The Origins of AIDS (2 page)

Before we move on, I want to point out that for readers unfamiliar with virology, the
Appendix
provides a brief overview of the viruses that we will be discussing. In a few chapters where this is necessary, elements of molecular biology will be discussed. I aimed to explain them succinctly to readers who have no training in this field.

With regard to toponymy, in English-language publications West Africa generally encompasses all countries on the Atlantic coast of Africa, plus some in the corresponding hinterland. I will rather use French terminology whereby West Africa starts in Mauritania, ends with Nigeria and also includes the corresponding hinterland. Central Africa (in colonial times, Equatorial Africa) starts with Cameroon and Chad, goes all the way to Rwanda and Burundi and also encompasses the two Congos, Gabon, the Central African Republic and Equatorial Guinea. Most of the story told in this book occurred in central Africa.

In former French colonies, city names did not change much after independence. Gabon’s major port is still called
Port-Gentil, despite the latter character’s dubious human rights record. However, in the former Belgian Congo, these traces of the colonisers were enthusiastically erased so that Léopoldville became Kinshasa, Stanleyville became Kisangani, Elisabethville was renamed Lubumbashi, and so on. The country itself was successively known as the Congo Free State, the Belgian Congo, the Democratic Republic of Congo (DRC) after 1960 (or Congo-Léopoldville, and then Congo-Kinshasa), Zaire under Mobutu’s dictatorship and then DRC again after Mobutu was overthrown.

The federation of Afrique Équatoriale Française (AEF) included four distinct colonies: Moyen-Congo (present day Republic of Congo, or
Congo-Brazzaville), Oubangui-Chari (
Central African Republic),
Gabon and
Tchad.
AEF disappeared as a geographic entity shortly before 1960 when independence was granted to the four countries. To avoid confusion between the two Congos, I will use the term Congo-Brazzaville
(it also changed names a few times) to designate the independent country that succeeded Moyen-Congo. Cameroun Français, or just Cameroun with the French spelling, refers to the part of current day
Cameroon that was administered by
France under a mandate from the League of Nations after World War I (WWI) and the United Nations after World War II (WWII), until the country became independent in 1960. The maps in this book use the names of countries and cities as they were known at the time of the events in question, and in principle the location of each city, district, region, river or park mentioned anywhere in the book should be shown on at least one of the maps.

 

June 1981 is the official birth date of the AIDS epidemic. In a short article published in the
Centers for Disease Control’s
Morbidity and Mortality Weekly Report
(
MMWR
), American clinicians described a cluster of five cases of
Pneumocystis carinii
pneumonia, an infection of the lungs hitherto seen only in patients with severe impairment of their immune system. These five initial cases had been diagnosed in 1980–1 among
gay men, all living in
Los Angeles, who had been previously healthy and were not receiving drugs that suppressed the body’s immune response. At the time,
the standard treatment for
Pneumocystis
pneumonia was an old drug called pentamidine, developed during WWII for the treatment of sleeping sickness, which happened to be highly active against
Pneumocystis
. Pentamidine was not commercially available and had to be distributed centrally from the CDC in
Atlanta. An astute CDC technician found it strange to have received several requests for pentamidine within a short period of time from hospitals in
California and, a bit later, from
New York as well
. This became the first step in the identification of the new syndrome by this federal agency
.
^1
–
2

Nobody could have imagined that, within three decades, more than twenty-nine million individuals would have died of AIDS, leaving in the process sixteen million orphans. By 2009, another thirty-three million were living with its HIV aetiological agent, making it by far the most dramatic epidemic since the Black Plague devastated Europe 500 years ago. Since that fateful day in 1981, more than 300,000 scientific articles and thousands of books have been published on HIV/AIDS. Most are biomedical but others analyse the psychosocial, historical, economic, geographic and even photographic features of AIDS. Thus the history of HIV/AIDS from 1981 to 2011 has been described in great detail.
Randy Shilts’
And the band played on
and
Laurie Garrett’s
The coming plague
contain captivating descriptions of the early years of the pandemic in the US and Europe. Some books have chronicled the AIDS epidemic in
Africa after the initial description of the disease, its devastating impact on the lives of so many, a few success stories and unfortunately many more failures in the response to HIV/AIDS, most tragically in
South Africa. For a summary of the dissemination of the virus between 1981 and 2006, I recommend
John Illiffe’s
The African AIDS epidemic. A history
.
^2
–
10

However, what happened before 1981 – how did the human race reach that point? – has, to my knowledge, only been addressed in Edward Hooper’s
The river
.
A journey back to the source of HIV and AIDS
. This book was written in support of the hypothesis that the emergence of HIV/AIDS was triggered by the contamination of an oral polio vaccine with a simian immunodeficiency virus through the use of chimpanzee cells during vaccine production. There is now overwhelming evidence that this did not happen, as we will see later.
¹¹

This book will summarise and assemble various pieces of the puzzle that have gradually been delineated over the last decade by a small group of investigators, to which I have added historical research of my own. Some elements are irrefutable, such as the notion that the
Pan troglodytes troglodytes
chimpanzee is the source of HIV-1. Other elements are less clear, for example the exact moment of the
cross-species transmission (sometime in the first three decades of the twentieth century). My own contribution focused around the idea that medical interventions requiring the massive use of reusable syringes and needles jumpstarted the epidemic by rapidly expanding the number of infected individuals from a handful to a few hundred or a few thousand. This set the stage for the sexual transmission of the virus, starting in core groups of sex workers and their male clients and later spreading to the rest of the adult population. Some parts of the story rely on circumstantial evidence, such as the links between the Congo and Haiti and the potential contribution of the blood trade in triggering the epidemic in Port-au-Prince, from where it moved into the US. Potentially sceptical readers should look at the whole story before making a judgement. I believe it is coherent, and that the weaker parts are supported by a strong body of evidence immediately before or after these uncertain areas.

My own background is that of an infectious diseases physician and epidemiologist. I started my career in the early 1980s as a medical officer in a bush hospital in Zaire, where I spent the four most challenging years of my life. The type of medicine that I practised there was not
much different from that of my colonial-era predecessors: approximate diagnoses, empirical treatments, lack of human and material resources, systematic re-use of syringes, needles and other medical supplies. I developed a fascination with sleeping sickness, a disease which happened to be epidemic in my district and around which I conducted research for the next twenty years. After completing my training in infectious diseases in Canada, I went back to Africa, this time as a clinical researcher at the
Medical Research Council Laboratories in
The Gambia, working on the epidemiology of HIV-2 infection and its interaction with sexually transmitted diseases (STDs). I returned to Canada in 1990 as an academic infectious diseases physician, but I also coordinated AIDS control projects in central and West Africa, which provided preventive and curative care to a large number of sex workers. During a sabbatical, I studied for a master’s degree in epidemiology. Epidemiology is a science which connects exposures (for instance, to some infectious agent) and outcomes (developing AIDS or cancer, death, etc.). I will not use much epidemiology in this book though I confess to an inborn love of numbers which, Mark Twain notwithstanding, can often prove or disprove an argument.

Eventually, these various professional interests coalesced, when I belatedly understood that there was probably a link between HIV-2 infection in Guinea-Bissau, its epicentre, and programmes to control sleeping sickness during the colonial era, when that country was known as Portuguese Guinea. An epidemiological study among elderly individuals in Bissau confirmed that subjects who had been treated for sleeping sickness or tuberculosis decades before were more likely than others to be HIV-2-infected (in contrast with HIV-1, HIV-2 infection is compatible with prolonged survival, which enabled us to document such associations).
¹²

I realised that during my time in Zaire patients under my care were probably infected with HIV-1 during health care. In the rather primitive 110-bed
Nioki hospital, in the
Mai-Ndombe region about 500 kilometres north-east of Kinshasa, we used glass syringes and reusable needles. Normally, these would go through the hospital’s autoclave after each use, which should have killed all pathogens, including viruses. However, I did not pay too much attention to how long they were boiled for by the nurses in between patients when the hospital ran out of electricity so that the autoclave could not be used. Power outages could last up to two months at a time, when the whole country was short of the diesel fuel needed for generators.

For sleeping sickness patients (up to 400 per year), we mostly relied on 6–12 intravenous (IV) injections of an old
arsenical drug called
melarsoprol. Melarsoprol was in short supply, so that even 0.1 ml remaining in the vial after administering the dose for a first patient would be used for the next
.
I also remember the unfortunate tuberculosis patients, who were given intramuscular (IM) injections of streptomycin every day for sixty days (or even longer for those who did not tolerate one of the oral antituberculous drugs), with fairly dramatic adverse effects (the drug was toxic to the inner ear, and many patients had a hard time walking, some of them permanently). At the time, ‘international health’ resources were an order of magnitude lower than they are today, and the much more effective and less toxic treatment for tuberculosis, comprising only oral meds, was deemed far too expensive at $50 per patient, compared to $10 for the streptomycin-based regimen
. Potentially even worse, in the twenty or so rural health centres which I supervised, several of which could only be reached by dugout canoe, formol tablets were put into a metal box along with the syringes and needles as a sterilisation measure. Abscesses following injections were rare, so this process killed the bacteria, but what about the viruses?

I do not believe that transmission via medical interventions plays an important role in HIV dynamics today and I agree with the experts who maintain that it contributes to less than 5% of recent HIV infections, although even a single case is unacceptable. However, I became convinced that transmission during health care contributed to the simultaneous emergence of HIV-1 and HIV-2 in different parts of the African continent fifty to seventy-five years ago.
¹³

These were sobering thoughts, and I started trying to connect the dots in the history of HIV. This book is the result of these efforts over the last five years. It would not have been possible without the support of my wife Lucie, a Congolese nurse, who kept my interest for Africa very much alive. Several friends and relatives died of an AIDS-like illness before and after the disease was identified in Africa.

Some may say that understanding the past is irrelevant, what really matters is the future. I disagree. There are at least two good reasons for attempting to elucidate the factors behind the emergence of the HIV pandemic. First, we have a moral obligation to the millions of human beings who have died, or will die, from this infection. Second, this tragedy was facilitated (or even caused) by human interventions:
colonisation, urbanisation and probably well-intentioned public health campaigns. Hopefully, we can gain collective wisdom and humility that might help avoid provoking another such disaster in the coming decades.