Newsday - December 27, 1988
Laurie Garrett

There were uninformed discussions of female circumcision, of ritual scarification and of the supposedly common use among Africans of heterosexual anal intercourse as a form of birth control.

Certainly the use of poorly sterilized needles in medical procedures was playing a role in the spread of the disease in Africa. And certainly practices such as female circumcision and scarification, along with the widespread use of blood transfusions to treat malaria, were playing a role in the spread of the HIV virus that causes AIDS.

But none of that explained why the disease spread so rapidly in some areas of the vast and diverse African continent, or why it was infecting males and females in equal numbers.

Certainly there are cultural explanations for the heterosexual nature of the AIDS epidemic in some areas of central Africa. A young man who works in AIDS public education explained the problem with a story. "When I had trouble with my wife, I naturally turned to my father for advice," he said. "My father said there was only one way to deal with the troublesome wife: Get another woman. That is his answer for everything in marriage. And if the second woman is a bother, get a third, or a fourth. This is what Kenyan men do. Now my father would tell me to keep all the women, and simply use each to keep the others in line. Use jealousy, I guess, as a weapon."

The young Nairobian sighed, "I am unusual, because I do not do these things. My wife and I discuss matters when we have difficulties, the same way you probably do in the States. But that is not so for most of my friends. Even those chaps you see walking down the streets there, wearing business suits from London, even they have several women and use them against one another. It is the way."

It may be the way in some areas, and it may help explain how one infected male might infect a number of women, and they, in turn, might infect an equal number of men. But sexual arrangements of this type in no way compare with the sexual profligacy seen in the New York and San Francisco gay communities in the late 1970s and early 1980s. And it also fails to explain why, when American AIDS researchers have put the odds of contracting AIDS from an infected heterosexual sex partner at one in 500, in some areas of Africa the odds are said to be about one in 10. Nor does it begin to explain why, when AIDS affects men and women equally in Africa, in the United States only 33 of the more than 80,000 reported cases have been documented as female-to-male transmission.

During the course of the African epidemic, various explanations for the differences between the epidemics in Africa, Europe and the United States have been in vogue. Currently, the most popular explanation is related to the high rate of genital ulcers, coupled with lack of male circumcision. A number of sexually transmitted diseases, such as syphilis, chancroid, gonorrhea and herpes simplex, can cause small ulcerated sores on male and female genitals. Scientists believe these genital ulcers serve as doorways into the body for the AIDS virus.

For similar reasons, it is reasoned, uncircumcised males are at greater risk than circumcised men, because of the tendency for inflammation, and occasionally sores, to develop under the foreskin.

At the University of Nairobi, Dr. Francis Plummer has studied female prostitutes and their male clients, looking at the correlation between genital ulcers, circumcision and AIDS. Plummer recruited 1,000 Ken- yan prostitutes for his study, 85 percent of whom were infected with the AIDS virus. He also studied a group of 429 men who had been their clients, following their health for two years.

Plummer found that among men who had a history of chancroid and genital ulcers, but were initially HIV-negative, the incidence of AIDS infection jumped from zero to 15 percent of the men.

Uncircumcised men in Plummer's study were eight times more likely than circumcised males to have had genital ulcer disease, he reported, and men who were both uncircumcised and had genital ulcers had a 50-50 chance of becoming infected with the AIDS virus after having intercourse just once with an infected prostitute. All of this has lead Plummer to conclude that "lack of circumcision and genital ulcers could explain up to ninety percent of the difference between American and African heterosexual transmission of the AIDS virus."

Zairean researchers working in the Matonge, the red light district of Kinshasa, the capital, reported that 40 percent of the prostitutes are infected with the AIDS virus. In addition, 84 percent had a recent history of at least one of the following genital ulcer-producing diseases: syphilis, gonorrhea and trichomoniasis. In general, the Zaireans found that 42 percent of the women with histories of genital ulcers were infected with HIV. And among those who had active genital ulcers when they were tested, two thirds tested positive for infection with the AIDS virus.

What does this have to do with the spread of AIDS? The theory is that although the virus may have a difficult time penetrating intact vaginal or penile tissue, if one of the sex partners has genital ulcers - sores - or both do, the virus has a gateway to the bloodstream. The connection to lack of circumcision - a connection not found in studies in the United States - is thought to be poor hygiene and the possibility of sores from a lack of circumcision.

But all of this is still speculative, said Dr. James Chin, who heads epidemiological research for the World Health Organization. Speaking in September at the Third International Conference on AIDS in Africa, he noted that although not yet proven, the association between genital ulcers, circumcision and AIDS is "less of a question now. Genital ulcers predispose people to AIDS. But the fact that AIDS can be transmitted in both directions [between men and women] is absolutely clear."

Ugandan Health Minister Samuel Okware described the genital ulcer and circumcision theory as "strong," but added, "It appears we are just at the beginning in understanding this problem."

Not all African researchers agree, however. For instance, top Zambian AIDS researcher Dr. Subhash Hira, who is well acquainted with the Kenyan studies, said in an interview that he could find no parallels in his country. For two years he has been studying a group of men and women who sought care at a clinic treating sexually transmitted diseases, "and we have compared those who had genital ulcers to those who never did. There was no difference, in terms of who got infected with HIV. The incidence was actually high in both groups." Hira's findings will soon be published in a major American medical journal.

Hira knows he is standing against the tide of current thinking, but he is adamant when he says "for an HIV-infected blood cell to go from one person'sgenitals to another does not need microorganisms. You do not need a chancroid lesion for a tiny lymphocyte to get in."

In Zambia, however, researchers see a correlation between sexually transmitted diseases and AIDS susceptibility. In the capital city of Lusaka, about 10 percent of the young adult population is infected with the AIDS virus. But among those adults who have a history of one or more sexually transmitted diseases (STD), more than a third are infected.

There are several possible explanations. Dr. Roy Widdus of the World Health Organization said in an interview in Ixtapa, Mexico, that there obviously is some sort of association between STDs and AIDS, but it may be rather complex. "For example," he said, "it may be related to the stage of the disease, the STD, when the person is exposed to the AIDS virus." Because of the state of health care in some countries, STD infections often go untreated for long periods of time before the victims seek medical attention, and more advanced infections may lead to greater vulnerability to the AIDS virus. But there's no strong evidence on this one way or the other.

Harvard University's Dr. Max Essex and Jay Levy of the University of California in San Francisco have independently offered another possible explanation for the heterosexual nature of the African AIDS epidemic: Frequent exposure to a variety of infectious diseases may overload the body's defense system, making people with STDs less able to fight off the AIDS virus once it has entered the body.

Many leading AIDS researchers support this notion, primarily because a number of other diseases, which do not generally cause genital ulcers, seem to increase a person's risk for AIDS. Among them are herpes (types 1 and 2), hepatitis, cytomegalovirus (CMV), Epstein Barr Virus (EBV), trypanosomiasis, human B lymphotropic virus (HBLV), malaria, and a newly discovered herpes virus called HBV.

Levy points out that gay San Franciscans faced epidemics of EBV, CMV and hepatitis long before AIDS appeared, and many men had lowered immune responses, lowered defenses, prior to their exposure to the AIDS virus.

Few Africans manage to reach the age of 30 without facing serious bouts of at least one of the diseases named above, as well as any number of parasitic infections. For example, according to Dr. Winsalis Kilama, director of Tanzania's malaria control program, all Tanzanians suffer at least one serious malaria infection during their lifetime. And researchers agree that immune defenses of individuals suffering acute malaria are severely compromised and weakened.

Because the heterosexuals at greatest risk for AIDS in the United States, the sexual partners of intravenous drug abusers, also have high rates of STDs and other infections, some scientists have accepted the notion that so-called co-infection is the key to AIDS susceptibility. But there are several leaps of faith involved in accepting the theory, not the least of which is explaining exactly how infection with one disease puts a person at increased risk for AIDS. While most researchers believe co-infection plays a critical role, they find the notion that the immune system is depressed by other infections overly vague. So the search is on for a detailed biological explanation of how, exactly, co-infection puts people at risk for AIDS.

Dr. Sebastian Lucas, a British pathologist who does research in a number of African countries, said in an interview in Arusha, Tan- zania, that he tried to answer the question by looking at the differences in the symptoms of AIDS patients in the United States and in Africa. The typical American AIDS patient may have pneumocystis pneumonia, skin cancers called Kaposi's sarcoma, tuberculosis, yeast infections and other symptoms that can, at least in part, be treated. Africans, on the other hand, have one symptom that overwhelms all others: wasting. Typically an African AIDS patient starts losing weight rapidly, develops intractable diarrhea, runs a very high fever, abandons all interest in food and may drop up to 30 percent of his or her body weight in less than two months. The only other disease that causes such dramatic weight loss and diarrhea is cholera. But cholera is not associated with AIDS in Africa.

Lucas reasoned that the key to this "choleralike" syndrome among African AIDS patients might also be the reason for their apparently greater susceptibility to the virus. In Lusaka, Zambia, he tested AIDS patients for a variety of infections known to produce acute diarrhea and found 54 percent had cryptosporidium protozoa, and 19 percent had isospora sporazites. In other words, said Lucas, "about half of all diarrhea in Zambian AIDS patients could be explained by parasites that are known to attack the intestines and stomach and cause diarrhea."

"But what," he asked, "can explain the other half? Why do these patients suffer such horrible diarrhea and wasting?" So far, Lucas has no solid answer to that question, but he does have a theory. HIV is known to infect macrophages, the cells of the human immune system that scavenge up invading bacteria, parasites and viruses. "Perhaps HIV is infecting the macrophages of the intestinal lining," reasoned Lucas, "and that is the cause of the diarrhea. I suggest this as a last act of desperation, but I do think there is something involved there."

In the last year, AIDS researchers around the world have gained a new appreciation of the importance of macrophages in the AIDS process. Dr. Steve Miles of the University of California in Los Angeles says he "suspects macrophages are going to turn out to be the most important element in the AIDS story."

At the Arusha meeting, Dr. Robert Gallo of the U.S. National Cancer Institute said, "We think macrophages are the earliest target for HIV infection" and provided evidence that these crucial cells serve as reservoirs for the lethal virus, carrying it throughout the body and spreading infection from one organ to another.

Jannin Bieberfeld of the Karolinska Institute in Sweden announced at the Arusha meeting that her studies demonstrate that HIV-infected macrophages are unable to kill off parasites. "I think," said Bieberfeld, "this could explain the poor response to parasites among AIDS patients."

But could the reverse also be true: Could macrophages affected by parasites be more vulnerable to the AIDS virus? That is a question now under active research in several laboratories around the world.

Another area of active inquiry involves the plethora of viruses commonly found among African AIDS patients, particularly herpes, HBLV, hepatitis and HBV. Increasingly African doctors report extraordinary infections with these viruses among their AIDS patients.

For example, Dr. Lunke Jungman pointed out a girl covered in herpes lesions to a visitor to Ndolage Hospital in northern Tanzania. The 14-year-old had no other symptoms but tested positive for HIV. "This is a new trend," Jungman said. "We see more and more primary herpes. The young people come in here now with herpes zoster, and every one of them is HIV-positive. And they are not wasted, they have no other symptoms, but they have . . . very very bad herpes."

Miles away, at Moranga Hospital, doctors described the same troubling experience of finding patients covered head to toe with herpes and later developing full-blown AIDS. And far away in Kinshasa, Zaire, Dr. Bela Kapita says he is seeing a dramatic increase in herpes among his AIDS patients.

Gallo thinks there is a connection. He told colleagues at the Arusha meeting that HBV, a newly discovered herpes virus, can co-exist inside a human cell alongside the AIDS virus. Furthermore, said Gallo, the HBV virus is capable of "turning on" latent AIDS viruses, stimulating them to reproduce in enormous quantities. Other researchers have presented evidence that, in test-tube studies, the AIDS virus can be switched on by other viruses, including herpes simplex, herpes zoster, HBLV and hepatitis.

It has not been proven, however, that people infected with, for example, herpes are more likely to absorb the AIDS virus when they are exposed to it.

There has been speculation that the AIDS virus itself may differ from one place on the globe to another and that the African strains may be more virulent. Dr. Luc Montagnier of the Pasteur Institute in Paris has studied hundreds of strains of HIV from around the world, finding significant genetic differences from strain to strain. But none of the differences that could affect virulence were restricted to strains from Africa, Montagnier said in an interview. Extremely virulent strains of HIV can be found around the world.

There are, of course, a few cultural practices that contribute to some degree to the African AIDS epidemic. African scientists insist, and have the data to support their claim, that these practices - such as female circumcision and ritual scarification - are confined in scope, are not uniformly followed throughout Africa and are responsible for, at most, a tiny fraction of the continent's AIDS cases.

In Lusaka, Hira suggests, however, that there may be differences in the way some people have intercourse, and these variations may increase the risk for transmission of the AIDS virus. "For example," he explained, "we know that dry sex is more prominent, I would say predominant, in Lusaka. It is the practice here to mop the vagina dry before inserting the penis. If dry sex is used as a regular sexual form of vaginal intercourse, then probably it would lead to tremendous amounts of abrasion, and when you have abrasion you can get more tearing of tissue and possibly passage of the virus."

Hira says a study of 3,000 Zambian women showed that less than half a percent acknowledged ever having engaged in anal intercourse, "so we think we can rule that out as a risk." He said he would like to see more studies done throughout Africa to determine exactly what heterosexual couples are doing in the bedroom. But such studies are considered overly intrusive, embarrassing or possibly racist by many Africans, and it is unlikely many countries will follow Zambia's example in putting their sex lives under such scrutiny.

Uganda's Okware said both the explanation for Africa's rapidly expanding heterosexual epidemic and the best way to slow the deadly disease can be summarized as follows: "The values of our ancestors must be emulated if we are to keep the tenacity of this virus at bay." While he protests Western press accounts of "sexual athleticism" among Africans, Okware acknowledges that AIDS is spreading rapidly among young adults who have moved into Africa's burgeoning cities, abandoned their traditional ways, and, in many cases, adopted the disco culture - with its sexual promiscuity - that was popularized in the United States.

Probably the strongest study of the epidemiology of African AIDS was one published earlier this year in the New England Journal of Medicine by Dr. Nzila Nzilambi and his colleagues at the Mama Yemo Hospital in Kinshasa and by the U.S. Centers for Disease Control. The study compared blood samples drawn in 1976 in Kinshasa and remote rural areas of Zaire to those taken in 1986 from the same areas. The researchers found that in 1976 about 1.4 percent of the residents of extremely remote villages were infected with the AIDS viruses. By 1986, that percentage remained unchanged. But in areas of trade, closer to Kinshasa, levels of HIV infection had risen dramatically. In Kinshasa, the incidence of infection increased tenfold.

Dr. Joe McCormick, who participated in the Zaire study, said during an interview that the study lent credence to the notion that AIDS has existed, in isolated areas, for centuries. "It's urbanization and social upheaval that are the keys" said McCormick. He pointed out that during the 1970s Africa underwent an unprecendented population shift, with people, mostly youths, moving from rural areas to big cities in numbers never seen before. In typical African countries, more than 95 percent of the population led rural agrarian lifestyles before World War II. Today, more than half of the people live in cities. Diseases that were once isolated in remote villages, such as African green monkey virus, Lhasa fever and, perhaps, AIDS, came into the cities with these waves of migration.

Africans are understandably sensitive about discussions of the origin of the AIDS virus, and they do not wish to have their continent labeled the harbinger of epidemics. As a result, many scientists now sidestep the whole question of the origin of this global epidemic.

Montagnier, however, thinks people must appreciate that "all genetic studies show the same thing - African and European strains of the AIDS virus have developed separately, and the African isolates have been around much longer than the European." AIDS, he says, has been in Africa longer, taking root in the most sexually active population. In most of Africa, that population consists of young heterosexual adults. In Europe and in the United States, where AIDS is a newer disease, the virus took hold among homosexuals.

"Human beings were in a state of equilibrium with the viruses for many millenia," Montagnier told his colleagues in Arusha. "Now we are in a state of disequilibria. We cannot exclude the possibility that the virus has changed, becoming more pathological. But the hosts, humans, have also changed . . . changed human sexual habits have given the virus entry [into the human race]."

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Always watch for outdated information. This article first appeared in 1988. This material is designed to support, not replace, the relationship that exists between you and your doctor.

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