Last update: September 5, 2008

This section includes reviews and/or commentaries of my book and my response to them.

Posted Sept 5, 2008 - A fairly detailed review in H-Net

Citation: Robert Van Howe “Review of James Chin, The AIDS Pandemic: The Collision of Epidemiology with Political Correctness,” H-Histsex, H-Net Reviews, November, 2007.
URL: www.h-net.msu.edu/reviews/showrev.cgi?path=276361201041910 .
Copyright _c 2007 by H-Net, all rights reserved. H-Net permits the redistribution and reprinting of this work for nonprofit, educational purposes, with full and accurate attribution to the author, web location, date of publication, originating list, and H-Net: Humanities & Social Sciences Online. For any other proposed use, contact the Reviews editorial staff at hbooks@mail.h-net.msu.edu .

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. Asthe 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.

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.[2] 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.[3]

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.[4]

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. [Point noted, but I wonder if he has had any experience in trying to convince a Berkeley graduate student that poverty and discrimination are not the major driving forces of HIV epidemics.] 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. [I'll let him do battle with the editorial staff - the AIDS field does have too many abreviations, but spelling out each in the text may also be somewhat excessive.] 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.[5] [I definitely do not recommend routine male circumcision (MC) in low HIV risk populations just as I don't recommend HIV/AIDS education directed primarily to the general population and all youth in low prevalence populations. MC field trials were stopped because the findings were conclusive that MC was about 60-70% effective in preventing HIV transmission in circumcised males. However, the development of mass MC programs in high HIV prevalence populations need to be carefully developed to avoid complications from inexperienced surgeons.] Finally (a verbal quibble), Chin uses parameters where factor or variable would be the proper usage. [To each his own - I prefer parameters since these factors or variables are either input or output parameters of most HIV/AIDS models.]

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.

Notes

[1]. 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).

[2]. 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 www.plosone.org/article/-info%3Adoi%2F10.1371%2Fjournal.pone.0000543

[3]. 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.

[4]. 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: 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 www.smh.com.au/-news/Opinion/HIV-supervirus-is-a-warning-to-all/2005/02/16/1108500157385.html

[5]. For a South African critique of the World Health Organization position, see A. and J. Myers, “Male Circumcision–The New Hope?,” South Africa MedicalJournal 97, no. 5 (May 2007): 338-341.

Posted Dec 17, 2007 - Full NATURE review

It should be noted that this review was prepared more than 6 months ago - before the reduction of the Indian HIV prevalence estimate and well before the release of the UNAIDS' 2007 update report in late November. This report confirms all of my major disagreements with UNAIDS that were described in detail in my book. UNAIDS has in fact been overestimating HIV prevalence and screaming that the AIDS pandemic was ever-increasing and ever-expending whereas global HIV incidence peaked about a decade ago!

NATURE - Vol 447|31 May 2007, page 531-532

Time for a change?
Two books on the AIDS pandemic in Africa challenge assumptions at the heart of the UN’s response.

Stephen Lewis and Paula Donovan

Has the tide turned away from AIDS orthodoxy?

Two books - strikingly different in tone and character - recount the global response to the AIDS pandemic with words of recrimination for the United Nations (UN). Helen Epstein and James Chin each raise searching questions about methods and motives, saving their most pointed barbs for UNAIDS, the body that coordinates the work of ten separate organizations within the UN system on the pandemic and tracks its spread.

Chin, a professor of clinical epidemiology at the University of California, Berkeley, has an axe to grind. He has long felt that the work of measuring HIV/AIDS and projecting its course is in the hands of scientists who lack epidemiological know-how. The results are inflated statistics and predictions of a global Armageddon with no basis in fact.

Over several pages, Chin describes how misapplied mathematical models have churned out exaggerated numbers, all flowing from the faulty assumption that national prevalence rates can be estimated by testing women in urban prenatal clinics and extrapolating to general populations. On this score, Chin has been vindicated by the US-funded Demographic and Health Surveys - the more accurate data gathered from randomly selected households in cities and rural areas - that are forcing UNAIDS to lower its estimates of national prevalence rates dramatically in country after country. (UNAIDS simply attributes these reductions to improved surveillance and will, says Chin, "ride to glory" on the myth that further declines prove the success of its prevention programmes, particularly among the young. In fact, he says, because most AIDS epidemics peaked in the mid-1990s, rates are receding naturally.)

Having been right on prevalence, Chin has to be taken seriously when he dismisses UNAIDS' doomsday predictions for India and China. Yes, this pandemic is an unparalleled public-health emergency, he says, but the double-digit prevalence rates seen in parts of Africa will never be reached elsewhere. That's because HIV takes hold among members of high-risk groups (men who have sex with men, injecting drug users, female sex workers), but only fans out to general populations where patterns of multiple, concurrent sexual relationships are the norm. Thus in many African countries, HIV traveled from a member of a high-risk group to each of his or her regular sex partners, then to their multiple regular partners, who introduced the virus to other networks until a vast web formed. It was not the number of sex partners - people everywhere average roughly the same number over their lifetimes - but the synchronicity of the encounters. According to Chin, in most of the world outside east and southern Africa, a culture of serial rather than concurrent sex partners has so far, and will continue to, confine HIV epidemics to high-risk groups. He predicts a slow rise in prevalence rates due primarily to life-prolonging treatment and to new infections, which from here on, he says, will be confined largely to people whose regular sex partners are HIV-positive.

If Chin is right - and to the non-scientist, at any rate, his textbook-like narrative is certainly provocative - the UN has wilfully deceived. Why? Because, he contends, the larger the numbers, the greater the carnage and the more the money flows in. Because associating the continent's horrific AIDS ordeal with African sexual practices might seem like racial stereotyping. Because it's easier to conduct prevention programmes among the general public than among the high-risk groups at society's edges. But why not over-reach, spreading prevention messages to entire populations, including those at highest risk? Because, Chin argues, given limited resources, only targeted prevention programmes can protect those most likely to become infected. Yet in place of that simple piece of logic, he sees an AIDS gestalt created in the service of fundraising.

UNAIDS identifies poverty, gender inequality, discrimination and lack of access to healthcare as underlying causes of sub-Saharan Africa's plague. Chin asserts that these problems must be addressed "because they create major barriers to effective HIV prevention and treatment programs, but they are not the primary or even the major determinants of high HIV prevalence". We're not sure that social scientists would agree (the line from poverty and gender inequality to high-risk commercial sex work seems fairly direct), but here again, it's hard to avoid the logic in the numbers.

There's much in Chin's book that Helen Epstein, author of The Invisible Cure: AIDS in Africa, would find palatable. Like Chin, she holds the bold view that the virus spreads beyond high-risk groups to the general population only through web-like networks of concurrent sex partners.

With elegant prose, a scientific background and a journalist's searching anecdotal eye, Epstein combines personal research and corroborative evidence from others to posit the view that where Africa's AIDS rates are highest, the key difference is not the numbers of sexual partners, but the timing. She then applies her theory to Uganda, the one country in Africa where a culture of concurrent sex partners was well entrenched and yet the prevalence rate of HIV/AIDS has been reduced dramatically since 1990.

Epstein describes how President Yoweri Museveni rallied his country in the 1980s with the mantra "Zero Grazing" that cautioned Ugandans not to have more than one partner at a time. She acknowledges the application of "ABC" - abstain, be faithful and use condoms - but asserts that an abrupt end to the practice of concurrent relationships was the decisive factor in reducing prevalence.

How was it brought about? Here we see Epstein at her best, explaining why Uganda succeeded where others failed. Above and beyond the messages from government bureaucrats, and a world away from donor driven aid ‘packages', the "personalized, informal, intimate, contingent, reciprocal nature of African society" led Ugandans to draw their own conclusions and fashion their own grassroots defence. Concludes Epstein, "the open discussions led by government field-workers in small groups of women and churchgoers, the compassionate work of the home-based care volunteers, the courage and strength of the women's-rights activists helped people see AIDS not as a disease spread by "others" but as a shared calamity, and this made discussion of sexual behavior possible without seeming preachy, condescending or out of touch".

Wealthier countries, such as South Africa and Botswana, looked to imported commodities and slick advertising campaigns, but in Uganda, the shocking pervasiveness of death was mellowed by the traditional African principle of ubuntu, or shared humanity, resulting in an indigenous response that stirred the collective conscience. Epstein speaks of the neighbourly exchange of caregiving as though it was a social movement, and in the mind's eye, the reader is convinced.

And then, like Chin, Epstein goes after UNAIDS. Mind you, her criticism is almost Victorian in its gentility, albeit unmistakable in its target. Where Chin uses a hatchet, Epstein wields the scalpel. She argues persuasively that the UN has long known that reduction in the number of sexual partners has been a factor wherever rates have fallen, from Uganda to San Francisco, and yet it refuses to act on it. Is it lack of respect for indigenous cultural awareness and survival instincts? She recounts how in 1993, a statistician now in the top ranks of UNAIDS misrepresented (mistakenly, it seems) findings about Uganda's success, erroneously claiming that researchers had noted an uptake in condom use and delay in sexual initiation, but no significant reduction in concurrent partners. The distortion prevailed. "It was only in 2006 that UNAIDS officials began to stress that the reduction of multiple sexual partnerships should be a key goal for AIDS prevention programmes in southern Africa," she reports. When the organization's executive director Peter Piot was asked about the omission in a list of questions Epstein sent him in 2004, he answered every question but that one.

The issue that lurks at the back of the mind of the reader in the case of both Chin's and Epstein's arguments is, what next? If UNAIDS has been locked in a rut of culturally questionable and epidemiologically flawed approaches, can it be rehabilitated? Chin would have us look harder at the scientific facts, and then start afresh with a new set of assumptions and projections; he would eliminate conflicts of interest by segregating epidemiologists from the officials concerned with advocacy and fundraising. Epstein would add to that the plea that programme planners rediscover the indigenous wisdom of African culture, which has successfully withstood threats since the dawn of humankind. Both books are guaranteed to spark animated discussion. Together, they pose the first open challenge to the UN's role in the most eviscerating plague in human history. ■

Stephen Lewis is former UN special envoy for AIDS in Africa, and Paula Donovan is an international HIV/AIDS consultant. They are in the process of setting up an international AIDS advocacy organization, AIDS-Free World.

The AIDS Pandemic: The collision of epidemiology with political correctness by James Chin
Radcliffe Publishing: 2007. 230 pp.
£27.50, $39.95

[Posted – June 24, 2007]
NATURE Book Review

In the 31st May, 2007 edition of NATURE, Stephen Lewis, a highly respected AIDS advocate and formerly the UN special envoy for AIDS in Africa, and Paula Donovan, an equally respected international HIV/AIDS consultant, reviewed two books about the AIDS pandemic. They reviewed my book and Helen Epstein’s -The Invisible Cure: AIDS in Africa.  The title and headings for their review were:

Time for a change?
Two books on the AIDS pandemic in Africa challenge assumptions at the heart of UN’s response.
Has the tide turned away from AIDS orthodoxy?

Clearly, I’m biased, but I found this review of my book to be fair and objective.  In contrast to some other reviewers, I believe they actually read my book through carefully.  They were able to succinctly summarize my chapters 6 (Understanding HIV/AIDS Numbers) and 7 (How Credible are HIV Estimates?) in a couple of sentences.

“Chin….has an axe to grind.  He has long felt that the work of measuring HIV/AIDS and projecting its course is in the hands of scientists who lack epidemiological know-how.  The results are inflated statistics and predictions of a global Armageddon with no basis in fact.”

I highly recommend this thoughtful and incisive review which concludes with the following sentences.  “Both books are guaranteed to spark animated discussion.  Together, they pose the first open challenge to the UN’s role in the most eviscerating plague in human history.”

This review did not defend UNAIDS’ “culturally questionable [Helen Epstein’s theme] and epidemiologically flawed [my theme] approaches.” Apparently, this review provoked UNAIDS to respond to both books on its website on June 11, and this galvanized me to develop my website on June 16 to respond to UNAIDS’ rather weak defense of its “scientific approach” for estimating and projecting HIV/AIDS numbers.

Aug 30, 2007 - UNAIDS under fire for mixing politics and science by Griffin Shea
http://news.yahoo.com/s/afp/20070830/hl_afp/healthaidsasiaun_070830051343

UNAIDS, the global standard-bearer in the fight against HIV, has come under stinging attack in two new books accusing it of allowing politics to trump science in its efforts to combat the disease. The most burning criticism, levied by American epidemiologist James Chin in his book "The AIDS Pandemic, [The collision of epidemiology with political correctness]" accuses UNAIDS of intentionally inflating its estimates of how many people have HIV in order to dramatise the epidemic and win more money from donors. Chin appeared vindicated in June [actually in early July], when India dramatically reduced its estimate of people infected to a range of 2.0-3.1 million from 5.7 million .... An equally sharp reduction was made in Cambodia, where the estimated infection rate was cut to 0.6 percent of adults from 1.6 percent. UNAIDS regional director for Asia Prasada Rao told AFP the decreases were only about improved science and said the dramatic reduction in the estimates showed the agency's willingness to embrace new data. "Ascribing motives to UNAIDS, that you are deliberately inflating the numbers to get more resources, that's really not something which I believe is acceptable," Rao said. In both India and Cambodia, Rao said the reduced estimates were made because of improved surveys. Earlier estimates were made based on data from clinics around each country, which experts used to guess how many people in the entire population have HIV. The new data came from random surveys of households, which provides a broader picture, he said. "I don't see any motive on the part of UNAIDS to inflate numbers. I don't think there is any axe to grind in this case, "Rao said... But Chin said he believes UNAIDS had intentionally used the upper end of all its estimates to try to make the epidemic seem as devastating as possible. "There is a fine line between deliberately lying with the numbers or using the upper range of estimates that are based on slim assumptions and unrepresentative data," he told AFP in an email...

[According to Helen Epstein, author of "The Invisible Cure", another book that is quite critical of UNAIDS] "The thing that bothered me is the way that they [UNAIDS] overblew the prospects for an Asian epidemic, she said "They got it almost perfectly wrong in some places. "They pushed for a targeting of the general population in places like India, when they probably should have targeted high risk groups, "But in Africa, the high number of people infected "includes absolutely everybody -- teachers, doctors, farmers, market traders, politicians, everyone".  Epstein said UNAIDS has tended to cite the prospect of the disease exploding in other parts of the world, without focusing enough on African nations that have long been the hardest-hit...

The books have sparked a wide-ranging debate among activists about how to fight the disease and raised questions about UNAIDS leadership. Rao insists the agency is open to criticism and has been adapting as new data becomes available. He worries that if UNAIDS is seen to be manipulating information, that could damage the agency's reputation and ultimately efforts to stop the disease. "UNAIDS is not saying the data is wrong. It is accepting the data and trying to harmonise the facts," he said. "That shows the openness that the organisation has got on this issue. And it is prepared to correct its data (and) revise its data based on other sources of information."

[Comment - My book provides details of the systematic overestimates of HIV prevalence made or accepted by UNAIDS over the past decade. I have never accused UNAIDS of lying or using false data. However UNAIDS and their scientific advisors have uncritically accepted high HIV estimates and projections derived from use of unrepresentative data and unfounded assumptions. Such high numbers "fitted" UNAIDS' socially and politically correct, but epidemiologically incorrect conclusions about the high potential risk of HIV epidemics in "general" populations in populous countries such as China, India, Indonesia, etc. UNAIDS cannot deny that it has made or accepted gross overestimates (up to 3-4 fold higher) of HIV prevalent numbers in virtually all high HIV prevalence countries (where estimated prevalence was at least 1 percent of the adult population). UNAIDS was not an early advocate of population based HIV surveys, but has been dragged, almost literally - kicking and screaming - to acknowledge that these population based surveys provide more representative and more accurate data for making HIV prevalence estimates. I do not doubt Rao's sincerity, but UNAIDS should admit that it had made or accepted gross overestimates of HIV prevalence and was slow to accept lower estimates from the score of population based surveys carried out over the past few years.

I obviously agree totally with Helen Epstein's comment on UNAIDS' position regarding HIV in Asia. There appears to be a fixed mind-set for UNAIDS, the World Bank, and probably for most official agencies involved with international AIDS programs - they are all in march-step with UNAIDS regarding the prospects for severe HIV epidemics in Asia. Peter Piot in his keynote address to the AIDS in Asia meeting, held in Manila in 1997, said "HIV will cut through Asian populations like a hot knife through cold butter!" However, aside from many explosive HIV epidemics in IDU populations and a slow but steadily increasing heterosexual HIV epidemic in Papua New Guinea, there have not been significant heterosexual HIV epidemics in the Asia-Pacific region, other than those that occurred in Thailand, Cambodia, Myanmar, and several Indian States during the 1980s and 1990s since Peter Piot's dire and colorful prediction.

In 2003, the World Bank asked me to prepare a detailed report on the prospects for severe HIV epidemics in Asia. I prepared a 50-page report and several months after submitting it I asked about its disposition. I was told that World Bank staff had prepared a detailed situation analysis of HIV/AIDS in the Asia region and my report was "helpful." In the final strategy paper they issued, that stressed the "impending storm" scenarios, my report was essentially boiled down to one footnote: "In contrast [to high range projections], low range estimates predict Asia HIV epidemics are constrained by low risk sexual behavior in the general population (Chin, 2003). It is disappointing that epidemiologists at CDC, NIH, all of the UN Agencies, International Agencies, etc., have remained mute about UNAIDS' paradigm - in the absence of effective education and prevention programs directed to the general public and especially to all youth, it is not a matter of if, but when heterosexual HIV epidemics will explode in current low HIV prevalence populations. Their collective silence gives tacit support to UNAIDS' politically correct but epidemiologically unrealistic paradigm!]

7 Aug, 2007 - Fair criticism - (submitted to the editors of Economic Times - India - but not published until Aug 30) by Professor James Chin University of California, Berkeley

In defense of the over-estimates made by UNAIDS around the world, Professor Geoff Garnett (letters, ET, 7 August) calls my criticism ("UN cries wolf about AIDS", ET, July 31) unfair because “estimation methods used by UNAIDS are guided by a reference group providing independent scientific advice." This makes the situation worse.

If UNAIDS' persistent exaggerations were the result of mistakes by a small group of over-worked technocrats it might be understandable although not forgivable. But that so many "experts" have toiled so long to get it so wrong casts doubt over the credibility of the agency and all involved with it.

Furthermore, his claim that numbers have fallen in Kenya and Haiti because the AIDS pandemic has "declined" is, at best, disingenuous. HIV prevalence has been decreasing in almost all regions and countries throughout the world because virtually all HIV epidemics are in their post peak phase. This observation runs counter to all UNAIDS reports that describes the AIDS pandemic as ever-increasing and ever-expanding.  However, last year UNAIDS was forced to acknowledge that annual global HIV incidence peaked by the late 1990s. Thus, UNAIDS' forced reduction of gross overestimates has obfuscated the current global pattern of decreasing HIV prevalence.

The bottom line is that gross overestimates of HIV prevalence have been made and UNAIDS (and their scientific advisors) should just acknowledge this reality instead of saying that such criticism is unfair.

7 Aug, 2007 - Economic Times (India) - Unfair criticism - Letter to editor by Prof Geoff Garnett Chair of The UNAIDS Reference Group on Estimates, Models and Projections (e-mail, August 2)

Many of the claims in James Chin's account of the HIV pandemic are unfair and inaccurate ("UN cries wolf about AIDS", ET, July 31). Estimation methods used by UNAIDS are guided by a reference group providing independent scientific advice.

Contrary to Chin's statement, these methods have regularly been published in peer reviewed journals. Sentinel HIV surveillance, originally recommended by Chin, has many biases when used to estimate the prevalence in a country's population.

In his reference to India, Chin's claim that UNAIDS estimated 5.7 m people living with HIV in 2005 and now the Indian National AIDS Control Organisation lowered the number to 2.5 m neglects to mention that UNAIDS has been working with India since 1998 and that all the estimates have been the results of work coordinated by NACO with UNAIDS and WHO support.

His claim that Kenya's HIV estimate was reduced from 2.3 m to 1.1 m in 2003 is based on the result of a population-based survey and the fact that the HIV epidemic had begun to decline. This decline is seen consistently in sampled sites, so is not a result of more representative data. Similarly for Haiti the reduced estimate is due to both adjustments to past estimates and the fact that the HIV epidemic is declining.

Based on the inclusion of the results of population-based surveys adjusted for non-response, HIV estimates for most countries in sub-Saharan Africa have already been adjusted. UNAIDS and its partners will continue to assist countries to obtain an accurate understanding of the epidemic.

31 Jul - Economic Times (India) - UN cries wolf about AIDS OP-ED article by James Chin

The UN agency coordinating global action against AIDS is wiping egg off its face after reluctantly admitting it had overestimated India's AIDS problem by more than half - following numerous similar exaggerations world-wide.

In 2005 the joint UN Programme on AIDS (UNAIDS) claimed there were 5.7 million infected with HIV in India, giving India the highest number in the world, but the Indian National AIDS Control Organisation (NACO) figures for 2006 released recently lowered the number to 2.5 million - and UNAIDS has had to admit the new estimate is more accurate.

Director Peter Piot, speaking to an AIDS conference in South Africa in June said UNAIDS's work "is further complicated by the mixed messages circulating around the world" and "denialist statements such as that UNAIDS overestimates the size of the epidemic..." The HIV overestimates made or accepted by UNAIDS in recent years total about 10 million - so who is the real denialist?

Since 2001, UNAIDS has been forced to acknowledge drastically-reduced HIV prevalence estimates in over a dozen African, Caribbean and Asian countries, as a result of well-designed "population-based" HIV surveys (randomly selected samples of urban and rural populations). Kenya's HIV estimate was reduced from about 2.3 million to 1.1 million in 2003. Ethiopia's estimate was reduced from nearly two million to about half a million in 2005. Haiti's estimate of almost 250,000 HIV-infected adults in 2001 was cut to less than 100,000 in 2006.

However, UNAIDS continued to defend its exaggerations up through 2006. UNAIDS were quick to respond to my charges, with spin rather than substance, referring vaguely to their "scientific approach" to calculating HIV numbers and the fact they collaborate with experts and governments. They refused to acknowledge that their approach was wrong or that the figures were bogus until the Indian revision exposed both. UNAIDS has simply glossed over the new estimates as being the result of better data and improved methods that are constantly evolving.

Some AIDS activists say there is no harm in overestimating the current size and potential severity of the AIDS pandemic since such exaggerations have successfully provided AIDS programmes with unprecedented global priority and support. It needs to be recognised that UNAIDS was established in 1995 as an advocacy and coordinating agency that almost immediately turned over responsibility for AIDS programme funding and technical guidance to other agencies and donors. However, UNAIDS did not turn over the responsibility for the estimation and projection of HIV/AIDS numbers. Since UNAIDS has declared itself to be primarily an advocacy agency, its objectivity in making or accepting high HIV estimates and projections needs to be questioned.

UNAIDS, AIDS programme advocates and activists have certainly used inflated HIV numbers effectively in their aggressive struggle for an increasing share of the limited international health budget. This success, however, has come at the expense of other equally urgent public health needs. Regardless of UNAIDS's systematic overestimation of HIV numbers, the severity of the AIDS pandemic in sub-Saharan Africa requires that AIDS programmes in this region continue to receive the highest public health priority. In India too, whether HIV prevalence is close to six million or "only" 2.5 million, AIDS remains a serious public health problem in this populous country.

A UNAIDS spokesperson has said that the new calculation for India reduces the world estimate to about 37.5 million people and that UNAIDS does not expect any more revisions from countries with major HIV and AIDS epidemics: "India was the last unknown." As of 2007, there are about 50 countries where HIV prevalence has been estimated to be more than 1% of the adult population. More than half of these countries have had their HIV prevalence estimate based on the flawed method that relied on "sentinel surveillance sampling" of mostly urban antenatal clinics. This was extrapolated to the total national adult population, although towns have the highest HIV prevalence.

So how can UNAIDS be so confident that there will not be any more revisions from countries with major HIV epidemics?

[Posted – June 16, 2007]
At the opening of the third South African AIDS conference in Durban, 05 June 2007, Peter Piot said:

The challenge is further complicated by the mixed messages circulating around the world. Denialist statements such as that “UNAIDS overestimates the size of the epidemic,” and “There’s too much money for AIDS” don’t help. Not least because there’s clearly a massive gap between what’s needed and what’s available..."

My response to Peter Piot about UNAIDS overestimating the size of the AIDS pandemic

I may be paranoid, but coming on the heels of the NATURE book review (May 31, 2007) that described what I consider “inflated” HIV numbers made or accepted by UNAIDS, I suspect that Peter Piot’s denialist statement was directed at me!  Peter Piot may label a statement that: “UNAIDS overestimates the size of the epidemic” as a denialist statement, but such a statement continues to be confirmed by the relentless downward revision of HIV prevalence estimates in about a dozen sub-Saharan African countries, several Caribbean countries, and a few Asian countries over the past couple of years – culminating in the Indian revision which should see the light of day by early July.  The overestimation of HIV infected adults from countries where population based HIV surveys have been carried out in recent years totals about 10 million!

Who is the real denialist about the size of the AIDS pandemic?  However, I do agree with him that “there’s clearly a massive gap between what’s needed and what’s available [for anti-HIV..."

UNAIDS’ reaction to my book and my response
Purnima Mane (Director of Policy, Evidence, and Partnerships at UNAIDS) sent a letter (March 23, 2007) to the editor in response to my OP-ED article in the March 11 edition of the SF Chronicle and UNAIDS responded on its website to my book on June 11.  Both of these UNAIDS responses are very similar and they are posted in this section of my website after my response to both Ms Mane’s letter and the UNAIDS website.

My response to UNAIDS

UNAIDS’ responses to my OP-ED article (Myths and Misconceptions of the AIDS Pandemic) in the March 11th edition of the San Francisco Chronicle and to my book were essentially to defend what they refer to as their “scientific approach” to their making up of the HIV numbers.  UNAIDS accuses me of mischaracterizing its HIV estimation process and tries to assure everyone that its HIV estimates“are not produced in isolation, but rather in close collaboration with world leading epidemiologists and national governments.”  However, UNAIDS’ HIV prevalence estimation process is not the issue at hand!  I have never accused UNAIDS of not being transparent and open about their estimation process.  I just happen to believe that the data and method they use to “cook” the HIV numbers are seriously flawed!  From my epidemiologic perspective, the contentious issue is that I’m convinced that UNAIDS, regardless of whether its HIV estimation methodology is “regularly reviewed by an international team of experts chaired by a leading academic from London University's Imperial College” or not, has for the past decade been making and/or uncritically accepting gross overestimation of HIV prevalence numbers.  Since 2001, UNAIDS has been forced to reduce HIV prevalence estimates in over a dozen African and Caribbean countries, and most recently in a couple of Asian countries drastically (up to several times lower) as a result of population based HIV serologic surveys. The total number of HIV infected adults overestimated by UNAIDS in countries where population based surveys have been carried out in the last few years is about 10 million.  Kenya’s HIV estimate was reduced from about 2.4 million to 1.2 million in 2003, Ethiopia’s estimate was reduced from close to 2 million to about a half million in 2005, Haiti’s estimate of almost 250,000 HIV-infected adults in 2001 was lowered to less than 100,000 in 2006, and India’s estimate will likely soon be reduced from close to 6 million to less than 3 million!

Thus, there can be no denial that many, if not most, HIV prevalence estimates made or accepted by UNAIDS have been grossly overestimated or “exaggerated.”  UNAIDS’ response to my assertion - that it has systematically overestimated and/or uncritically accepted gross overestimations of HIV prevalence - has been to simply ignore the stark reality that some gross overestimations have occurred.  UNAIDS has steadfastly refused to admit that it has grossly overestimated or exaggerated HIV prevalence and simply glosses over the new revised lower HIV prevalence estimates as the result of better data and improved methods that are constantly evolving.  I have for the past decade been consistently criticizing the UNAIDS’ standard use of mostly urban sentinel antenatal clinics where the highest HIV prevalence might be expected and then extrapolating these biased findings to the total national adult population.  I was invited to participate in a meeting of the UNAIDS Reference Group on Estimates, Modelling, and Projections in Madrid in late 2002 where I gave a presentation describing this major problem, but apparently what I had to say went in one ear and out the other!  This flawed method accounts for the bulk of the UNAIDS’ overestimation of HIV prevalence but has been somewhat ignored by UNAIDS and their scientific advisors until the population based HIV surveys forced them to revisit this methodology.

UNAIDS in its June 11 response on its website also said that I have asserted “that there have not been significant heterosexual HIV epidemics in any Asian country and that UNAIDS is being alarmist in advocating for strong national responses in Asia.”  This accusation is puzzling to me since I do not say this in my book nor have I ever said it!  Perhaps some staff at UNAIDS may have misinterpreted my often stated conclusion that there will not be any “generalized” heterosexual HIV epidemics in Asian-Pacific countries (with the possible exception of PNG). I’m well aware of the explosive heterosexual HIV epidemics in Thailand, Cambodia, and in several states in India that were related to large brothel type sex networks since I was the senior author of a paper describing HIV prevalence patterns in Asian-Pacific countries (Chin J, Bennett A, and Mills S: Primary determinants of HIV prevalence in Asian-Pacific countries. AIDS 12 (suppl B): S87-S91, 1998).  Our conclusion from our review of the general patterns and prevalence of heterosexual risk behaviors in Asian-Pacific countries was that, aside from potential HIV epidemic spread in pockets of sex workers and their clients, that the general patterns and prevalence of risky sex behaviors in most Asian-Pacific populations are insufficient to fuel and sustain any significant heterosexual HIV epidemics.

I have and continue to strongly advocate focused outreach programs in Asian-Pacific countries to sex workers and their clients to prevent heterosexual HIV epidemics regardless of what the actual potential for explosive HIV epidemics may be.  I continue to believe that HIV awareness programs directed to the wider public and all youth are not essential for the prevention of heterosexual HIV epidemics outside of sub-Saharan Africa and such general programs directed to the wider public should only be supported after prevention programs targeted to sex workers and their clients are adequately funded.

I’m fairly confident that whoever wrote the UNAIDS response to my book did not read it.  Near the end of the June 11 response is the sentence – “Numerically, low prevalence epidemics in Asia still mean very large numbers of people affected and requiring appropriately targeted prevention and treatment services.”  I couldn’t agree more! The following text is from page 178 of my book.

“…In China and throughout the world, I believe that there has been insufficient attention given to the different patterns of sexual risk behaviors that exist and range from the highest risk (hundreds to thousands of different sex partners annually) to the lowest (a few different sex partners during a lifetime). It is socially and politically correct to assume that, because sexual risk behaviors are present in all populations throughout the world, all populations are, therefore, at almost equal risk of epidemic sexual HIV transmission. There is an occasional disclaimer that perhaps heterosexual HIV epidemics may not ever be quite as severe as those in SSA. As a very old and experienced infectious disease epidemiologist, I fully recognize that any heterosexual epidemic, no matter how “small” in populous countries such as China, India, and Indonesia could quickly total several million or more new HIV infections during this decade. However, I cannot understand the need to have huge numbers of HIV infections to make AIDS a very high priority public health problem. As a global community, “we” would not tolerate a few human mad cow disease cases, yet if a country has “only” a few thousand HIV infections, AIDS activists somehow feel belittled.

I am not preaching public health complacency, but I am preaching that effective prevention of HIV transmission in low prevalence countries must be targeted primarily to the highest HIV risk populations and not to the general public and youth. I am also saying that there has been and continues to be insufficient public health attention and effort directed to the regular sex partners of HIV-infected persons in both developed and developing countries.”

I want to thank UNAIDS for their responses to my OP-ED article and my book because they have given me an opportunity to clarify my disagreements as well as my agreements with UNAIDS to my public health friends (I still have a few!) and colleagues in Geneva and throughout the world.

I welcome any questions, comments, and disagreements with anything I have included in my response to UNAIDS.  I think the probability that UNAIDS will continue to post comments or any further response to my book on its website are slim to none, but I’m prepared to defend everything I have included in my book.

OK, the ball is back in UNAIDS’ court!

Jim Chin
Stockton California
June 14, 2007

[UNAIDS] Response [on the UNAIDS website] to the book The AIDS Pandemic: the collision of epidemiology with political correctness

Geneva, 11 June 2007 –UNAIDS wishes to correct multiple mischaracterizations that appear in a book published by Radcliffe Publishing, entitled The AIDS Pandemic: the collision of epidemiology with political correctness by James Chin. These errors deal with the process and results of the estimations of the AIDS pandemic, made with technical assistance from the UNAIDS Secretariat and WHO.

An op-ed piece by Dr Chin, published in the San Francisco Chronicle in March 2007, summarizes the claims made in the book. Dr Chin wrote, “Many myths and misconceptions about the AIDS pandemic are spread by the Joint United Nations Program on HIV/AIDS (UNAIDS) and other mainstream AIDS agencies and activists, either unintentionally out of ignorance or intentionally by distortion or exaggeration, including fear of a generalized epidemic.”

The underlining theme of Dr Chin’s book is incorrect. The UNAIDS Secretariat and WHO work with other partner organizations, as well as individual countries, to monitor the status of the AIDS epidemic and to guide the response to it. Estimates are not produced in isolation, but rather in close collaboration with world leading epidemiologists and national governments. The regularly reviewed methodology is based on recommendations of an international team of experts chaired by a leading academic from London University's Imperial College, UK.(1) UNAIDS Secretariat and WHO data are not influenced by political or fundraising agendas.

The UNAIDS Secretariat and WHO have been open in publicizing the methods used to assess the magnitude of the past and current epidemic, and the evolution of these methods in the light of new data . In recent years, adjustments to earlier published estimates of prevalence, mortality and new infections for many countries have been presented in a transparent fashion, and the UNAIDS Secretariat and WHO expect there will be more adjustments as new data and methodological refinements become available.

Chin also asserts that there have not been significant heterosexual HIV epidemics in any Asian country and that UNAIDS is being alarmist in advocating for strong national responses in Asia. While the data show that levels of HIV prevalence in the general population of Asian countries have remained contained, concentrated epidemics of HIV affect female commercial sex workers, men who have sex with men, injecting drug users, and the partners and children of those persons. Numerically, low prevalence epidemics in Asia still mean very large numbers of people affected and requiring appropriately targeted prevention and treatment services.

The AIDS response has always invited a high-level of debate and discussion. The UNAIDS joint programme welcomes this debate and stands by its scientific approach. The AIDS epidemic continues to evolve and the response must evolve accordingly. It’s critical for countries to “know their epidemic” in order to focus HIV prevention, treatment and care programmes to reach those at highest risk of infection. UNAIDS will continue to use the best available data to advocate for the most effective response for the millions in need.

(1) For full list of participants: http://www.unaids.org/en/HIV_data/Epidemiology/reference_group_list.asp

Letter to SF Chronicle editors – March 23, 2007

UNAIDS responds
Editor -- In response to the March 11 Open Forum article by James Chin, "Myths and misconceptions of the AIDS pandemic": UNAIDS disagrees with Chin's assertions on AIDS data. We work with WHO and many of the world's most-respected epidemiologists, as well as individual countries to monitor the status of the AIDS epidemic. Estimates are not produced in isolation, but in close collaboration with national epidemiologists and governments.

We stand by our scientific approach. The AIDS epidemic continues to evolve and the response must evolve accordingly. Counter to Chin's claims, UNAIDS has underlined the need to "know your epidemic" and to focus HIV prevention, treatment and care programs to reach those at highest risk of HIV infection.

Articles such as Chin's minimize the devastation the AIDS epidemic has had, and continues to have across the world. U.N. efforts have been critical in moving many countries out of denial and into action. We will continue to use the best available data to advocate for the most effective response for the millions in need.

PURNIMA MANE, director
Policy, Evidence and Partnerships
UNAIDS, Liechtenstein

Myths and misconceptions of the AIDS pandemic

James Chin
Sunday, March 11, 2007

Many myths and misconceptions about the AIDS pandemic are spread by the Joint United Nations Program on HIV/AIDS (UNAIDS) and other mainstream AIDS agencies and activists, either unintentionally out of ignorance or intentionally by distortion or exaggeration, including fear of a generalized epidemic.

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.

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).