VIRUSMYTH HOMEPAGE
PRESIDENTIAL AIDS ADVISORY PANEL REPORT
SETTING THE SCENE
Chapter 1
1.1 Background
The South African government is currently confronted with the challenge of responding to the growing AIDS (Acquired Immune Deficiency Syndrome) epidemic. The government’s response has been characterised in the main by a prevention strategy, supported by a multi-sectoral programme involving partnerships between government departments, civil society, NGOs (non-government organisations) as well as other sectors like the women’s sector, faith-based organisations, the youth, traditional healers and traditional leaders.
The nature of the AIDS epidemic in South Africa, and sub-Saharan Africa in general, has been a growing cause for concern and recent developments in several areas of the response have created a need to evaluate some of the interventions. It is also an established fact that the determinants of the epidemic and some of the factors that continue to fuel it lie outside the health sector. The strategies adopted by the South African government for an effective response to this challenge have incorporated this reality.
Early in 2000, the South African government posed pertinent questions on several key issues relating to this epidemic. Among these were questions relating to the accuracy of the tests currently used to make the diagnosis of human immunodeficiency virus (HIV) infection; the impact of poverty and malnutrition on the ability of people to respond to this infection; and the relationship between HIV infection and many other infections which are common in Africa such as Tuberculosis (TB), malaria, hepatitis as well as other parasitic infections.
Discussions among officials of the South African National Department of Health (NDOH), local and international experts in the fields of AIDS and HIV yielded a variety of differing and consensual views on some of the matters. Opinions on some of the pertinent issues were so diverse that it seemed important to interrogate these in an open debate. The South African government became aware of divergent views on the existence, detection and actions of the 'primary' aetiological agent for AIDS, the human immunodeficiency virus (HIV). Theories were being advanced to explain causes of AIDS other than HIV infection. Views were also expressed which doubt the accuracy of the data upon which the extent of the disease in South Africa, as well as globally, is being assessed. In fact, some of these views questioned the authenticity of the claim that an AIDS epidemic exists at all in South Africa.
In order to gain a full knowledge of AIDS, a decision was taken to invite an international panel of experts to South Africa and provide a platform for them to deliberate on the issues pertaining to the subject. The report of such deliberations will be used to inform and advise the government as to the most appropriate course of action to follow in dealing with AIDS. This decision was endorsed by the Cabinet of the South African government in April 2000. A world-wide search took place to identify eminent specialists in the fields of AIDS and HIV, ranging in scope from basic scientists, physicians, historians, economists, public health professionals as well as policy makers. It was also decided that persons living with AIDS, as well as lay persons would be invited to serve on the panel.
1.2 Composition of the Presidential AIDS Advisory Panel
Both local and international scientists were invited to form part of the Presidential AIDS Advisory Panel. They were:
Invited by the President and were present at both meetings
Professor Salim S Abdool-Karim
Dr Stefano M Bertozzi
Dr Harvey Bialy
Dr Awa Marie Coll-Seck
Dr Etienne de Harven
Dr Ann Duerr
Professor Peter Duesberg
Dr Christian Fiala
Dr Helene Gayle
Dr Roberto A Giraldo
Dr ET Katabira
Dr Claus Koehnlein
Dr Manu VL Kothari
Dr Clifford Lane
Dr Marsha Lillie-Blanton
Dr Malegapuru W Makgoba
Professor Sam Mhlongo
Professor Ephraim Mokgokong
Professor Stephen Owen
Dr Jorge Perez
Dr David Rasnick
Mr David Scondras
Dr Joseph Sonnabend
Dr Zena Stein
Dr Gordon Stewart
Invited by the President and present only at the first meeting
Dr W Chalamira-Nkhoma
Dr Andrew Herxheimer
Proffesor Luc Montagnier
Dr Walter Prozesky
Dr Mark D Smith
Dr Stefano Vella
Dr Jose M Zuniga
Invited by the President and present only at the second meeting
Dr Stephen Chandiwana
Professor Roy Mugwera
Professor Eleni Papadopoulos-Eleopoulos
Prof Heinz Spranger
Dr Valender Turner
Invited by the President but could not attend
Professor Francoise Barre-Sinoussi
Dr Robert Gallo
Dr Kaptue
Dr Souleymane M'Boup
Professor Fred Mhalu
Professor Valerie Mizrahi
Professor Pierre Mpele
Dr Paranjape
Dr Praphan Phanuphak
Professor Robert Root-Bernstein
Dr Kary Mullis
Present at the second meeting only - invited by the Secretariat
Professor Jerry Coovadia
Professor Charles Geshekter
Dr Glenda Gray
Dr Anthony Mbewu
Professor James McIntyre
Dr Lynn Morris
Dr Dan Ncayiyana
Dr Philip Onyebujoh
Dr Priscilla Reddy
Professor Barry Schoub
Professor Allan Smith
Dr Jimmy Volmink
Professor Allan Whiteside
Dr Carolyn Williamson
Mr Winston Zulu
Those who were not able to attend the first meeting in Pretoria, as well as other invited scientists, could, however, participate in the Internet discussion forum that ran between the first and the second panel meetings.
1.3 Terms of reference for the Presidential AIDS Advisory Panel
The terms of reference set for the panel before the first meeting in May 2000 were:
- The following questions needed to be addressed in dealing with this issue of the evidence of viral aetiology of AIDS and related concerns about pathogenesis and diagnosis:
- What causes the immune deficiency that leads to death from AIDS?
- What is the most efficacious response to this cause or causes?
- Why is HIV/AIDS in sub-Saharan Africa heterosexually transmitted while in the western world it is said to be largely homosexually transmitted?
- What is the role of therapeutic interventions in the context of developing countries? This should cover therapeutic interventions in the following contexts:
- In patients with AIDS
- In HIV-positive patients
- In the prevention of mother-to-child transmission
- In the prevention of HIV transmission following occupational injury
- In preventing HIV transmission following rape
- Prevention of HIV/AIDS
- The discussions above should be underpinned by considerations of the social and economic context, especially poverty and other prevalent co-existing diseases and the infrastructural realities of developing countries.
The international panel met on two occasions in Pretoria (6-7 May 2000) and in Johannesburg (3-4 July 2000). In opening the first meeting of the panel on 6 May 2000, President Thabo Mbeki quoted from a World Health Organisation (WHO) report on "Global situation of the HIV/AIDS pandemic, end 1999". The report stated that of the 5.6 million people, who were [newly] infected with the HIV in 1999, 3.8 million lived in Sub-Saharan Africa. During the same year [1999] it was estimated that 2.2 million people in Sub-Saharan Africa died of HIV/AIDS, which figure represented 85% of the global total of death due to HIV/AIDS [in 1999]. In addition, the report stated, there were more women than men among the 22.3 million adults and 1.0 million children in sub-Saharan Africa who are estimated to be living with HIV/AIDS.
This report as well as other information at the disposal of the government, President Mbeki stated, pointed to the reality that South Africa and sub-Saharan Africa were confronted by a catastrophe. As governments are not expected to respond to catastrophes by merely doing what is routine, the South African government wanted to respond to this catastrophe in a manner that recognisedthat we were faced with a catastrophe. This was particularly important in this case as we were talking about the lives of millions and millions of people.
President Mbeki referred to the interventions that were implemented at national government level, as well as at the level of other layers of government, to combat HIV and AIDS which the Minister of Health, Dr Manto Tshabalala-Msimang had earlier informed the panel of. An appropriate response to this catastrophe necessitated that the government be properly informed as to what it was dealing with. It was when he was in the process of informing himself that he realised that the profile of HIV/AIDS in sub-Saharan Africa had changed quite drastically between 1985 and the mid-1990s. Important among these changes was the HIV/AIDS profile in Southern Africa moving from being confined to a sub-population of male homosexuals in 1985 to being an endemic disease within a short period of seven years.
It was the desire of the South African government to get answers to questions like these that prompted him to establish an Advisory Panel of experts to assist the government in its informed response to the HIV/AIDS catastrophe.
A secured Internet facility was provided to enable the panellists to engage in in-depth deliberations and discussions during the period between the two meetings. The two meetings were characterised by robust debates and exchanges of views which were facilitated by presentations by panellists. The Internet debate set up between the two meetings lacked the robustness and vigour of the two meetings, the primary reason being the unevenness of inputs from panellists. Very few panellists who subscribe to the notion that HIV causes AIDS took advantage of the Internet medium to further the debate.
The lack of participation in the Internet debate by panellists who subscribe to the HIV theory of AIDS was lamented by the Minister of Health when she opened the second meeting of the panel on 3 July 2000. The Minister reminded the panellists that they had been invited because of the expertise and experience that they each brought to the debate. She further informed the panel that the participation rate and the nature of the participation in the Internet debate had indeed influenced the structuring of the second meeting of the panel.
Extensive references to original articles and sources were made, especially during the Internet deliberations (Appendix 1). It should, however, be recorded that at times panellists, without any supporting data or evidence, made broad and sweeping statements.
1.4 The report
The transcripts from audio recordings of the two meetings and the electronic record of the Internet deliberations will undoubtedly provide the South African government with a rich source of information as it confronts the AIDS challenge. It is only these transcripts that will convey the full richness of the deliberations, debates and discussions that took place over a two-month period. However, the audio recordings will only convey the temperament of the two meetings. This report captures the deliberations of the panel. It was written from these transcripts and will undoubtedly lack the completeness that the transcripts themselves can boast of.
For ease of reading and to fully capture the extent of the deliberations from the first meeting, through the intervening Internet discussions and then the second meeting, the report is presented in a format that captures the major identified themes and topics. The report therefore treats the entire exercise as one event and is not structured in such a manner as to distinguish whether input was made during the first or second meeting or during the intervening Internet debate.
It should be noted that it is not the purpose of this report to present a comprehensive compilation of the source materials referenced during the deliberations. A comprehensive compilation of these reference materials will nevertheless be catalogued in a separate document for ease of access.
The Presidential AIDS Advisory Panel was constituted in such a manner as to bring together diverse expertise and experience on the subjects of HIV and AIDS. Each member of the panel was invited in her/his personal capacity as an expert and not as the representative of a particular group or position. Although this wide representation of expertise included panellists who held contrasting viewpoints on some or most issues, it was not the intention of the principal sponsors of the panel to create a platform for confrontation between holders of particular points of view. Therefore, the mandate of the facilitators of the discussions was to ensure as smooth as possible a 'round-table' discussion among a group of experts. The gallant efforts of very able facilitators did not succeed in preventing the panel from polarising into two main camps based on whether HIV is the primary aetiological agent for AIDS.
The report attempts to reflect as objectively as possible the content of the deliberations, contrasting opposing views, highlighting areas of consensus and identifying gaps in knowledge. It was written with no intention to favour, reinforce or disfavour any particular viewpoint or side as any such favouritism would be contrary to the spirit and instruction of the Cabinet of the South African government. The report represents a summary of the deliberations, debates, views, opinions and recommendations and explicitly avoids passing judgement on the validity, or lack thereof, of the arguments made by the panellists individually or collectively. It needs to be emphasised that facilitators and rapporteurs were not judges who were expected to pronounce a verdict on winners and losers.
Finally, the report reflects the recommendations made by the panellist and identifies areas for future research and collaboration. Where consensus was not reached, the recommendations reflect the divergence of views. Considerable care has been taken to employ a language which does not take for granted one set of conclusions.
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