James Chin. The AIDS Pandemic: The Collision of Epidemiology with Political Correctness. Oxford: Radcliffe Publishing, 2007. xix + 311 pp. $35.00 (paper), ISBN 978-1-84619-118-3.
Reviewed by Robert Van Howe (School of Human Medicine, Michigan State University)
Published on H-Histsex (November, 2007)
Dispelling Some of the AIDS Myths
A few months ago, I was invited to be a consultant to the Centers for Disease Control on the issue of HIV control in the United States. In a breakout discussion group, I pointed out that the epidemic was different in Africa because of the different sexual mixing pattern there. Another consultant, an infectious disease specialist, blew off my remarks by saying we have the same mixing patterns in the United States. This is precisely why James Chin needed to publish The AIDS Pandemic.
Chin is a seasoned and extremely well-qualified epidemiologist who was immersed in the AIDS epidemic at its genesis while at the California State Bureau of Communicable Disease Control in 1981. As the AIDS epidemic unfolded, it opened a new chapter in his career and a role in the initial efforts to understand and control the spread of HIV. His analysis of the AIDS epidemic in various theaters around the world is dead-on; however, he is at odds with the view of the epidemic propagated by various AIDS advocacy groups, such as UNAIDS. His expertise, together with his dissent from the hyperbole spun by so many interested (politically correct) agencies, make this book required reading for anyone interested in the AIDS epidemic.
The book is based on four basic theses that Chin supports and defends. The first thesis is that "[E]pidemic HIV transmission requires human behaviors that involve having unprotected sex with multiple and concurrent sex partners and/or routinely sharing needles and syringes with other injecting drug users." Based on HIV transmission dynamics, HIV epidemics cannot occur in populations where high-risk patterns and the highest prevalence of such risk behaviors are not present. Consequently, heterosexual risk behaviors in most populations outside of sub-Saharan Africa are not sufficient to sustain significant epidemic HIV transmission. The heterosexual epidemic is sustained in sub-Saharan Africa because of the high sex partner exchange rate within a large open sex network. Using straightforward, simple epidemiological principles, Chin demonstrates that if sexually active persons have many different sex partners over a lifetime, but only one at a time for months or years, it is difficult for HIV to spread rapidly through sexual intercourse within that sexual network. When multiple sex partners are concurrent, however, HIV and any other sexually transmitted infection can spread rapidly and extensively through a sexual network. It is on the basis of this thesis that Chin has accurately predicted the failure of heterosexual epidemics to occur outside of sub-Saharan Africa, despite predictions by such organizations as UNAIDS of imminent heterosexual epidemics in Asia and heterosexual epidemics sprouting from regular sexual partners of infected intravenous drug users.
His second main point is that the potential for HIV to spread into the general population is a "glorious" myth and an exaggeration perpetuated by UNAIDS, AIDS program advocates, and activists. The motivation of these organizations is partly to avoid further stigmatization of persons with the highest levels of HIV-risk behaviors, such as men having sex with men, intravenous drug users, sex workers, and their clients. The prevailing UNAIDS paradigm is that HIV causes AIDS and that, without effective prevention programs, it is only a matter of time before heterosexual HIV epidemics erupt in almost any population with currently low HIV infection rates. The picture is further muddied by those who believe that AIDS is not caused by HIV, but rather by poverty, discrimination, and lack of access to healthcare. Chin easily eviscerates the UNAIDS position by using calculations that support the first thesis. He also shows other myths about HIV/AIDS to be fallacious by examining the data (demonstrating, for example, that HIV rates in sub-Saharan Africa are higher among the more affluent, thus undermining the poverty-as-cause-of-AIDS myth), or by showing that myth evolved from the failure to properly understand the manner in which HIV is spread and how AIDS manifests itself over time. He does admit that poverty, discrimination, and lack of access to healthcare interfere with the timely diagnosis and treatment of HIV, but they do not contribute to its transmission.
In his third thesis, Chin argues that most HIV/AIDS estimates and projections made or accepted by UNAIDS are gross overestimates. The problem with estimating the incidence and prevalence of HIV and AIDS is that good data are not available. Consequently, those making the estimates have to do the best they can. Chin reports that when he was involved in making estimates, the estimates were conservative and defendable. Since his departure, however, the estimates have been as much as 50 percent too high. As more accurate data became available, he has been vindicated. The other problem with these inaccurate estimates is that they have been used in models designed to calculate the future trajectory of the epidemic. A model is only as accurate as its assumptions, and many of the predictive models have yielded wildly inaccurate predictions. Fortunately, the author provides more accurate estimates and predictions based on sound epidemiological principles. Chin also hints at the dark side of overestimating. With a greater number of HIV cases, it paints the epidemic as more dire, thus allowing UNAIDS and other AIDS advocacy groups to solicit more funds, thus facilitating increasingly self-serving research and barrow pushing. Likewise, when it becomes evident that the situation is better than previously estimated, these same organizations are likely to take credit for the improvement.
Finally, he shows that the annual global HIV incidence peaked almost one decade ago. This is good news, and Chin has the numbers to support his position. It means the worst is over, but we are not out of the woods yet. Several things need to be done. Chin believes that the major focus on preventing "generalized" HIV epidemics is a waste of resources that would be better focused on persons with the highest HIV-risk behaviors, even if this means stigmatizing them. This would also include focusing on HIV-negative partners of persons known to be HIV positive. Although the spread of HIV to faithful sex partners of HIV-positive persons is tragic, it is "non-epidemic" spread. While this form of transmission will continue despite public health efforts, it will not lead to new epidemics. Chin particularly notes that condom use has been highly effective in Uganda and among female sex workers in Thailand; however, several faith-based organizations and the present U.S. administration, while well meaning, have adopted a moralistic approach that interferes with the effort to increase condom use.
The AIDS epidemic will end only when there is a change from high-risk behaviors. Unfortunately, public health efforts have not been very successful at affecting behavior (as noted by the obesity epidemic in the United States). Chin rightly believes that we need to bring the behavioral scientist to not only measure behaviors, but also to find ways of encouraging us to change behaviors.
HIV must also be put into perspective. Chin states that more attention should be paid to measles, whooping cough, and tetanus, as these easily preventable diseases still kill millions of children each year. His hope is that lessons learned from the AIDS epidemics will provide the beginning of true global health programs.
There are several pearls buried within the text. I learned that UNAIDS declared itself an advocacy agency and not a scientific or technical agency. This designation has provided me with a new understanding of their actions. The recounting of the author's career was interesting without being self-indulgent or distracting. I appreciated his candor when recounting his frustration with the barriers he encountered when trying to get his views, accurate as they are, published in medical literature. His straightforward style is refreshing and educational.
This book can be appreciated by anyone interested in HIV infections. Chin explains well the epidemiological principles and calculations such that someone without a background in epidemiology can understand his arguments. The book should be read by his critics, as many of them obviously are ignoring or ignorant of simple epidemiologic principles. The level of hostility Chin has received from his critics appears to be a result of Chin landing a direct blow. I hope that the publication of this book will refocus their efforts on the epidemic in a more useful direction.
There are a few aspects of the book that are less satisfactory. First, the major theses are repeated too frequently. Chin developed the book from a university course and states that it took half a term for his students to buy into what he was saying. By the end of the book the message was being hammered a little too hard. Second, the number of abbreviations (a three-page glossary) was excessive. In the second edition, it would be wise to drop the glossary and spell out the abbreviations throughout the text. Third, Chin buys into the circumcision-is-protective-against-AIDS propaganda without a careful examination of the issue. Given his position on where efforts should be directed, I cannot believe that he would endorse circumcision in low-risk populations. And, even for high-risk populations, I expect that he would want a well-reasoned, ethically aware and thoroughly researched comparison of the relative strengths, weaknesses, and costs of competing interventions. Finally (a verbal quibble), Chin uses parameters where factor or variable would be the proper usage.
All in all, The AIDS Pandemic is an essential text for those who wish for a better perspective on the issue than that provided by sensationalist media and self-interested lobby groups. I hope someone has provided my infectious disease colleague with a copy.
. These points are also made forcefully in Philip Setel, A Plague of Paradoxes: AIDS, Culture and Demography in Northern Tanzania (Chicago and London: Chicago University Press, 1999).
. The importance of prostitution, both formal and informal, in the spread of AIDS has been emphasized by John Talbott, "Size Matters: The Number of Prostitutes and the Global HIV/AIDS Pandemic," PLoS ONE, no. 6 (June 2007); online at http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0000543.
. The ineffectiveness of moralistic approaches (including circumcision) in controlling syphilis in the late nineteenth century has been emphasized in Robert Darby, "Where Doctors Differ: The Debate on Circumcision as a Protection against Syphilis, 1855-1914," Social History of Medicine 16 (Spring 2003): 57-78; and Robert Darby, A Surgical Temptation: The Demonization of the Foreskin and the Rise of Circumcision in Britain (Chicago: University of Chicago Press, 2005): chap. 12.
. The very successful AIDS prevention program adopted by Australia in the late 1980s is a model of what can be achieved. See the discussion broadcast on the Australian Broadcasting Corporation: http://www.abc.net.au/unleashed/stories/s2107613.htm. See also "HIV 'Supervirus' is a Warning to All," Sydney Morning Herald, February 17, 2005: "'Australia must continue to shun a US-led holy war against AIDS,' writes Bill Bowtell, a former senior adviser to the Australian health minister (1984-87), former national president of the Australian Federation of AIDS Organisations and the principal architect of Australia's very successful response to HIV/AIDS." Available at http://www.smh.com.au/news/Opinion/HIV-supervirus-is-a-warning-to-all/2005/0 2/16/1108500157385.html.
. For a South African critique of the World Health Organization position, see A. and J. Myers, "Male Circumcision--The New Hope?," South Africa Medical Journal 97, no. 5 (May 2007): 338-341.
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Robert Van Howe. Review of Chin, James, The AIDS Pandemic: The Collision of Epidemiology with Political Correctness.
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