San Francisco Chronicle - March 11, 2007
James Chin

UNAIDS continues to perpetuate the fallacy that only aggressive HIV/AIDS prevention programs -- especially directed at youth -- can prevent the eruption of heterosexual HIV epidemics where prevalence is currently low. More than two decades of observation and analysis point to far different conclusions -- there are no "next waves" of HIV epidemics just around the corner and the AIDS pandemic is now in its post-epidemic phase.

The highest HIV infection rates are found in many sub-Saharan African populations because up to 40 percent of adolescent and adult males and females in these populations routinely have multiple and concurrent sex partners, and they also have the highest prevalence of factors that can greatly facilitate sexual HIV transmission. In most other heterosexual populations, the patterns and frequency of sex-partner exchanges are not sufficient to sustain epidemic sexual HIV transmission.

UNAIDS and most AIDS activists reject this analysis as socially and politically incorrect, saying it further stigmatizes groups, such as injecting drug users, sex workers and men who have sex with men. However, all available epidemiologic data show that only the highest risk sexual behavior (multiple, concurrent and a high frequency of changing partners) drives HIV epidemics among heterosexuals or men who have sex with men, anywhere in the world.

Most AIDS activists claim, without any supporting data, that high HIV prevalence in groups of men who have sex with men or injecting drug users will inevitably "bridge" over to the rest of the population and lead to "generalized" HIV epidemics. This entrenched myth persists even though there is little, if any, HIV spread into any "general" population except from infected injecting drug users and man who have sex with men or bisexuals to their regular sex partners.

Without a constant flow of alarming news releases warning about HIV being on the brink of spreading into general populations, AIDS activists fear that the public and policymakers will not continue to give AIDS programs the highest priority -- hence these "glorious myths," lies told for a noble cause.

This alarmism goes against all the evidence. Global and regional HIV rates have remained stable or have been decreasing during the past decade (except possibly among drug users in Eastern Europe). HIV has remained concentrated in groups with the riskiest behavior. Several decades of experience support the conclusion that HIV is incapable of epidemic spread among the vast majority of heterosexuals.

Most of the public, policymakers and media have no inkling that the UNAIDS working assumption is inconsistent with established facts -- indeed, until 2006, no major public health or international development agency had openly challenged this assumption.

Some cracks in this wall of silence began to appear during 2006 with the publication of several studies which questioned the UNAIDS view.

Since 2000, dozens of population-based HIV sero-surveys have forced UNAIDS to reduce its overestimates in most high-HIV-prevalence countries by around 50 percent or more: examples include Kenya's estimate in 2001 of 14 percent reduced to 6.7 percent and Haiti's 2001 estimate of 6.1 percent reduced to 2.2 percent in 2006.

Estimates of HIV prevalence in China has been decreasing rather than increasing and the estimate now of more than 5 million HIV infections in India is likely to be cut by half or more as the result of recent, and more accurate, studies.

In 2007, UNAIDS needs to come up with more realistic HIV estimates and projections, especially when more mainstream epidemiologists and the news media begin to question the basis of the UNAIDS assumption.

Continued denial of these realities will lead to further erosion of the credibility of UNAIDS and other mainstream AIDS agencies, raising the danger of people underestimating the real threats.

Regardless of my epidemiologic disagreements with UNAIDS, I totally agree with mainstream AIDS experts, who declare that this is no time to be complacent about strengthening HIV treatment and, above all, HIV prevention programs.

Although many countries have overestimated their numbers, there are now at least 20 million HIV-infected people in sub-Saharan Africa and several million in Asia and these numbers can be expected to remain close to these levels for a decade or more.

AIDS is a severe problem in sub-Saharan Africa and to a lesser extent in Caribbean countries and a few Southeast Asian countries, as well as among men who have sex with men, injecting drug users and sex workers throughout the world.

This means that scarce health resources in countries with low HIV prevalence should be targeted primarily at those who are at the highest HIV risk, instead of being misdirected to the wider public.

We must cut through the overestimates of HIV prevalence and the exaggerated potential for generalized HIV epidemics so we can concentrate money and efforts on prevention and palliative care where it really matters.

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James Chin, a professor of epidemiology at UC Berkeley, is a former chief of the surveillance, forecasting and impact Assessment unit of the Global Program on AIDS of the World Health Organization. He is the author of "The AIDS Pandemic: the collision of epidemiology with political correctness" (Radcliffe, Oxford, 2007).

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