F A Guide toOAIDSCResearch andU CounselingS Volume 15 Number 6 May 2000

is full of conspiracies and that “main- HIV, AIDS, and the stream” views are always wrong. For still others, it supports political and religious Distortion of Science beliefs that allow them to condemn peo- Martin Delaney ple’s behaviors, most notably, injection drug use and sex between men. For the politically inclined, it provides a rational- In the past year, there has been a noisy sounding excuse to reject spending public resurgence of claims that HIV does not money on the problem. This mix of person- cause AIDS and that AIDS is not contagious. al and political needs constitutes fertile Proponents of this view insist that AIDS is ground for keeping the denialist view alive, caused by personal behavior, notably drug no matter what the science actually says. abuse, or by the drugs used to treat AIDS. But AIDS is not simply a matter of politics This view was first stated back in 1987 by or belief. It is a real disease that has , a professor of molecular already killed vast numbers of people and biology at the University of , threatens millions more in the near future. Berkeley, who today is viewed as the leader Nothing would be better than to discov- of the “HIV denialist” movement.* Dues- er that HIV is harmless and that the night- berg’s claims have been debated and refut- mare of AIDS has disappeared. But wishing ed repeatedly in scientific journals and will not make it so. The denialist view— even by a special panel assembled by the based as it is on the distortion of science— National Academy of Sciences. is fundamentally dangerous, since it sets Over the years, there have been dozens the stage for another wave of transmission of new discoveries that further strengthen and death. the evidence that HIV causes AIDS, includ- It would take a book to refute all of the ing most recently, the success of combina- denialists’ arguments word by word, but it tion HIV antiviral treatment. Today, nearly is not difficult to reduce them to a short list every physician treating HIV-infected peo- of statements they repeat over and over. ple has seen how suppressing levels of HIV The denialists’ articles and books sound causes the clinical symptoms of disease to convincing only if the reader is not familiar disappear. Though there are debates about with the science of AIDS, the natural history the optimum time to start treatment, and of the disease, or the history of the epidem- while its effects may not be permanent ic. Complete, documented responses to and may come at the cost of side effects, denialist arguments are available through the reduction in the death toll has been the National Institutes of Health.1 Simpler dramatic, leaving little room to doubt that answers to the core claims follow below. HIV is the driving factor in AIDS. *Editor’s note: While Today, a new generation of people, some Claim #1: Widespread Scientific Support this issue of FOCUS who themselves have HIV, some who are The denialists say that there is an “expo- does not include an afraid of getting it, and some with unspo- article by an “HIV nentially growing” group of international denialist,” the Clear- ken political agendas, are hearing the AIDS experts who do not believe that HIV inghouse on pages 4 denialist story for the first time and finding causes AIDS. This simply is not true. There and 5 does include a it attractive. For many, it provides relief are only a few active scientists associated list of articles and from the anxiety induced by a diagnosis of with this view, none better known than organizations repre- senting both sides of HIV infection or the fear of contracting it. Peter Duesberg. Very few are physicians, the issue. For others, it reinforces the belief that life and fewer still treat people with AIDS. is essentially a scientific one, but Editorial: Sense and Credibility the answer is founded on trust. Robert Marks, Editor I know society can marginalize truth tellers when their assertions are unpopular or alien, but I can- As the first epidemic since Ironically, the most reasonable not believe that the truths of most microbiology triumphed over criticism made by the denialists diseases like polio and smallpox, is also the one that most resound- AIDS researchers and activists— AIDS has held our imaginations ingly contradicts their claims. The and the work of organizations like captive since it sprung upon us in drug development process in a Project Inform—has been poi- 1981, a powerful indication that “free market” is fraught with soned by drug company cash. our complacency about infectious conflicts of interest. Drug compa- I believe that people like Martin disease was unwarranted. In nies operate with the same specu- Delaney, John James, Paul Vol- response, AIDS has inspired cre- lative calculus that any business berding, and Jay Levy care more ativity among everyone from uses: R&D is an investment, profit about saving lives than lining people with HIV trying to rebuild is the goal. I am certain that most their pockets with lies. I just do their lives to researchers trying to scientists, even executives, at not buy the central contention comprehend an elusive organism. drug companies seek to cure and of the denialists that we are all From this fertile stew of wonder treat disease or symptoms, but pawns of the drug companies. and wariness has arisen the debate the enterprise as a whole is natu- But perhaps the most convinc- about whether HIV indeed causes rally fueled by the simple impera- ing indicator that HIV is the cause AIDS. The vast majority of scien- tive to make money. of AIDS has nothing to do with tists believe this to be true, and we Drug companies depend on the what I write here or the more at the AIDS Health Project agree. academic system—researchers at compelling remarks of Martin But it is not surprising that universities—to corroborate their Delaney and hundreds of other there are those who doubt. Per- claims of safety and efficacy and commentators; it is personal sonally, I welcome skeptics; ques- on the government to certify experience—an experience that tioning even the obvious forces these findings. As part of this people who did not live in time me to think in different ways process, drug companies do fund before HIV treatment may not about “reality,” and at a time when research. It is crucial that there share. People I know got sick and “spin” is high art, it may be wisest be watchdogs—organizations like died even when they took no HIV to doubt first and reconsider later. Project Inform and ACT-UP, and treatments or recreational drugs. Yet, not every uncomfortable newsletters like AIDS Treatment People I know stopped dying assertion is automatically true; News, as well as the FDA—to when they took combination and not every accepted belief is police this process. treatments. Their lives have not the result of a conspiracy. In this For most people, understanding become easy or painless, and no issue of FOCUS, Martin Delaney AIDS is about accepting the inter- one I know believes that AIDS has identifies not only the holes in the pretations of “experts.” Whether been conquered. But because they arguments of “AIDS denialism,” HIV is the cause of AIDS depends are treating the virus, my friends but also the defects in the process on which information source we are living, and their lives are im- of denialists. find most credible. The question measurably better than they were.

References None, including Duesberg, have conducted and AIDS have met the test of peer review 1. National Institutes any original AIDS research, either in the lab that guides the scientific process. of Health. The Rela- or in patients. Many, perhaps most, work in tionship between AIDS unrelated scientific fields such as physics, Claim #2: An Old Disease with a New Name and the Human Immu- history, or literature. Some who are still The denialists say that AIDS is not a new nodeficiency Virus. Washington, D.C.: claimed by the denialists as supporters disease, simply a collection of old ones National Institute of long ago changed their views, and others grouped under a new name. It is true that Allergy and Infectious have, themselves, died of HIV disease. people with HIV disease do not succumb Diseases, National In- There is no evidence whatever of a directly to HIV infection, but to a well- stitutes of Health, 1995. groundswell of scientific opinion moving known list of opportunistic pathogens such 2. Popovic M, toward the denialist viewpoint. as Pneumocystis carinii, cytomegalovirus Sarngadharan MG, In contrast, there is a body of thousands (CMV), and Mycobacterium avium complex Read E, et al. Detection, isolation, of scientists worldwide who strongly sup- (MAC). “Acquired Immune Deficiency and continuous pro- port the belief that HIV causes AIDS. They Syndrome” refers to an illness that causes duction of cytopathic have the appropriate credentials in virology, the collapse of the immune system, which retroviruses (HTLV-III) immunology, infectious disease, epidemiol- in turn renders the body vulnerable to a from patients with ogy, and often have a great deal of direct series of potentially deadly infections AIDS and pre-AIDS. Science. 1984; experience treating people with HIV disease. that the body would otherwise have little 224(4648): 497-500. Their views and experiments regarding HIV trouble handing. HIV, the human immuno- 2 FOCUS May 2000 deficiency virus, is the cause of the col- papers to the journal Science, papers that lapse of the immune system. were fully peer reviewed (and later subject AIDS is new and different because it to one the most intensive review processes affects specific populations of people who ever given to scientific articles).2-5 The four have no other reason for being severely papers described how the virus was routine- immune compromised. AIDS first came ly found in people with various symptoms to the attention of physicians when large associated with AIDS and was absent in numbers of healthy, young, gay men began those who lacked either symptoms or AIDS- coming down with Pneumocystis carinii associated risk factors. The papers conclud- (PCP), an extremely rare pneu- ed to the satisfaction of most scientists that monia previously seen only in people with HIV was the cause of AIDS and went on to severely suppressed immune systems. As describe new methods for growing the virus more men came down with in large quantities and for creating a blood PCP and then other rare dis- test to detect the presence of antibodies to eases, it also became clear that the virus. While no the disease was clustered in A reporter learned of the impending particular cities, in specific publication of the Science articles and “single” paper neighborhoods, and even called the government press office, threat- within groups of people who ening to “break” the story. In response, the is viewed as knew each other. Most of these Department of Health and Human Services complete proof infections were not themselves (DHHS) called a press conference in order contagious, but they were to make sure the story was told accurate- that HIV is the suddenly appearing in ways ly. Gallo was in France working with the that looked like the outbreak French team on a statement they had cause of AIDS, of a contagious disease. planned to make together; DHHS ordered Doctors realized that there him back to the United States overnight there is the far must be a new, underlying to appear at the press conference. Science disease destroying the im- published the papers shortly afterwards. more compelling mune systems of these people. Over the subsequent months, various foundation of Today, AIDS is far more French, British, and U.S. research teams widespread. But even in Africa, published several more peer-reviewed proof built by where people have long suf- papers, all of which further strengthened fered from malnutrition, poor the link between HIV and AIDS. Today, the more than 500 sanitation, and parasitic ill- National Institutes of Health summary docu- nesses, doctors had not seen ment on the relationship of HIV to AIDS of them. such widespread severely cites approximately 500 scientific papers. compromised immunity until While no “single” paper is viewed as com- HIV emerged. Moreover, AIDS plete proof that HIV is the cause of AIDS, is also common in urban there is the far more compelling foundation areas, where malnutrition does not play of proof built by more than 500 of them. as large a role as it does in rural Africa. Claim #4: The Test Does Not Work Claim #3: No Proof that HIV Causes AIDS The denialists say that neither the The denialists say that there is no proof HIV antibody test, used to detect HIV infec- that HIV causes AIDS and no single scien- tion, nor viral load and CD4+ cell counts, 3. Gallo RC, tific paper that offers such proof. This which measure disease progression, mean Salahuddin SZ, myth has been repeated endlessly like a anything. These claims are sometimes Popovic M, et al. mantra since 1987. The denialists claim accompanied by stories of the personal ex- Frequent detection and isolation of that one scientist, Robert Gallo at the perience of the author of one of the AIDS cytopathic retrovirus- National Cancer Institute, simply called a denialist books, What if Everything You es (HTLV-III) from press conference one day and proclaimed Thought You Knew about AIDS Was Wrong?6 patients with AIDS that he had found the cause of AIDS, with- Christine Maggiore says she underwent a and at risk for AIDS. Science. 1984; out having data or undergoing traditional series of different HIV antibody tests and 224(4648): 500-503. scientific peer review. This is pure fiction. did not get consistent answers. Therefore, In early 1983, French researchers isolated she concludes, the tests mean nothing. 4. Schüpbach J, It is true that people sometimes get what Popovic M, Gilden RV, a previously unknown retrovirus from the et al. Serological anal- lymph nodes of a person with early symp- is called an “indeterminant” test result, ysis of a subgroup of toms of AIDS, although they did not yet often due to temporary changes in body human T-lymphotropic have enough data to prove the virus was the chemistry affecting the antibody test. retroviruses (HTLV-III) cause of AIDS. In the spring of 1984, Gallo Because no laboratory test is ever perfect, associated with AIDS. Science. 1984; and his team of U.S. researchers submitted most test centers never attempt to draw 224(4648): 503-505. a comprehensive series of four scientific conclusions from a single test result. 3 FOCUS May 2000 Usually they begin with the enzyme-linked Blot. Their basic contention is that the HIV immunosorbent assay (ELISA), which is test can cross-react. That is, a substance in simple, quick, and cheap. The test’s main the body, for example, mycobacteria or problem is that it can give false yeast, which is superficially similar to the positive results, although chemistry of HIV antibody, is detected by improved technology has greatly the test, making the test’s results meaning- A more minimized this possibility to less less. These views—primarily theoretical than 1 percent. When a person rather than research-based—are in conflict common claim gets a seropositive ELISA result, with those of regulatory agencies and scien- proper procedure calls for retest- tists worldwide, who say such concerns are is the circular ing with a more complex test not borne out in the field. Although some called the Western Blot, which has body substances can cross-react with the argument that a much lower rate of false posi- HIV test, with few exceptions, these reac- since many tives. Rarely, even the Western tions lead only to “indeterminant” results Blot can produce an indeterminant and not to false positives or false negatives. people who result, and then, the whole proce- More importantly, several large cohort dure must be repeated. Maggiore’s studies have shown a profound and con- have died of book seems to indicate that sistent relationship between a positive repeated testing in her case con- HIV antibody test result and the eventual AIDS took HIV firmed that she was not HIV-posi- development of AIDS. People who lack a tive in the first place. The mistake positive result almost never experience antiviral drugs, that Maggiore and other denialists opportunistic diseases, AIDS-like disease, the treatments make is that they attempt to draw or a similar decline in CD4+ cells.7,8 scientific conclusions based on In common usage, HIV testing is still themselves their personal experiences or that more accurate than most of the medical of other single individuals. diagnostic tests used for other health prob- killed them. Not all versions of the ELISA lems. The Food and Drug Administration test are equally accurate, and this (FDA) and the Centers for Disease Control becomes particularly clear in and Prevention (CDC) routinely monitor other parts of the world. One of diagnostic laboratories and tests for quali- the reasons the U.S. government patented ty. While it is true that HIV testing is not the original HIV antibody test in the mid- of uniform quality worldwide, and some 5. Sarngadharan MG, Popovic M, Bruch L, et 1980s was to enforce strong quality con- countries do not routinely use confirma- al. Antibodies reactive trols and to ensure the most consistent tory testing, there is no basis for condemn- with human T-lym- results. Rather than applauding this effort, ing the value of all HIV tests. photropic retroviruses writers like Maggiore betray their bias by Other denialists like have (HTLV-III) in the serum of patients with AIDS. suggesting the patent was sought out of raised similar questions about viral load Science. 1984; greed by the researchers. The researchers tests, but these concerns are likewise mis- 224(4648): 506-508. themselves had nothing to do with seeking leading. Mullis, because he won a Nobel the patent, and at the time it was filed, 6. Maggiore C. What if Prize for his early work in the development Everything You government researchers could not profit of polymerase chain reaction (PCR) testing, Thought You Knew from patents issued in their names. is probably the second most recognized about AIDS Was A group of three researchers from Perth, denialist scientist after Duesberg. PCR is Wrong? 4th ed. Studio Australia are often cited by denialists as one of the mechanisms used to quantify City, Calif.: American Foundation for AIDS a source of information about flaws in the viral load. While Mullis asserts that PCR was Alternatives, 2000. HIV tests, both the ELISA and the Western never meant to be used in the way it is to

immune deficiency disease. Medical Clearinghouse: HIV Denialism Hypotheses. 1999; 52(1): 59-67. Johnson SC, Gerber JG. Advances in Diseases. May 2000; http://www.niaid.nih. References HIV/AIDS therapy. Advances in Internal gov/spotlight/hiv00/default.htm. Community Voices: News and Views on Medicine. 2000; 45: 1-40. AIDS Causality from AIDS Activists and Friedmann PD. Inventing the AIDS Educators. AEGIS. May 2000; http://www. virus. Perspectives in Biology and Kurth R. Does HIV cause AIDS? An aegis.org/topics/aids_debate.html. Medicine. 1997; 40(3): 467-469. updated response to Duesberg’s theo- ries. Intervirology. 1990; 31(6): 301-314. Duesberg P, Rasnick D. The AIDS dilem- Galaea P, Chermann JC. HIV as the ma: Drug diseases blamed on a passen- cause of AIDS and associated diseases. Lederer B. The case of the missing co- ger virus. Genetica. 1998; 104(2): 85-132. Genetica. 1998; 104(2): 133-142. factors. POZ. April 2000. Focus on the HIV-AIDS Connection. Habeshaw JA, Wilson SE, Hounsell EF, Mirken B. Answering the AIDS denial- National Institute of Allergy and Infectious et al. How HIV-1 lentivirus causes ists: CD4 (T-cell) counts, and viral load.

4 FOCUS May 2000 determine viral load, his theoretical con- predictor of AIDS, except in the sense that cerns cannot contradict the empirical evi- it increased the risk of HIV transmission. dence from one of the largest and longest The only factor that differentiated those running AIDS studies: the Multicenter AIDS who developed AIDS from those who did Cohort Study (MACS).9,10 Through the not was the presence of HIV antibodies. 7. Vermund SH, Hoover DR, Chen K. CD4+ MACS, John Mellors and his colleagues have A more common claim in recent years is counts in seronegative followed several thousand HIV-positive the circular argument that since many peo- homosexual men: The people over periods ranging from three to ple who have died of AIDS took HIV antiviral Multicenter AIDS more than 10 years and found a profound drugs, the treatments themselves caused Cohort Study. New and predictable relationship between viral the illness. It is true that HIV antiviral drugs, England Journal of Medicine. 1993; load levels, CD4+ cell counts, and the risk like medications used for other serious 328(6): 442. of HIV disease progression or death. illnesses, can have toxic side effects and, in some circumstances, cause death. But the 8. Sheppard HW, Claim #5: Antibodies Conquer Infection Ascher MS, Winkelstein data from clinical trials are abundantly W Jr., et al. Use of T The denialists say that no infectious clear: side effects do not appear in every- lymphocyte subset disease causes illness years after infection one; they are not always serious in nature; analysis in the case or after the development of antibodies, and most significant, when used properly, definition for AIDS. Journal of Acquired and that the very existence of antibodies the drugs do far more good than harm. Immune Deficiency means the infection is over. This often Denialists seem to be unaware that peo- Syndromes. 1993; repeated assertion is the most easily ple were dying horrible deaths from AIDS 6(3): 287-294. refuted of all the denialist claims. before any HIV antiviral drugs were avail- 9. Mellors JW, Kingsley There are many conditions that can lead able. In a recent publication, Christine LA, Rinaldo CR, et al. to severe illness years after initial infection Maggiore conceded she had no idea why Quantitation of HIV-1 by the causative agent, including hepatitis, people died “of AIDS” before antiviral drugs RNA in plasma pre- herpes, and CMV. Most of these infections, were available. Denialists like to claim that dicts outcome after seroconversion. very much like HIV disease, stimulate the HIV drugs have only been tested against Annals of Internal body to make antibodies for years without laboratory markers, such as viral load, and Medicine. 1995; signs of obvious clinical illness. This not in terms of their effects on survival. 122(8): 573-579. denialist declaration, perhaps more than Like many of their claims, this is simply 10. Mellors JW, Muñoz any other, demonstrates the profound false. The very first studies of zidovudine A, Giorgi JV. Plasma medical confusion of its proponents. (ZDV; AZT) demonstrated a statistically viral load and CD4+ significant (though not long-lasting) sur- lymphocytes as prog- Claim #6: Drugs = AIDS nostic markers of HIV-1 vival gain. Later studies of two-drug combi- infection. Annals of In- The denialists say that drug abuse and nations showed up to 50 percent increases ternal Medicine. 1997; HIV antiviral medications are the real in time to progression to AIDS and in sur- 126(12): 946-954. causes of AIDS. Canadian, European, and vival when compared to people receiving 11. Schechter MT, U.S. studies have repeatedly disproved single-drug therapy. In more recent years, Craib KJ, Gelman KA, this assertion.11-13 Because drug use was three-drug combination therapies have et al. HIV-1 and the common in the gay community, it was one produced another 50 percent to 80 percent aetiology of AIDS. of the very first factors suspected of caus- improvements in progression to AIDS and The Lancet. 1993; 341(8846): 658-659. ing AIDS. Over the years, researchers in survival when compared to two-drug conducted studies comparing gay men regimens.14,15 As of today, tens of thou- 12. Asher MS, Sheppard who used drugs over long periods of time sands of people have participated in clinical HW, Winkelstein W Jr, et al. Does drug use cause to groups of gay men who did not use studies of HIV antiviral drugs, and no one AIDS? Nature. 1993; drugs but had otherwise similar behav- with any memory of the earliest days of the 362(6416): 103-104. iors. They found that drug use was not a epidemic can believe that the shortcomings

AIDS Treatment News. 21 April 2000. Contacts Project Inform, 205 13th Street, Suite 2001, San Francisco, CA 94103, 415- U.S. Public Health Service and Infectious Project Inform, Survive AIDS (formerly 558-8669, 415-558-0684 (fax), http:// ACT-UP/Golden Gate), and Treatment Diseases Society of America. 1999 www.projectinform.org (web site) USPHS/IDSA guidelines for the prevention Action Group assert that HIV is the cause of opportunistic infections in persons of AIDS. ACT-UP/San Francisco and HEAL Survive AIDS, PMB 542, 584 Castro infected with human immunodeficiency deny this premise. Street, San Francisco CA 94114, 415-252-9200, 415-252-9277 (fax), virus. Morbidity and Mortality Weekly ACT-UP/San Francisco, 1884 Market [email protected] (email). Report. 1999; 48(RR-10): 1-59, 61-66. Street, San Francisco, CA 94102, Whitaker RE. Re-assessing the virological 415-864-6686, 415-864-6687 (fax), Treatment Action Group (TAG), 350 [email protected] (e-mail). approach to HIV pathogenesis: Can it ex- Seventh Avenue, Suite 1603, New York, NY 10001, 212-971-9022, 212-971- plain AIDS as an immunological disease? HEAL , 11684 Ventura 9019 (fax), [email protected] (e-mail). Journal of Theoretical Biology. 1997; Boulevard, Studio City, CA 91604, 187(1): 45-56. 213-896-8260, 818-780-7093 (fax). See also references cited in articles in this issue.

5 FOCUS May 2000 of antiviral therapy outweigh the lives continued to increase yearly until 1996, 13. Keet IP, Krijnen P, Koot M, et al. Predict- extended or saved by these medications. at which time it began to fall dramatically. ors of rapid progres- That was the year that three-drug combina- sion to AIDS in HIV-1 Claim #7: Still Healthy without Medications tions became widely used. The number of seroconverters. AIDS. The denialists say that there are HIV- deaths dropped again in 1997 and in 1998; 1993; 7(1): 51-57. positive people (often pointing to them- figures for 1999 are not yet available.18 14. Hammer SM, selves as examples) who do not take AIDS Squires KE, Hughes drugs and stay healthy for several years, Conclusion MD, et al. A controlled and that this somehow proves that HIV is The denialists almost never directly trial of two nucleoside analogues plus indi- harmless. What’s missing in this reasoning address or challenge the accumulated data navir in persons with is any understanding of the natural, untreat- that scientists use to determine that HIV is human immunodefi- ed history of HIV disease. The denialists the cause of AIDS. Instead, they make rea- ciency virus infection confuse the question of whether HIV is the sonable sounding but tangential arguments, and CD4+ cell counts of 200 per cubic cause of AIDS with the question of whether pointing out and often misunderstanding millimeter or less: HIV has yet caused AIDS in themselves. occasional anomalies, and dwelling on a AIDS Clinical Trials On average, HIV-infected people who have few eccentric publications, while almost Group 320 Study. New access to health care and a reasonable diet, entirely overlooking the real body of data. England Journal of Medicine. 1997; will take about 10 years to progress to AIDS. Every epidemic throughout history has 337(11): 725-733. This means that 10 years after infection, had its “denialist.” Some epidemics have about half will have progressed to AIDS and been blamed on rats, some on foreigners, 15. Cameron DW, Heath-Chiozzi M, another half will have not. A small percent- Jews, or other disfavored local ethnic Danner S, et al. age progress rapidly to AIDS within two to groups. Very often, epidemics have been Randomised placebo- three years, while some reach 15 years or blamed on the people who suffered from controlled trial of longer without progressing, even without them, their illness being seen as some ritonavir in advanced treatment. At 20 years after infection, the kind of moral failure. Sound familiar? HIV-1 disease: The Advanced HIV Disease percentage who are still well without treat- There is nothing wrong with holding Ritonavir Study Group. ment becomes vanishingly small.16,17 There unpopular or unconventional views, and The Lancet. 1998; is nothing unusual about this. Many other it is often wise to challenge conventional 351(9102): 543-549. diseases—such as cancer, heart disease, and wisdom. But it is also wise to know when 16. Pantaleo G, multiple sclerosis—affect people differently to accept the value, as well as the limits, of Graziosi C, Fauci AS. over different periods of time. accumulated knowledge. Unfortunately, in The immunopatho- Many factors—ranging from access to this case, denialist views result in public genesis of human immunodeficiency health care to diet and personal outlook— disregard for AIDS prevention efforts and virus infection. New may contribute to the rapidity of progres- undermine increasingly difficult efforts England Journal of sion. Researchers have also identified at to fund AIDS support and care programs. Medicine. 1993; least two different genes that inhibit or And, especially today, they threaten the 328(5): 327-335. slow HIV disease progression, and one that already mind-boggling challenge of coping 17. Hessol NA, Koblin may even make some people “uninfect- with AIDS in developing nations. BA, van Griensven GJ, able.” While many people, especially the The debate over whether HIV causes AIDS et al. Progression of has been staged over and over again. The human immunodefi- denialists, like to think their good fortune ciency virus type 1 is due to something they are personally answer is not going to change, no matter (HIV-1) infection doing (or not doing), it is likely that the how many new recruits can be attracted by among homosexual genetic package they received from their the balm of denial. There are real problems men in hepatitis B parents deserves much of the credit. to be faced in combating AIDS worldwide; vaccine trial cohorts in Amsterdam, New the cause of AIDS is not one of them. York City and San Claim #8: Fewer Deaths Not Due to Treatment Francisco, 1978-1991. The denialists say that recent reductions American Journal of in the HIV death rates are not caused by Epidemiology. 1994; 139(11): 1077-1187. the new antiviral treatment combinations, Comments and Submissions and they show misleading charts to prove We invite readers to send letters 18. Centers for this assertion. This claim boldly misstates Disease Control and responding to articles published in Prevention. HIV/AIDS or misrepresents actual CDC statistics. FOCUS or dealing with current AIDS Surveillance Report. Denialists state that the number of deaths research and counseling issues. We 1999; 11(1): 1-43. had already begun to drop as early as 1993, also encourage readers to submit arti- and therefore claim that the reduced death Authors cle proposals, including a summary of rate we see today has nothing to do with the the idea and a detailed outline of the Martin Delaney is the new treatments. On closer examination, it article. Send correspondence to: Founding Director of becomes clear that they are confusing either Project Inform, one of the rate of new infections or the number Editor, FOCUS the nation’s leading of people with AIDS with the number dying UCSF AIDS Health Project, Box 0884 HIV treatment educa- tion and advocacy from the disease. CDC records show that the San Francisco, CA 94143-0884 organizations. number of AIDS deaths in the United States 6 FOCUS May 2000 Finally, in 1992, Duesberg stated that the Recent Reports AIDS epidemic predicted to hit Thailand had failed to materialize; by 1991, there Duesberg’s Primary Concerns Rebutted were only 123 people with AIDS. But, by the end of 1993, as the numbers of people with Cohen J. The Duesberg phenomenon. Science. 1994; 266(9): 1642-1649. HIV grew to more than 700,000 people, the number of people with AIDS grew to 8,000. In response to claims by retrovirologist Peter Duesberg and others that HIV is harm- AIDS and Koch’s Postulates less and that illicit drug use and zidovudine Harden VA. Koch’s postulates and the etiology (AZT; ZDV) are the true causes of AIDS, a of AIDS: An historical perspective. History and three-month investigation by Science con- Philosophy of the Life Sciences. 1992; 14(2): 249- cludes that HIV is the cause of AIDS. The 269. (U.S. National Institutes of Health.) investigation cites four main conclusions. Peter Duesberg claims that HIV does not Duesberg and his critics consider people cause AIDS because it fails to meet Koch’s with hemophilia to be the group that pro- postulates, criteria commonly used to vides the best test case for the HIV hypothe- identify the cause of a disease. But other sis, because there are solid data comparing researchers disagree with Duesberg’s con- seropositive people with seronegative peo- clusions and his strict interpretation of the ple, the health status of hemophiliacs has postulates, according to a review of how been tracked for more than a century, and the postulates have evolved since Robert there are likely to be fewer “confounding” Koch formulated them in the 19th century. variables like illicit drug use in this popula- Duesberg adheres to a form of the pos- tion. Duesberg suggests that contamination tulates based on the later work of Koch, of “factor VIII,” a clotting factor commonly who did not regard the postulates as rigid used in treating hemophilia, causes AIDS. criteria. This version requires a pathogen He says that HIV infection is a “harmless to meet the following conditions: it must passenger” that accompanies these other be found in all cases of the disease; it contaminants, and its presence indicates must be capable of being isolated and only that a person has had contaminated grown in a laboratory; it must cause the transfusions. Several studies, however, have same disease if given to another organism; found no association between factor VIII and it must be identified in this organism. levels in hemophiliacs and AIDS. Instead, According to Duesberg, HIV fails the first the greatest predictor of AIDS- two postulates because the virus is not related death was HIV infection. detectable in all cases of AIDS, and HIV Duesberg has cited the fact cannot be isolated in a number of AIDS In the debate that HIV does not satisfy Koch’s cases. Other researchers, however, point over the cause postulates, the criteria used to out that this is the result of deficiencies prove that a specific microbe in current laboratory techniques and that of AIDS, causes a specific disease. But increasingly sensitive tests detect HIV recent research—a case study infection among more people with AIDS. opponents and of three lab workers who were Duesberg also believes that HIV violates accidentally infected with a pure the third postulate because pure HIV does proponents rely strain of HIV—is considered not reproduce AIDS when inoculated into definitive. In that case, one chimpanzees or accidentally into healthy on the same worker developed AIDS, and humans. Duesberg’s opponents contend the CD4+ cell counts of all three that most viruses act differently in each data to support dropped significantly, even species, that accidental needlesticks have diametrically though these lab workers had no caused people to develop AIDS, and that other risks for HIV and only one cases not resulting in AIDS indicate indi- opposed chose to take antiviral drugs. vidual differences in immune responses. Duesberg cites data on illicit- In addition, a historical perspective conclusions. drug-related immune deficien- reveals that scientists, including Koch him- cies and on how ZDV interrupts self, have sometimes modified Koch’s postu- vital biochemical processes as lates according to common sense, proper evidence that these are the training, and sound reasoning. The postu- causes of AIDS. Other researchers contend lates have been altered in response to new that these immune abnormalities do not discoveries and immunological testing fall under the definition of AIDS. In addi- developed to demonstrate the links between tion, although ZDV has long-term toxic elusive viral agents and two diseases: hep- effects, it also prevents the development atitis B and infectious mononucleosis. Thus of AIDS-related diseases in the short term. Howard Ricketts and Simeon Wolbach were 7 FOCUS May 2000 not hampered when rickettsiae would alized according to potency, adverse not grow on lifeless media; Thomas Rivers effects, adherence, drug-drug interactions, found that the polio virus caused polio even and potential for alternative treatment though the virus could not be isolated from options, according to the updated antivi- every case at a given time; and Baruch ral treatment recommendations of the F Blumberg realized that the presence of International AIDS Society–USA Panel. A Guide toOCUAIDS Research and CounselingS antigen could indicate hepatitis B infection Although all HIV-infected clients should Executive Editor; Director, even though the virus could not be isolated. have the option of antiviral therapy, treat- AIDS Health Project ment depends on their health status and James W. Dilley, MD The Cause of AIDS and Dissent in Science ability to adhere to medication. Both HIV Editor Fujimura JH, Chou DY. Dissent in science: Styles viral load and CD4+ cell levels are useful Robert Marks of scientific practice and the controversy over the indicators of rate of disease progression, Assistant Editors cause of AIDS. Social Science and Medicine. 1994; but viral load is generally more accurate. Alex Chase 38(8): 1017-1036. (Stanford University; and John Tighe, MSW Clinical benefits of early treatment are not Harvard University.) definitive, and it is important to acknowl- Founding Editor; Advisor Michael Helquist In the debate over the cause of AIDS, edge quality of life issues, complications opponents and proponents rely on the same of antiviral drug therapy, and long-term Medical Advisor Stephen Follansbee, MD data interpreted in different ways to sup- adverse effects of treatment, including Design port diametrically opposed conclusions, possible limitations of future medication Saul Rosenfield according to a commentary that examines options. It is also useful to refer patients Production “styles of scientific practice,” the historically with primary infection to clinical trials. Carrel Crawford specific processes, methods, and rules for Adherence can be reinforced by giving Saul Rosenfield constructing data and verifying theories. patients clear, written instructions and Marsha Stevens Early in the epidemic, Peter Duesberg by asking nonjudgmental questions about Circulation framed his critique using a “laboratory” how the medications fit into their lives. Carrel Crawford Cassia Stepak style of scientific practice, which tightly Patients can also benefit from knowing Interns meshes ideas, tools, and data, and requires that some adverse effects are mild or Pegoh Pajouhi a high degree of internal consistency. transitory and that other regimens might Matthew Simons Other AIDS researchers use an “epidemio- be substituted for the current one. New logical” style of practice, which has been regimens should be chosen to respond FOCUS is a monthly pub- lication of the AIDS constructed over time to study diseases to the specific reasons for changing and Health Project, affiliated across populations. Unlike the verification based on the remaining medication with the University of exercise used by the laboratory style— options. Further, alternative drug regi- California San Francisco. triangulating data to confirm a single mens should include medications that are Twelve issues of FOCUS are $36 for U.S. residents, point—those applying an epidemiological the most potent, the most tolerable, and $24 for those with limited style create a mosaic framework of data, the least likely to be cross-resistant. incomes, $48 for individu- als in other countries, $90 materials, technologies, and knowledge. for U.S. institutions, and Since information is inseparable from $110 for institutions in its means and situations of production, the other countries. Make checks payable to “UC mosaics constructed by AIDS researchers Next Month Regents.” Address sub- might be incomplete and include incon- scription requests and cor- The disproportionate effect of AIDS respondence to: FOCUS, gruities. Epidemiologists argue that these in African American and Hispanic com- UCSF AIDS Health problems are unavoidable because dis- munities is not news. But recent CDC Project, Box 0884, San eases behave differently in different popu- Francisco, CA 94143- data show for the first time that, among 0884. Back issues are $3 lations. Epidemiologist Warren Winklestein new AIDS cases, people of color form each: for a list, write to the states, "[Duesberg] does not seem to above address or call the majority in the men-who-have-sex- (415) 476-6430. understand this." For Duesberg, epidemiol- with-men category. The next two issues ogy’s “natural updating,” which occurs as To ensure uninterrupted of FOCUS explore this disparity. delivery, send your new new technologies are applied to new prob- In the June issue of FOCUS, Rafael address four weeks before lems, is analogous to moving the goal you move. Diaz, PhD, a researcher at the Center posts in the middle of the ball game. Printed on recycled paper. for AIDS Prevention Studies of ©2000 UC Regents: Updated Antiviral Recommendations University of California San Francisco, All rights reserved. interprets the AIDS statistics and their Carpenter CC, Cooper DA, Fischl MA, et al. ISSN 1047-0719 Antiretroviral therapy in adults: Updated recommen- meaning for Latino men who have sex dations of the International AIDS Society–USA Panel. with men. Brenda Storey, LCSW, a The Journal of the American Medical Association. social worker at the Mission Neighbor- 2000; 283(3): 381-390. (Brown University; University hood Health Center in San Francisco, of Miami; Columbia University; Harvard University; discusses the clinical issues of working and University of California San Francisco.) with Latino men, particularly, recent No initial HIV therapy is superior to immigrants with and at risk for HIV. others, and a regimen should be individu- 8 FOCUS May 2000 searchable archive FREE DID YOU KNOW?

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