicians and other prescribers, biomedical researchers and their institutions, but did not suggest specific data elements. Some authors of the report argued that this database should also provide explanatory material about payments received (e.g., for an educational or marketing purpose) and information on all financial ties (e.g., equity ownership, patent rights) in addition to industry payments and gifts [22].

While it may be unrealistic and undesirable to ban contact between pharmaceutical companies and health professionals we should work to make those relationships completely transparent. We welcome further debate on this topic.

Acknowledgments

Thanks to Joanne Knight for her contribution to coding the data.

Author Contributions

ICMJE criteria for authorship read and met: JR RM EW LB DH. Agree with the manuscript's results and conclusions: JR RM EW LB DH. Designed the experiments/the study: RM. Analyzed the data: JR EW DH. Collected data/did experiments for the study: EW. Wrote the first draft of the paper: RM. Contributed to the writing of the paper: JR RM EW LB DH. Developed the data coding scheme, checked all data entries, designed and co-ordinated data analyses, interpreted the data: JR. Conceptualization and interpretation: LB. Helped design the data collection instrument and analysis plan: LB.

References

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Pregnancy, not nevirapine cause of liver toxicities in HIV-positive women

Eduard Grebe — Thu, 19 Nov 2009 15:20:02 +0000

Michael Carter writes on aidsmap:

Results of US research “challenge the notion that nevirapine is uniquely associated with hepatotoxicity during pregnancy.” The study did however show that pregnancy itself increased the risk of liver toxicities in women with HIV. The research is published in the November 27th edition of AIDS.

Increased risk of hepatotoxicity in HIV-infected pregnant women receiving antiretroviral therapy independent of nevirapine exposure.

Ouyang DW, Shapiro DE, Lu M, Brogly SB, French AL, Leighty RM, Thompson B, Tuomala RE, Hershow RC.

OBJECTIVE: To estimate whether the association between nevirapine (NVP) and hepatotoxicity differs according to pregnancy status in HIV-infected women. METHODS: The present analysis included HIV-infected pregnant women on antiretroviral therapy (ART) from two multicenter, prospective cohorts - the Women and Infants Transmission Study and the International Maternal Pediatric Adolescent AIDS Clinical Trials protocol P1025 - and HIV-infected nonpregnant women from one multicenter, prospective cohort - the Women's Interagency HIV Study. Using multivariate Cox proportional hazards regression, the interaction between NVP and pregnancy status in terms of hepatotoxicity was investigated. NVP use was dichotomized as use or no use and was further categorized according to ART exposure history. We investigated two outcomes: any liver enzyme elevation (LEE; grade 1-4) and severe LEE (grade 3-4). RESULTS: Data on 2050 HIV-infected women taking ART were included: 1229 (60.0%) pregnant and 821 (40.0%) nonpregnant. Among the pregnant women, 174 (14.2%) developed any LEE and 15 (1.2%) developed severe LEE as compared with 75 (9.1%) and 5 (0.6%), respectively, of the nonpregnant women. In multivariate adjusted models, NVP was not significantly associated with risk of LEE, regardless of pregnancy status; however, pregnancy was associated with an increased risk of any LEE (relative risk 4.7, confidence interval = 3.4-6.5) and severe LEE (relative risk 3.8, confidence interval = 1.3-11.1). The association of pregnancy and LEE was seen, regardless of prior ART and NVP exposure history. CONCLUSION: No significant association between NVP and LEE was observed, regardless of pregnancy status, but pregnancy was significantly associated with increased hepatotoxocity in HIV-infected women.

PMID: 19617813 [PubMed - in process]

The Shameless Rian Malan

Eduard Grebe — Thu, 19 Nov 2009 14:17:00 +0000

by Nathan Geffen, 19 November 2009

In 2001, Rian Malan wrote an article in Rolling Stone questioning the accuracy of HIV tests in order to disparage the evidence of a growing HIV epidemic in South Africa. In 2003 he published similar articles in the Spectator and Noseweek. All these articles were replete with errors. I subsequently debunked the latter two in a January 2004 article.

One of Malan's errors was particularly serious. He presented miscalculated, massively understated estimates of AIDS deaths which he falsely attributed to Stats South Africa. As I wrote then, the mistake was so serious and obvious that it raised questions about Malan's basic competence as a research journalist -or more disturbingly- about his motives and integrity.

In Mbeki's 2004 State of the Nation speech he quoted from Malan and spoke warmly about him. It was not explicitly about HIV, but to anyone following the debate at the time, it was clear that Mbeki was grateful for Malan's support on AIDS.

In the last year and especially the last few weeks, following the speeches of President Jacob Zuma and Minister of Health Aaron Motsoaledi, state-supported AIDS denialism has been destroyed. If Malan had any shame, he would have stayed out of the public light after supporting an ideology responsible for the deaths of hundreds of thousands of people. But he is shameless and his denialist scribblings have continued (see this rebuttal of Malan by Eduard Grebe in 2007).

His latest appeared on Politicsweb on Friday 13 November. Malan pointed out, correctly, that Zuma and Motsoaledi quoted a wrong and over-stated estimate for the 2008 deaths. The mistake, based on Home Affairs data, was an honest one. In contrast to the untruths in Malan's articles, it was not in service of a deadly ideology. On the contrary, Zuma's speech and Motsoaledi's dense-with-statistics 47-slide presentation, were for the most part superb and demonstrated renewed political will to combat the epidemic.

Yet Malan wrote this jaundiced rant, “This country is full of HIV consultants and researchers and specialist HIV hacks who are paid a lots of money on account of their supposed expertise. The state president says that the Aids equivalent of an atom bomb has detonated among our people AND THERE'S NO REACTION AT ALL FROM ANY OF THEM. They all knew, like I did, that Zuma's number was bullshit, but they were perfectly happy to let it stand, cos big Aids numbers are good for business, innit? NOT ONE OF THOSE MOTHERS SAID ANYTHING! They think you are stupid and want to keep you that way.”

He also confirmed his AIDS denialism, “In other words, there is no apocalypse. No massive Aids related death surge. If anything, death registrations are stable.”

Actually, as I explained in an article on Politicsweb, there has undoubtedly been a massive AIDS-related death surge; we have simply reached the crest of that surge thanks to the ARV programme. And if the programme falters AIDS deaths will grow again. Only a shameless denialist like Malan could tell such an obvious lie – again. He is also guilty of exactly what he accuses others of: distortion of statistics to promote his career. If there is to be a commission of inquiry into AIDS denialism, Malan should be questioned about his motives and actions.

AIDS and mortality in South Africa

AIDSTruth — Wed, 18 Nov 2009 08:59:17 +0000

By Nathan Geffen, 16 November 2009

On 2 November 2009, Statistics South Africa released the latest mortality data, which goes up to 2007 (Stats SA, 2009). This table gives the number of recorded deaths per year:

Year	Number of recorded deaths by Stats SA
1997	317,131
1998	365,852
1999	381,820
2000	415,983
2001	454,847
2002	502,031
2003	556,769
2004	576,700
2005	598,054
2006	612,462
2007	601,033

You do not need to be a statistician to be astounded by this. Recorded deaths have increased over 90% in a decade. Improved death registration and population growth can account for only a small portion of this increase. The vast majority of additional deaths are due to the HIV epidemic. A huge body of evidence shows this. For example, there has been a three-fold increase in TB deaths over the same period and TB is the leading cause of death in people with HIV. Also the age pattern of the deaths --younger instead of older adults comprise the bulk of them-- and the drop in the median age of death from 51 in 1997 to 44 in 2007 are consistent with the way AIDS works. (For more detailed evidence see Dorrington et al. 2006, Dorrington et al. 2001 and Stats SA, 2002).

Also noticeable is that the number of deaths appears to have stabilised from 2005 to 2007 and perhaps has even begun to decrease slightly. This is most likely due to the state's antiretroviral (ARV) treatment programme.
Unfortunately because the public sector programme has not been well monitored and there are numerous treatment providers in the private sector, there is not accurate data on the number of people on treatment. But by using several sources of data, including figures published by the Department of Health, medical aid data and public sector ARV procurement data it is possible to make reasonable estimates. Muhammad Aarif Adam of Sanlam and Leigh Johnson of the Centre for Actuarial Research have made plausible calculations of the number of people on treatment in the middle of each year up until mid-2008, shown in the next table (Adam and Johnson, 2009).

Year	No people on treatment
2001	6,000
2002	15,000
2003	26,000
2004	47,000
2005	109000
2006	229,000
2007	371,000
2008	568,000

The programme began in earnest in 2004 and the stabilisation of the death rate has coincided with it. If you consider that many, perhaps most, of the people on the programme would be dead by now that would easily account for stemming rising deaths. Make no mistake; there has been a massive surge in deaths in South Africa for more than a decade and AIDS deaths continue to be very high; deaths might have stabilised but at a very high number. Life-expectancy declined to the low-50s. At least though, we are implementing the most effective known scientific medical intervention to mitigate the effects of the disease and it now appears that life-expectancy is increasing again.

But many unnecessary deaths occurred because of the delayed rollout of the ARV treatment programme. Two studies have conservatively estimated that former President Thabo Mbeki's AIDS denialist policies cost well over 300,000 lives (Nattrass, 2008; Chigwedere, 2008). Mbeki did not pursue this deadly policy without help though. Officials in government, civil servants and even some journalists supported his policy, tried to give it legitimacy and for a time succeeded in quashing the demand for a treatment rollout from health workers and AIDS activist organisations, like the Treatment Action Campaign (TAC). Thankfully, we have moved beyond this awful era of South African history.

PS: The last two weeks have seen what I believe is the final death-knell of state-supported AIDS denialism. Both President Zuma and Minister of Health Motsoaledi have delivered important speeches showing their intention to fight the epidemic. On page 35 of his presentation Motsoaledi quoted mortality data for 2008 from Home Affairs which appears to be far too large. I am unaware of how this number was derived and it appears to be an error. In other respects Motsoaledi's speech was excellent and his mistake is of no great importance.

References

Adam M and Johnson L. 2009. Estimation of adult antiretroviral treatment coverage in South Africa. September 2009, Vol. 99, No. 9 SAMJ

Chigwedere P. 2008. Estimating the Lost Benefits of Antiretroviral Drug Use in South Africa. JAIDS Journal of Acquired Immune Deficiency Syndromes. 49(4):410-415, December 1, 2008.

Dorrington R et al. 2001. The impact of HIV/AIDS on adult mortality in South Africa.

Dorrington R et al. 2006. The Demographic Impact of HIV/AIDS in South Africa.

Nattrass N. 2008. AIDS and the Scientific Governance of Medicine in Post-Apartheid South Africa. African Affairs 2008 107(427):157-176.

Statistics South Africa. 2002. Causes of death in South Africa 1997-2001 : Advance release of recorded causes of death.

Statistics South Africa. 2009. Mortality and causes of death in South Africa, 2007: Findings from death notification.

The Lancet reviews AIDS denialist film "House of Numbers"

Eduard Grebe — Tue, 17 Nov 2009 19:32:10 +0000

Talha Burki writes in The Lancet Infectious Diseases:

Strange, perhaps, for The Lancet Infectious Diseases to review House of Numbers. It is a threadbare documentary that claims there is no connection between HIV and AIDS. It arrives at this conclusion through a toxic combination of misrepresentation and sophistry. At best, it is a misguided and misbegotten film; at worst, it is downright malevolent.

All of which makes a fine case for ignoring it. HIV/AIDS denialism is an ideology in disgrace; the ravings of what Stephen Lewis—former UN Special Envoy for AIDS in Africa—describes as a “lunatic fringe”. To debate House of Numbers is to attend the film with an honesty and dignity that is entirely alien to its nature. Far better to leave it mouldering in the clutches of cranks and conspiracy theorists.

Only, denialism kills. A study published in the Journal of Acquired Immune Deficiency Syndromes found that South Africa's former reluctance to roll-out antiretroviral-drug programmes—a consequence of former President Thabo Mbeki falling under the sway of the denialist movement—cost more than 330 000 lives. Today, South African policy is very different; “the era of denialism in South Africa is completely over”, stated Barbara Hogan upon her appointment as Health Minister after Mbeki's removal. But it is not inconceivable that the denialist movement might gain ground elsewhere, with similarly catastrophic results.

House of Numbers purports to be an investigative piece by Brent Leung, a filmmaker with “unanswered questions” about the AIDS pandemic. But the disreputable credo of denialism is easy to recognise. The belief system can be summarised as follows: AIDS is not caused by HIV. It is instead a disease related to poverty, malnutrition, and homosexual lifestyles. Antiretroviral drugs are poisonous—“AIDS by prescription” claims Peter Duesberg, spearhead of the denialist movement, and a prominent figure in this film—the pharmaceutical industry is in on the conspiracy, as are the major health organisations. “Could it be that the real epidemic is extreme poverty not HIV?”, Leung disingenuously asks.

If you have a subscription to The Lancet, read the full article here.

The Lancet Infectious Diseases, Volume 9, Issue 12, Page 735, December 2009

doi:10.1016/S1473-3099(09)70316-0