HEALTH: by Lucy SullivanNews Weekly
Kirby Institute report silent on incidence of AIDS
, May 10, 2014
Social scientist Dr Lucy Sullivan reviews the Kirby Institute’s recent 144-page Annual Surveillance Report 2013 on HIV, viral hepatitis and sexually-transmitted infections (STIs) in Australia.
The institute between 1986 and 2011 was known as the National Centre in HIV Epidemiology and Clinical Research. In April 2011, on the organisation’s 25th anniversary, it was renamed the Kirby Institute in honour of former High Court judge Michael Kirby. It employs approximately 200 researchers and conducts clinical trials in more than 20 countries.
Human immuno-deficiency virus (HIV)
The identification of human immuno-deficiency virus (HIV) as an infection was soon followed by its acceptance as the precursor to the disease cluster already defined as acquired immuno-deficiency syndrome (AIDS).
The Hon. Michael Kirby AC CMG.
The Kirby Institute for Infection and Immunity in Society, based at the University of New South Wales, Sydney, has recently published its Annual Surveillance Report 2013 on HIV, viral hepatitis and sexually-transmitted infections (STIs) in Australia.
In the report the institute continues, without explanation, its policy of recent years of omitting reference to AIDS itself. There is no reporting of the incidence of AIDS morbidity and mortality. This leaves HIV infection without a recorded associated disease syndrome, and the ability to link HIV infection to rates of disease expression is consequently lost.
Instead, the report focuses attention on documenting drug treatments; but, in the absence of documentation of morbidity and mortality, the epidemiology of AIDS is obscured and inaccessible. For all the reader knows, there is no evidence of association between HIV infection and disease and death rates which justifies the drug treatment in the first place.
The number of cases of newly-diagnosed HIV infection each year (which is not the same as newly acquired HIV infection) fell during the early years of notification from an accumulated high to a low of 724 in 1999, but has persistently risen since then to reach 1,104 in 2008 and 1,250 in 2012 — a rise of 75 per cent since 1999. The rates are now fairly similar in Australia’s four most populous states, at four to five persons diagnosed per 100,000 population, but lower elsewhere.
In 2012, 87 per cent of cases were in males. Transmission continues to be primarily by male homosexual contact (70 per cent), of which close to half were of overseas birthplace. The Kirby Institute’s report offers no suggestions as to the reasons for the low rate in the Australian heterosexual population, particularly as it contrasts with higher rates in heterosexuals who are migrants from high-prevalence countries. Some 34 per cent of cases of heterosexual transmission in Australia were of persons from a high-prevalence country, far above their proportional representation in the population.
The total number of HIV-infected persons in Australia is currently estimated at 25,700.
Hepatitis B and C
By contrast, the rate of diagnosis of hepatitis B was stable from 2008 to 2012, at about 31 per 100,000 population, while that of hepatitis C fell from 52 to 44.
The actual number of hepatitis B diagnoses was 6,200 and of hepatitis C, 8,800 — respectively five and seven times greater than for HIV. The large male bias of HIV does not appear in hepatitis: in 2008, 45 per cent of hepatitis B diagnoses and 37 per cent of hepatitis C diagnoses were in women; and in 2012 the figures were 43 per cent and 35 per cent, respectively.
The estimated number of chronic cases of hepatitis B in Australia currently is 207,000 and of hepatitis C, 230,000 — respectively eight and nine times the level of HIV. The number of deaths from hepatitis B infection in 2012 is estimated at 383; but, as for HIV, no estimate is offered for hepatitis C.
In 2012, of the hepatitis infections of known exposure category, only 4.3 per cent of hepatitis B infections were associated with homosexual contact, as against 29 per cent with heterosexual contact, and 43 per cent with intravenous drug use (IDU). In the same year, 3.2 per cent of hepatitis C infections were associated with sexual contact (homo- and hetero- are not distinguished) and 95 per cent with intravenous drug use.
Thus hepatitis B and hepatitis C have quite different transmission characteristics, with hepatitis C, despite free needles, firmly attached to IDU practices.
Sexually-transmissible diseases (STDs) other than HIV
The incidence of sexually-transmitted diseases, in the decades following the post-World War II availability of penicillin, had become insignificant in population terms. Its rise from the 1970s cannot be dissociated from the rise in sexual promiscuity which was proselytised in ’60s and ’70s liberation philosophy. The revolution in medication proved no match for the rich matrices of interpersonal genital and oral contact that ensued.
Chlamydia, which in its genital form can result in infertility in women, remained the most frequently reported notifiable sexually-related infection in 2012, with 82,700 diagnoses, and a population rate of 355 per 100,000. This was an increase from 58,427 and a rate of 265 per 100,000 in 2008. In 2008, 59 per cent of diagnoses, and in 2012, 58 per cent, were in women.
The rate of diagnosis of gonorrhoea increased from 35 per 100,000 in 2008 to 58.9 in 2012, with an increase in total diagnoses from 7,679 to 13,649. In 2008, 35 per cent of diagnoses, and in 2012, 30 per cent, were in women.
Diagnoses of syphilis increased from 6.1 per 100,000 in 2008 to 6.7 in 2012, with an increase in total diagnoses from 1,322 to 1,534. The increased rates were in Queensland, Victoria and New South Wales. In 2008, 11 per cent of diagnoses, and in 2012, 10 per cent, were in women. Of diagnoses with identified sexual exposure, 76 per cent were of homosexual origin in 2008 and 77 per cent in 2012.
Thus syphilis has transmission and infection characteristics similar to HIV, being found predominantly in the male population, and among males, in homosexual men.
These figures make it clear that the sexual promiscuity preached by liberation philosophy, which was only gradually adopted by the general population across the ’70s and ’80s, continues to accelerate even in the absence of the positive encouragement of former years. The cost to the taxpayer in medication and treatment is not estimated in the report, but is bound to be considerable. The cost to the individual in the unanticipated consequences of disease and infertility is personal as well as economic.
Transmission of HIV and hepatitis B and C
The free needle program in New South Wales was introduced to prevent this transmission of the blood-borne HIV between intravenous drug users. It is therefore anomalous that HIV infection shows no association with injecting drug use, in marked contrast to hepatitis C, which continues to occur almost exclusively in people with a recent history of injecting drug use (IDU), indicating its genuine status as a blood-transmitted as well as a blood-borne infection. The same cannot be said for HIV which lacks this association with IDU.
If HIV is in fact blood-transmitted as well as blood-borne, is it that injecting drug users and homosexual men are almost entirely distinct populations? Hardly. Or that homosexual men who are ID users, unlike their heterosexual counterparts, are strictly observant of injecting hygiene and do not share needles?
We still await a considered explanation of this unanticipated outcome, which suggests that although HIV is detected in the blood it is not transmitted via the blood. Mucous, as well as blood, has in the past been suggested as the vector for HIV transmission, and is certainly a more constant bodily accompaniment to sexual contact.
Alternatively, it might be that neither blood nor mucous are vectors for HIV transmission and the presence of HIV in the blood derives from other, perhaps self-generated, factors. Given the distinctive characteristics of homosexual activity, behavioural factors that result in the depletion of the immune system are suggested. HIV then becomes more properly an intervening variable — a marker of disease-producing behaviours that predispose to the contraction of the AIDS-defining diseases rather than the causal infection per se.
This could explain the low incidence of HIV infection in the heterosexual Australian population, together with its heterosexual presence in countries with lower health standards than Australia.
Attention should surely be given, also, to the strong association of syphilis — unlike the “other” sexually-transmissible infections, but like HIV — with homosexual contact.
“Disappearance” of AIDS
If AIDS as a disease category was discarded because of the multiplicity of diseases that compose the syndrome, this need not have implied a total abdication of reportage of diseases associated with HIV. It would be perfectly possible to compare the incidence of a range of infections and diseases individually and in toto in the HIV-infected and in the population as a whole, and thereby identify those for whom HIV emerges as the precipitating or an associated factor.
With an epidemiological vacuum now placed between HIV infection and the development of severe illness leading to death, the disease consequences built on HIV become shadowy indeed, and epidemiological investigation of other routes to AIDS is obviated.
Lucy Sullivan, PhD, is an Australian social scientist. Her book, False Promises: Sixties Philosophy Against the Church: A Social Memoir Enhanced by Statistics, 1903-1993 (Windsor, NSW: Windrush Press, 2012), is available from News Weekly Books. The Kirby Institute’s 144-page report, reviewed above, is available at: www.kirby.unsw.edu.au