PRESIDENTIAL AIDS ADVISORY PANEL REPORT A synthesis report of the deliberations by the panel of experts invited by the President of the Republic of South Africa, the Honourable Mr Thabo Mbeki March 2001 Contents CONTENTS ..................................................................................................................... 2 ACKNOWLEDGEMENTS ................................................................................................... 7 ABBREVIATIONS ............................................................................................................ 8 CHAPTER 1 – SETTING THE SCENE .................................................................................. 9 1.1 BACKGROUND.............................................................................................................................9 1.2 COMPOSITION OF THE PRESIDENTIAL AIDS ADVISORY PANEL ............................................................10 1.3 TERMS OF REFERENCE FOR THE PRESIDENTIAL AIDS ADVISORY PANEL ................................................11 1.4 THE REPORT.............................................................................................................................13 CHAPTER 2 - AETIOLOGY AND TRANSMISSION OF AIDS ................................................ 15 2.1 INTRODUCTION.........................................................................................................................15 2.2 DOES HIV CAUSE AIDS?............................................................................................................16 2.2.1 Visualisation and Isolation of the Virus ..........................................................................16 2.2.2 PCR (Polymerase Chain Reaction) and ELISAs ...............................................................18 2.2.3 Clinical and Laboratory Evidence of Causation...............................................................19 2.2.4 Evidence from Animal Models........................................................................................22 2.2.5 Epidemiological Evidence ..............................................................................................22 2.3 ALTERNATIVE HYPOTHESIS ON THE CAUSE OF AIDS..........................................................................23 2.3.1 The Chemical AIDS Hypothesis......................................................................................23 2.3.2 The Immunotoxicological Hypothesis.............................................................................24 2.3.3 The Oxidation Hypothesis..............................................................................................24 2.4 THE INVOLVEMENT OF COFACTORS (OR RISK FACTORS) IN AIDS.........................................................24 2.4.1 Involvement of cofactors in HIV-causes-AIDS Hypothesis..............................................25 2.4.2 Risk factors that are the primary cause of AIDS according to alternative hypotheses/theories......................................................................................................27 2.5 TRANSMISSION OF HIV AND AIDS ...............................................................................................28 2.5.1 HIV Transmission as Estimated from ‘AIDS Deaths’ .......................................................29 2.5.2 Sexual Transmission......................................................................................................30 2.5.3 Mother-to-Child Transmission........................................................................................32 2.5.4 Blood-borne transmission and Occupational Exposure ...................................................33 2.5.5 Epidemiology of Transmission .......................................................................................34 CHAPTER 3 – SURVEILLANCE ........................................................................................ 37 3.1 WHAT ARE THE QUESTIONS AND ISSUES? .......................................................................................37 Presidential Aids Advisory Panel Report 2 3.2 OVERVIEW ON THE NECESSITY FOR SURVEILLANCE............................................................................37 3.3 SOUTH AFRICAN EPIDEMIC – FACT OR FICTION................................................................................38 3.3.1 AIDS mortality...............................................................................................................39 3.4 EPIDEMIOLOGICAL THEORY OF CAUSAL INFERENCE...........................................................................41 3.5 SOCIO-ECONOMIC RISK FACTORS ..................................................................................................42 3.6 DIFFERENCES IN THE AFRICAN EPIDEMIC, COMPARED WITH EUROPE AND THE USA .................................43 3.7 THE ROLE OF MATHEMATICAL MODELS IN FORECASTING THE EPIDEMIC..................................................44 3.8 SURVEILLANCE RECOMMENDATIONS – WHAT SHOULD BE DONE ABOUT THE SOUTH AFRICAN EPIDEMIC?.......45 3.8.1 Deliberations of the panel .............................................................................................45 RECOMMENDATION ..............................................................................................................................45 3.8.2 Discussion on mortality data .........................................................................................45 RECOMMENDATION ..............................................................................................................................45 3.8.3 Recommendations from panellists who do not subscribe to the causal linkage between HIV and AIDS................................................................................................................45 3.8.4 Recommendations from panellists who subscribe to HIV as the cause of AIDS ..............46 3.8.5 General recommendation ..............................................................................................48 CHAPTER 4 - HIV TESTS AND THEIR ACCURACY............................................................49 4.1 HIV TESTING ...........................................................................................................................49 4.1.1 ELISA test....................................................................................................................50 4.1.2 Western Blot .................................................................................................................51 4.1.3 PCR test for viral load ...................................................................................................52 4.1.4 CD4 count.....................................................................................................................53 4.2 VIRUS ISOLATION OR CO-CULTURING.............................................................................................53 4.3 MORATORIUM ON HIV TESTING ...................................................................................................53 4.4 RECOMMENDATIONS ON HIV TESTING ...........................................................................................54 4.4.1 Proposed studies and experiments ................................................................................54 4.4.2 Recommendation on future HIV testing.........................................................................55 4.4.3 General recommendations on testing ............................................................................55 CHAPTER 5 –THE TREATMENT OF AIDS AND THE USE OF ANTI-RETROVIRAL DRUGS ...... 56 5.1 INTRODUCTION.........................................................................................................................56 5.2 EVIDENCE IN SUPPORT OF THE USE OF ANTI-RETROVIRAL DRUGS .........................................................56 5.3 EVIDENCE AGAINST THE USE OF ANTI-RETROVIRAL DRUGS..................................................................57 5.4 RECOMMENDATIONS ON TREATMENT WITH ANTI-RETROVIRAL DRUG .....................................................59 5.4.1 Recommendations on the use of anti-retroviral drugs from the group opposed to their use................................................................................................................................59 5.4.2 Recommendations from the proponents of anti-retroviral drug use................................60 RECOMMENDATIONS: ...........................................................................................................................61 CHAPTER 6: PREVENTIVE AND PROPHYLACTIC MEASURES AGAINST AIDS ................... 63 Presidential Aids Advisory Panel Report 3 6.1 PREVENTION OF AIDS FROM THE POINT OF VIEW OF PANELLISTS WHO DO NOT SUPPORT THE CAUSAL LINK BETWEEN HIV AND AIDS ..........................................................................................................64 6.1.1 Recommendations.........................................................................................................64 6.2 PREVENTION OF AIDS FROM THE POINT OF VIEW OF PANELLISTS WHO SUPPORT THE CAUSAL LINK OF HIV TO AIDS ....................................................................................................................................65 6.2.1 General recommendations.............................................................................................66 6.2.2 Recommendations on prevention of HIV/AIDS through sexual transmission ..................66