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Rethinking AIDS: The Tragic Cost of Premature Consensus.

The biologic world is rarely simple, and the relationship between acquired immunodeficiency syndrome (AIDS) and the human immunodeficiency virus (HIV) is no exception. In Rethinking AIDS, Robert Root-Bernstein, an associate professor of physiology at Michigan State University, argues that AIDS "is not caused by a simple HIV infection but is a syndrome requiring multiple, concurrent causes of immune suppression." This profoundly changes the profile of those at risk for acquiring AIDS. As he sees it, "No one at risk for AIDS has a normal immune system to begin with."

According to Root-Bernstein, HIV is not the only path to developing AIDS. As he points out, many inherited and acquired causes of immune deficiency are known, but many still remain a mystery, and many immune deficiencies result in illnesses that are also associated with AIDS. For him, the existence of HIV-negative individuals with immune deficiencies and AIDS-like illnesses is evidence that HIV is not the only cause of AIDS. But not all immune deficiencies are AIDS, and not all individuals initially diagnosed as having AIDS actually have the disease. Nevertheless, Root-Bernstein uses this feeble foundation to begin making his case for an alternative view of what causes AIDS.

Root-Bernstein's suggestion that those who become infected with HIV are destined to do so because of their previously compromised immune systems is specious. And to imply that individuals can be protected from HIV infection or AIDS if they eat right, don't smoke, practice only heterosexual oral or vaginal intercourse, avoid drugs of all types, and practice other behaviors that do not threaten their immune systems is misleading and dangerous.

To make his case, Root-Bernstein tries to reinterpret much of the experience we have with AIDS. For example, he dismisses AIDS cases associated with transfusion, receipt of contaminated clotting factor concentrates, and perinatal transmission as proof of the role of HIV "since none of the recipients of the HIV is healthy at the time of infection." He further disputes the role of HIV with a claim that it "is definitely not pure in these cases." Furthermore, he largely ignores the cases attributed to heterosexual transmission among couples in developed countries in which one spouse had been the recipient of contaminated blood or blood products or who had engaged in risky behavior not known to the other spouse.

By asking, "Where is the HIV anyway?" he implies that the risk of heterosexual transmission has been greatly overstated. Because the reported rates of HIV infection among prostitutes in the United States and other countries are low (except among prostitutes who also inject drugs), Root-Bernstein concludes that "HIV cannot be a sexually transmitted disease, in the usual sense of the term." But there are explanations for the lower rate of HIV transmission. The acute phases of syphilis, gonorrhea, herpes, and many other sexually transmitted diseases are characterized by areas of inflammation or one or more ulcerative lesions that exude blood, serous fluid, or pus. Millions of the disease-causing organisms are present and are readily transferred to sex partners, making the odds of transmission very high. In contrast, HIV does not primarily reside in the genital tract, but rather, its appearance there in the infected individual reflects delivery via the blood-stream as either free virus or in infected lymphocytes in semen or vaginal secretions. Active lesions may serve as an additional portal of exit from an HIV-infected person, or as a portal of entry to an uninfected person. Root-Bernstein chooses to emphasize only the hypothetical immunologic risks associated with multiple concurrent infections, not the physical pathways for sexual transmission of HIV created by the genital ulcerative lesions.

To support his assertion that AIDS is a danger only to those whose behavior weakens their immune system, Root-Bernstein cites stable or declining trends in HIV seroprevalence among U.S. military recruits as evidence that "HIV infections among the general population are no more common in 1992 than they were in 1985." But military recruits are not the general population, and declining incidence reflects changes in the recruit population itself. Most military recruits are between the ages of 17 and 21, male, and less likely than average to be homosexual or users of injected drugs. More extensive serosurveys of HIV in the United States show increasing numbers of women and minorities to be infected, reflecting a distinct change in the distribution of infection in the general population.

Health care workers

Root-Bernstein acknowledges only four cases of AIDS among health care workers and suggests that "the ones who seroconvert may well be those with other immuno-suppressive risks." Noting that physicians and dentists allegedly have the highest rates of drug abuse among professionals and that anesthesiologists and many surgeons and nurses are exposed to repeated and prolonged doses of anesthetics, Root-Bernstein speculates that for health care workers "the combination of drug abuse or anesthesia, exposure to HIV, and probable transmission of other infectious agents associated with AIDS, such as hepatitis or cytomegalovirus, would be no different from that encountered by an intravenous drug abuser using a dirty needle."

Not only is the analogy strained, it also ignores the documented instances of HIV seroconversion among laboratory and other health care workers who are not physicians or nurses but who were nonetheless infected via exposure in the workplace. He does mention the laboratory worker who became infected (via a cut) with a cultured strain of HIV, but he attributes the failure of that worker to develop AIDS after four years of followup to the purity of the virus, rather than to any usual time between infection and illness, and asserts that "no laboratory researcher exposed to HIV has yet been reported to have developed AIDS." In fact, the Centers for Disease Control and Prevention recently reported that 8 of 36 health care workers with documented occupational transmission of HIV have developed AIDS; the distribution of AIDS cases by occupation among these 8 parallels the distribution of HIV among all 36 and does include laboratory workers.

In trying to get around the signficance of AIDS among transfusion patients, Root-Bernstein creates a convoluted argument claiming that transfusion patients who do not receive HIV-infected blood suffer the same mortality as HIV-positive patients. But the real issue is that some people survive the medical conditions that provoked the transfusion, but become infected with HIV and go on to develop AIDS. These patients are clearly different from those who recover after their transfusions but do not develop AIDS because they were not infected with HIV.

Sometimes, he seems not to know what anyone with his training must know. For example, he interprets the failure of chimpanzees to develop AIDS after HIV infection to mean that HIV is "incapable of causing AIDS by itself or perhaps at all." This naive dismissal of species specificity of pathogenic organisms is damning in its denial.

Rethink AIDS? Of course, we should always be reexamining our assumptions. But let us not do so by attacking those living and working with AIDS. Let us tackle the problems that have exacerbated the epidemic--illicit drug use and unprotected sex with multiple partners. On this we agree with Root-Bernstein, who says, "If we want to control AIDS, it is not vaccines, antiretroviral drugs, or other medical miracles that we need. We need to solve the social, economic, health-education, and medical-care problems that create the conditions that permit AIDS to develop in the first place." And let us also see to it that persons infected with HIV get the medical, social, and preventive services they need to continue living productive lives.

Rethink, yes. But don't ignore the facts. More important, respond.
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Author:Jones, Wanda K.; Curran, James W.
Publication:Issues in Science and Technology
Article Type:Book Review
Date:Sep 22, 1993
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