In 2009, UNAIDS stated that, "Since the beginning of the epidemic, almost 60 million people have been infected with HIV and 25 million people have died of HIV-related causes." Although still a major problem in the developed world, it is no longer the death sentence that it was in the 1980's and early 1990's. In the third world, AIDS is devastating. The 2009 report further states, "Sub-Saharan Africa is the region most affected and is home to 67% of all people living with HIV worldwide and 91% of all new infections among children." Also, "In sub-Saharan Africa the epidemic has orphaned more than 14 million children."
Acquired Immunodeficiency Syndrome (AIDS) was officially recognized by the Center for Disease Control in 1981. It is a syndrome characterized by a dramatic decline in immune function with a drop in the class of white blood cells called CD4+ T-helper cells, thus leaving victims prone to deadly infectious diseases and cancers. The cause was not known at first, it quickly became apparent in the late 1980's that a recently described virus was a necessary agent in the process. The virus has been aptly named the Human Immunodeficiency Virus (HIV).
It is a retrovirus who's RNA is used to create DNA by the enzyme 'reverse transcriptase', which is then incorporated into the host T-cell DNA. The T-cell then produces copies of the virus, which overtake and kill the T-cell. The copy viruses then invade other T-cells and the process continues. HIV is transmitted through the mixing of blood cells mainly through sexual activity (especially anal intercourse), blood transfusions and the sharing of hypodermic needles.
The discover of HIV as a causative agent in AIDS was first proposed by physician and cancer researcher, Robert Gallo M.D. He was a leading researcher in retroviruses as causative agents in leukemia. The virus was brought to his attention a year earlier by French researcher, Luc Montagnier. Gallo's 1984 Science article described the "Human T-Cell Leukemia Virus III" and proposed that it was the agent responsible for the destruction of T-cells in AIDS. Dr. Gallo has been at the forefront of HIV/AIDS research.
By now, this theory has been so well studied and supported by countless lines of research (in both basic and clinical sciences) that it has become foundational. Each line of evidence (epidemiology, microbiology / virology, immunology, genetics / molecular biology, chemistry, biochemistry, etc) independently lead to the conclusion that HIV is the necessary causative factor in AIDS and that treatments directed at inhibiting the life-cycle of HIV (anti-retroviral agents or 'ARVs') also treat and prevent AIDS.
Since HIV is not eliminated entirely in infected patients, the ARV treatments must continue indefinitely. ARVs have side-effects and management can be problematic. However, the side-effects are usually tolerable and are relatively nothing compared to the inevitable, devastating and deadly effects of uncontrolled HIV infection and AIDS. Older medications like AZT have considerably more side effects than newer agents.
Consensus was reached in the second half of the 1980's that HIV is the causative factor in AIDS. In 1988, the Institute of Medicine issued Confronting AIDS: Update 1988. From the epidemiology data, it stated that, "New information about HIV infection and its epidemiology has emerged either to confirm or alter earlier impressions of the disease. One question that has been resolved is the causative agent of AIDS. HIV and AIDS have been so thoroughly linked in time, place, and population group as to eliminate doubt that the virus produces the disease. The committee believes that the evidence that HIV causes AIDS is scientifically conclusive."
The overwhelming evidence for the theory is presented at length by the National Institute of Allergy and Infectious Disease (NIAID), a division of the NIH.
In the span of 20 years or so, the Acquired Immunodeficiency Syndrome was recognized; a theory for its causative agent (HIV) was made and verified beyond any reasonable doubt; treatments were discovered; systems for monitoring the disease and managing patients were developed; and infected patients with an otherwise fatal diagnosis were given the chance to live relatively normal lives. It would be difficult to imagine better examples of science and practice in action.
Yet, some deny it. And this denial is deadly.
In the early 1980's, the science was very messy. The information needed to form a foundational theory was not available yet. In science, such times should be filled with wide differences of opinion as different scientists explore different ideas.
In the early days of AIDS research, many respectable scientists did not favor the HIV theory. One such scientist was molecular biologist, Peter Duesberg who, in his 1987 Cancer Research paper, doubted the role of retroviruses as pathogens. His 1988 Science article was titled HIV is not the cause of AIDS. Duesberg sparked heated debates. His ideas were deeply criticized by Robert Gallo. He continued to deny the notion that HIV and AIDS are linked. In 1994, Science published the special news report The Deusberg Phenomenon.
Again, dissent among scientists is expected in the early days of research for any new scientific topic. Dissent is even necessary, otherwise claims may proliferate without serious attempts at falsification. But, as the data and conclusions from multiple lines of research begin to solidify and a healthy consensus forms, scientists should ultimately concede to the evidence even if the evidence contradicts their ideas. However, scientists are human, and humans tend to be biased to their beliefs. They tend to ignore or rationalize evidence that is counter to their beliefs. Cognitive dissonance theory predicts that people with actually strengthen their position against the consensus, often passionately. Thus, they become 'dug in' with their position and self-identify with it. They must deny the consensus to preserve their self identity . Eventually, no amount of evidence can sway them. Such has been the case with Peter Duesberg, who continues to deny that HIV is the necessary causative agent in AIDS.
Duesberg's denialism and reputation as a scientist has fueled the larger AIDS denialism movement. Numerous websites and blogs are devoted to this dangerous form of denialism. A frequently quoted 2006 article appeared online in Harper's Magazine by Cecilia Farber entitled Out of Control: AIDS and the corruption of medical science. This rambling litany of anecdotes and fallacies encompassed many of the myths of the AIDS denial movement, most based on Deusberg's pseudoscience, pseudoskepticism and denialism. Some of the points of this article are addressed below. Numerous take-downs of the article can be found here.
AIDS denialism causes tragic harm in that a potentially controllable condition of HIV/AIDS is allowed to devastate its victims, including the infected children of denialist infected parents. An example is the high profile case of Eliza Jane Scovill who died in 2005. She was 3 years old. The autopsy confirmed that the cause of death was Pneumocystis pneumonia, an AIDS defining illness. Her mother, Christine Maggiore tested positive for HIV prior to Eliza's birth. She was influenced by Duesberg and chose to deny that HIV causes AIDS. She declined treatment for herself and rejected treatment during pregnancy to prevent transmission. Maggiore's denialism is linked directly to Eliza's death. Maggiore took Eliza to doctors who were also AIDS denialists (and vaccine denialists for that matter). Maggiore died in 2008. No autopsy was done, but her death certificate states that she died of "Disseminated herpes viral infection" and "bilateral bronchial pneumonia".
AIDS denialism has been linked to hundreds of thousands of deaths. South Africa is one of the nations that has been hit the hardest by AIDS. A 2008 Journal of Acquired Immunodeficiency Syndrome study revealed that, between the years 2000 and 2005, over 330,000 South African deaths were directly linked to the AIDS denialism of South Africa's government and President Thabo Mbeki. Mbeki
apparently felt that AIDS was a conspiracy promoted by Western pharmaceutical companies to poison South Africa with ARVs. He resigned from office in 2008 (for different reasons).
A list of personal anecdotes of individuals harmed by AIDS denialism can be fount at Tim Farley's What's the Harm website.
The AIDS denialism movement is multifaceted and likely motivated by various reasons. Different denialists argue from different stasis points.
Some denialists argue from the stances that HIV does not exist or does not cause AIDS.
It has been attested that the diseases attributed to AIDS in Africa are really due to poverty and poor living conditions. This myth has been debunked. While it is true that people living in extreme poverty with poor living conditions and lack of food have high mortality rates, HIV infected people in these conditions develop extreme immunodeficiency and die in much greater numbers than those who are not infected.
A 2000 cohort study of nearly 20,000 Ugandans demonstrates the increased rate of death compared to uninfected controls.
A 1995 Lancet study of Tuberculosis in Côte d'Ivoire found that tuberculosis patients with HIV and immunodeficiency did far worse than uninfected controls.
A 1999 Pediatric Infectious Disease Journal study of children in Malawi showed conclusively that mortality rates were much higher in HIV infected children than uninfected controls.
The 2001 MRC South Africa technical report on The Impact of HIV/AIDS on Adult Mortality in South Africa contains a mountain of statistics that makes the burden of proof of the Myth that AIDS does not exist so large as to be untenable.
In the developed world, denialists have claimed that intravenous drug abuse (IVDA) alone causes AIDS and that HIV may be a harmless passenger. This view was supported by Peter Duesberg in the early 1990's. Again, dissention among scientists when the data is not clear is considered a healthy thing in the scientific process. Duesberg pointed out the correlation between the rise in IVDA and AIDS. Also, in the early days, testing for HIV was not as efficient as it is now. He pointed out that not all AIDS patients test positive for HIV. These and other points raised by Duesberg were appropriately considered by fellow researchers and flaws were found in his reasoning. A 1992 Lancet article presented a point-by-point take-down of his arguments. Instead of recognizing that his arguments had flaws, Duesberg continued to focus only on confirming evidence for his theories and rationalized or ignored disconfirming evidence. This 'digging in' process is fueled by cognitive dissonance and is characteristic of denialism.
Another point of conjecture among denialists is the notion that ARVs (antiretroviral drugs) cause AIDS, not HIV. This argument seems to stem from a conspiracy theory mindset. Distrust of governmental agencies and the profit-motivated pharmaceutical industry fuels conspiracy theories of sinister plots to create symptoms and invent a disease that is caused by the very treatments that they are selling.
According to the Farber's article in Harper's Magazine, Deusberg is a proponent of this idea. "Duesberg thinks that up to 75 percent of AIDS cases in the West can be attributed to drug toxicity. If toxic AIDS therapies were discontinued, he says, thousands of lives could be saved virtually overnight."
The notion of ARVs causing AIDS is preposterous. Research supporting ARVs is mountainous. A pubmed search on "antiretroviral therapy" yields 32,073 results with 5827 review articles as of 2/5/12. But even before considering the decades of published research that refutes this, one should consider the basic fact that the overwhelming majority of people who have died of AIDS never took ARVs.
In syllogistic terms:
If ARVs cause AIDS (antecedent), then only patients on ARVs should have AIDS (consequent).
Many patients not on ARVs have AIDS (Denying the consequent is proper logic).
Therefore, ARVs do not cause AIDS.
Denialists may concede that HIV/AIDS exists, but our tests are unreliable and we cannot diagnose HIV. We can therefore not reliably define who has HIV and AIDS.
Supporters of this notion either do not understand the statistics of current methodology or deny them. The commonly used blood test for HIV antibodies is quoted as 98% sensitive and specific. If you recall from the Statistics and Risk section, this means that 2 out of 100 uninfected people will test falsely positive and 2 out of 100 infected people will test falsely negative. The positive and negative predictive values of the screening tests will depend entirely on the pretest probability of the population being screened.
In a population with a disease prevalence of 10%, the positive predictive value of the screening test is 85%. If the prevalence is 20%, then the PPV is 92%. This is a very good test. Furthermore, the antibody test is complimented by other, very good confirmatory tests like the 'viral load'.
When combined with other findings (eg. CD4 count and rare, AIDS defining infections), a complex argument is made and supported independently or convergently by the separate lines of evidence. The burden of proof then shifts to the denialists to rationalize each of the lines of supporting evidence.
Some AIDS denialists may concede that HIV exists and causes AIDS. They may also concede that we can test for it. However, they claim that the treatments cause unacceptable side-effects and should not be used. Upon researching this claim, one finds that it really stems from Deusberg's argument in 1992 that AZT, when used as monotherapy, hurts more than it helps.
In the 1980's, AZT was the first ARV for the treatment of AIDS and therefore was used as 'monotherapy' and in higher relative doses than would be used today. As such, it did have numerous side-effects. However, studies have shown that it prolonged the lives of AIDS sufferers. Today, AZT would not be used as monotherapy. Even for the 1980's and early 1990's, this argument was factually not true. For modern times, it is a pure strawman argument.
In the early 1990's, much of the research and denialist ammunition came from studies of the first ARV, zidovudine (AZT). The 1994 Concorde study is sometimes quoted, which compared different strategies for introducing and using AZT. The end results were not encouraging. The abstract states, "there was no significant difference in progression of HIV disease". The Concorde study has been said to support the notion that AZT actually causes AIDS. However, the study showed no such thing. More on this can be found on
AIDSTruth.org (as discussed below).
Currently, AIDS therapy typically utilizes 3 ARBs in combination (Highly Active AntiRetroviral Therapy, or 'HAART'). Such 'cocktails' are generally well tolerated and allow patients to lead relatively normal lives. Resistance can develop over years and patients must be monitored closely for this. The agents are changed if signs of resistance develops to stay ahead of the evolution of HIV. The utility of HAART is supported through multiple studies and reviews of studies. Below are a few examples.
The 1997 French study in the journal AIDS showed the unquestionable utility of the addition of a newer class of medications called protease inhibitors. Combining older ARVs with protease inhibitors really worked. This was at the beginning of HAART. "Comparison of the three centres that used HAART earliest to the three centres that used it latest showed a clear benefit to early HAART with a drop in hospitalization days by 41%, new AIDS cases by 41% and deaths by 69%."
The 2000 Journal of Urban Health review article reveals the decline in death rate even if introduced in late-stage AIDS.
The 2003 Lancet study of over 9,800 patients throughout Europe and South America showed that not only did HAART lead to significant drops in morbidity and mortality, but that it is well tolerated. "The initial drop in mortality and morbidity after the introduction of HAART has been sustained. Potential long-term adverse effects associated with HAART have not altered its effectiveness in treating AIDS."
The safety of HAART was confirmed in the 2012 AIDS study of over 12,000 patients. "we found no of an of both all-cause and non-AIDS-related deaths with cumulative cART ."
Concerns about non-HIV related complications among HAART users was addressed in the 2008 Clinical Infectious Disease article. The study followed over 2800 patients over 9 years. It concluded, "Among patients with a CD4 cell count <350 cells/mm3, receipt of HAART was associated with a significantly decreased incidence of comorbidities not related to HIV infection or AIDS."
In 2009, Pope Benedict went to Cameroon, Africa. He stated his position against the use of condoms in a nation plagued by HIV. To justify this statement, he went on to say, ""It (AIDS) cannot be overcome by the distribution of condoms. On the contrary, they increase the problem." The Catholic Church has long held a doctrine against contraception, which is a philosophic position and they are free to hold such a position. However, Pope Benedict is rationalizing this doctrine by trying to convince people that condoms not only do not prevent the spread of HIV, they make the problem worse! This is an empiric claim and therefore should be subjected to healthy skepticism. Let's consider the issue of condom use and HIV.
Many studies have been done that support the use of condoms to prevent HIV. A 2001 Cochrane review of the literature states, "Overall effectiveness, the proportionate reduction in HIV seroconversion with condom use, is approximately 80%." This is pretty clear evidence that proper condom use reduces the spread of HIV.
The Pope may have been implying that condom use would increase sexual promiscuity, and therefore increase the spread of HIV even with the above in mind. Well, this was studied 15 years prior to the pope's African trip. A 1994 American Journal of Public Health study compared groups of teenagers in 2 cities; one group was given condoms and counselling. The other was used as a control. The results showed, "The program promoting and distributing condoms had no effect on the onset of sexual activity for females, the chances of multiple partners for males, or the frequency of sex for either males or females." And the conclusion was, "An HIV prevention program that included the promotion and distribution of condoms did not increase sexual activity among the adolescents in this study."
The Pope's claims regarding condom use and HIV are not based in science. They stem from his preexisting beliefs against contraception. Again, this belief is part of a belief system and is not a scientific matter. When the Pope denies the science of HIV/ AIDS to rationalize the underlying belief, he becomes a denialist and subject to skepticism.
Peddlers of pseudoscience become AIDS denialists from the stasis point of quality when they actively promote implausible and unproven treatments over established ones.
Mathias Rath is a German vitamin salesman. He actively promoted the use of high-dose vitamins (his products) to officials in South Africa as the preferred treatment for AIDS patients. We discussed the problem of AIDS denialism in South Africa in the paragraphs above. Rath's pseudoscience directly informed by Rath's pseudoscience. Rath also dubiously promotes his products as cancer cures
Others promote dubious "cures" for AIDS. Promoters of these products are either deluded or criminal. They are fraudulently selling products under the guise of a cure to patients with an incurable (but treatable) disease. As of this writing (Feb, 2012), there is no cure for AIDS. These pseudoscience promoters deny life-prolonging scientific medicine to make a profit off of desperately ill, naive patients.
The arguments from conjecture, definition and quality collapse under the weight of overwhelming evidence.
One can speculate that there are many motives for AIDS denialism.
The simplest is plain old cognitive dissonance. In the early days of this new science, things were not clear. Scientists, like Duesberg, who took an early stance that AIDS may be due to other factors became invested in their position. As the research progressed, it began to contradict that position. In light of disconfirming evidence, these scientists did not reject their position as the philosophy of science suggests they should. Instead, they committed themselves even further with denialism.
Others may hold preexisting biases against those at risk for HIV. Perhaps there is a subconscious anti-gay or anti-sex sentiment that informs their beliefs. If so, holders of these beliefs may feel the need to rationalize their sentiments with denialism. Others, like the Pope, rationalize their anti-contraception bias with condom denialism.
Denialism may be driven by a conspiracy theory mindset. People who are biased against institutions like pharmaceutical companies and governmental agencies will likely be suspicious of any science that would result in financial or political benefit to these institutions.
And finally, promoters of pseudoscientific treatments against HIV (or other chronic conditions) stand in direct opposition to scientific medicine. If they wish to sell bogus science, they must become denialists to rationalize the use of their nostrums over science based medicine.
A group of prominent AIDS researchers from around the world compiled this online resource for combating AIDS denialism. The site is called AIDSTruth.org. There you will find the common denialist myths, the counter arguments, and a list of prominent AIDS denialists (including a list of AIDS denialists who have died of AIDS complications).
Check it out.
Whether it be against vaccines, AIDS or other serious medical issues, denialism costs lives. Denialism is wasteful. For a problem as immense as HIV/ AIDS, denialism is directly responsible for the suffering and death of thousands each year. Skeptical doctors should be familiar with denialism rhetoric so that they may guide their patients on the best path.
John Byrne, M.D.
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