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COMMENTS ON NELSON MANDELA/HSRC STUDY OF HIV/AIDS IN SOUTH AFRICA
The Perth Group January 2003
The validity of the principal aim of this study, to “Identify prevalent risk factors that predispose South Africans to HIV infection”, is based on the method used to “Determine HIV prevalence in the population…using linked anonymous HIV saliva tests”.
Since the validity of the principal aim as well as all other conclusions regarding HIV are based on the validity (specificity) of the antibody test, our comments will only address this topic.
ANTIBODY TEST METHOD
The antibody test used in this study was the oral mucosal transudate test (OMT). A transudate refers to fluid that has passed from the bloodstream through the walls of a capillary. Oral mucosal transudate is distinct from saliva and is obtained by use of a “specially treated cotton fiber pad that is attached to a nylon stick. This collection pad draws antibodies from the tissues of the gum and cheek into the mouth and into the pad. The collection pad (OraSure® HIV-1 Oral Specimen Collection Device), is placed between the lower cheek and gum for 2-5 minutes”. http://www.orasure.com/products/OMT (Thus the Mandela/HSRC study did not use saliva tests).
After collection the manufacturers recommend “The OraSure® HIV-1 pad is then placed in a vial with preservative and sent to a clinical laboratory for testing with an initial "screening" assay (ELISA)”. In the ELISA assay the transudate fluid is incubated with a mixture of proteins claimed unique to HIV. A reaction between the antibodies in the transudate and the proteins in the test kit produces a change in optical density of the reaction mixture. This is quantified by a spectrophotometer and the reading is compared with that of a “negative control”. An arbitrarily defined ratio is defined as “reactive”.
Contrary to the manufacturer’s recommendations, in the Manedela/HSRC study only a “screening” ELISA test is performed. However, in almost all countries of the world not even serum ELISAs are used to prove HIV infection. This is because HIV experts do not regard the test as specific. That is, there are individuals who are not infected with HIV who react in the test. Indeed, in Australia the majority of reactive ELISAs are not positive on the test used to “confirm” HIV infection, that is, the Western blot test. In other words, their ELISA reactivity is falsely positive and is due to non-HIV antibodies. Given that Africans are exposed to a plethora of antigenic stimulating agents, the number of falsely positive ELISAs in Africa is predictably far greater. In the July 2000 Presidential AIDS Advisory Panel Professor William Makgoba assured panelists that in South Africa all the reported positive tests are based on ELISAs “confirmed” by the Western blot. The manufacturers of the Orasure System recommend “a supplementary test, the OraSure® HIV-1 Western blot assay, is performed to verify the result of the screening assay. This process is referred to as the OraSure® HIV-1 testing algorithm”.
However, in the Mandela/HSRC study Western blot “confirmatory” tests were not performed. Thus in the developed world the serological data reported in the Mandela/HSRC study would not be accepted as proof of HIV infection.
According to the authors of the Mandela/HSRC study “The sensitivity and specificity of the Orasure device when tested with the Vironostika EIA is 99%,and also 99% (Gallo et al.1997)”. The specificity reported in the Gallo et al study can be questioned on several grounds including possible conflict of interest1 and not being performed blindly. Most importantly, the specificity of the antibody test was not determined in the only scientifically valid manner, that is, using a gold standard which is independent of the antibody test. This is obligatory because it is a well known fact that antibodies directed against one particular agent or substance may also react (“cross-react”) with an unrelated agent or substance. For example, antibodies directed against the infectious agents which cause the fungal and mycobacterial diseases highly prevalent in Africa cross-react with the proteins in the ELISA tests;2-5 Such cross-reactivity results in false positive antibody tests. The only means of distinguishing “true” reactivity (“genuine” HIV antibodies) from “false” reactivity (“non-HIV antibodies”) is to compare the presence of absence of reactivity with the presence of absence of HIV itself, as determined by HIV isolation/purification.5-7
In the Gallo et al study, rather than using an HIV isolation gold standard, “True positives (n=673) were defined by clinical status, (ie, diagnosed AIDS) and/or by serum Western blot results”. Neither clinical status nor the Western blot can be used as a gold standard for HIV infection.
Clinical status (diagnosed AIDS) “gold standard”
The reason that HIV experts are convinced HIV causes AIDS is that AIDS patients have a positive antibody test. Yet when it comes to proving the specificity of the antibody test the same experts claim that the presence of AIDS proves the positive antibody test is due HIV infection. Thus the clinical (AIDS) “gold standard” is a circular argument. It is not possible on the one hand to use the antibody tests as proof for a causal role of HIV in AIDS and then on the other hand claim that AIDS is proof for the presence of HIV. It is also important to note that (a) in the developed world the clinical diagnosis of AIDS is not made without an antibody test; thus the clinical gold standard is tantamount to one antibody test acting as the gold standard for another; (b) in Africa a solely clinical diagnosis of AIDS in Africa is permitted and undertaken according to the Bangui definition but this is markedly different and less rigorous than its counterpart in the developed world.
Use of a clinical “gold standard” is also problematic for another reason. If AIDS is used as a de facto for the presence of genuine HIV antibodies, as the authors of this study do, then individuals without AIDS should act as a de facto for the absence of genuine HIV antibodies. Acting on this premise all positive tests in non-AIDS individuals must be regarded as false positives. This must apply to the vast majority of positive individuals in the world including those reported in the Mandela/HSRC study.
The Western blot “gold standard”
The use of the “serum Western blot results” as a gold standard is also invalid. This is because one antibody test cannot act as a gold standard for another antibody test unless it there is prior proof the former is 100% specific as measured against the HIV isolation gold standard. This is not the case for the “serum Western blot”.6, 8 Nor is such a gold standard possible, as some of the best known HIV/AIDS experts attest: “One difficulty in assaying the specificity and sensitivity of human retroviruses [including HIV] is the absence of a final 'gold standard’”.9 "Diagnosis of HIV infection is based almost entirely on detection of antibodies to HIV, but there can be misleading cross‑reactions between HIV‑1 antigens and antibodies formed against other antigens, and these may lead to false‑positive reactions. Thus, it may be impossible to relate an antibody response specifically to HIV‑1 infection. In the presence of clinical and/or epidemiological features of HIV‑1 infection there is often little doubt, but anti‑HIV‑1 may still be due to infection with related retroviruses (e.g. HIV‑2) which, though also associated with AIDS, are different viruses" [italics ours].10 (As mentioned, the clinical status cannot be used as a gold standard for HIV infection. Nor can “epidemiological features”). One antibody test manufacturer includes the following caveat in the test kit packaging: “At present there is no recognized standard for establishing the presence or absence of HIV-1 antibody in human blood”.11
Even if such a gold standard did exist the specificity of the HIV Western blot cannot be determined because the test is not standardised (see Addendum). The criteria for a positive Western blot vary between laboratories, institutions and countries. In the United States, in New York City for example and under the CDC criteria (Addendum, 6th column), a person with a p41 and a p24 band would be diagnosed HIV positive and infected. Yet the same person would not be positive in Australia or in Africa under the WHO criteria, or in France. Clearly such a test could not be considered “extraordinarily accurate” yet it is the test used to “confirm” reactive ELISA tests and is regarded as the gold standard for the presence or absence of HIV in the human body. It is also the basis of all medical advice and treatment that follows.
In addition to the fact that the specificity of the Western blot has not been determined by use of a viral isolation gold standard and the Western blot is not standardised, there is also the problem of the origin of the proteins used in the WB test kits. In their study Gallo et al state “A Western blot interpretation of positive requires that at least 2 of the 3 cardinal bands (gp160/1 20, gp41, p24) are scored as present. (On Western blot strips, gp160 and gp120 appear as separate bands, but for purposes of interpretation, gp160/120 are counted as a single cardinal band. Thus, if either gp160 or gp120 is present in sufficient intensity, the gp160/120 cardinal band is scored as present.)”.
The authors of the Mandela/HSRC do not seem to be aware that (i) 1983 as well as in 1984 Montagnier did not consider the p41 an HIV protein but the ubiquitous cellular protein actin.12 This was still the case in 1996 since Montagnier did not regard reactivity to p41 in the Western blot as antibody directed against an HIV protein.13 In 1997 Bess and his colleagues at the US National Cancer Institute published protein electrophoretic patterns of “infected” cell culture supernatants banded in sucrose density gradients (“purified HIV”). Proteins of molecular weight "near 42 kDa" (42,000) were labelled "Actin"; (ii) Since:
(a) p160 is found only in “infected” cultures but not in HIV itself;
(b) the p120 protein is said to be a constituent of the knobs (spikes) on the surface of HIV yet immediately after being released from the cell membrane "HIV particles" passes an average of 0.5 knobs per particle which are rapidly lost. However “it was possible that structures resembling knobs might be observed even when there was no gp120 [knobs] present, i.e. false positives".14 Thus “purified” (cell free) HIV is devoid of p120;
(c) HIV proteins for use in the Western blot are obtained from banded culture supernatants, that is the “cell free” 1.16 gm/ml “retroviral” band;
it means that neither p160 nor p120 in the Western blot test kits can be HIV proteins. The explanation for the presence of these bands was found by Pinter and his colleagues as far back as 1989—that p160 and p120 in the Western blot are oligomers [composed of integral numbers of subunits] of gp41.15
Since there is no proof that the p41, p120 or p160 proteins in the Western blot are HIV in origin, one can only agree with Zolla-Pazner and that "Confusion over the identification of these bands has resulted in incorrect conclusions in experimental studies. Similarly, some clinical specimens may have been identified erroneously as seropositive, on the assumption that these bands reflected specific reactivity against two distinct viral components and fulfilled a criterion for true or probable positivity. The correct identification of these bands will affect the standards to be established for Western Blot positivity:it may necessitate the reinterpretation of published results". There is no doubt this applies in Africa because, according in the Gallo study and thus in the Mandela/HSRC report, an African is deemed infected with HIV by possessing antibodies which react with his or her own proteins (see Addendum).
Like all other HIV/AIDS experts, Gallo et al consider p24 as a “cardinal” (fundamental) HIV protein and WB band. According to Montagnier to characterise a protein as an HIV protein first it is absolutely necessary to purify the virus. In an interview which he gave to the French Journalist Djamel Tahi in 1997, he stated: "analysis of the proteins of the virus demands mass production and purification. It is necessary to do that".16 In 1983 Montagnier and his group claimed to have purified HIV by banding culture supernatant in sucrose density gradients. They reported that the 1.16 gm/ml band was “purified virus”. In the same interview Montagnier was asked why he and his colleagues did not publish an electron micrograph of the 1.16 gm/ml band to prove that the band represented "purified" virus, as they claimed. He answered that even after a "Roman effort" they were unable to find particles with the "morphology typical of retroviruses” in their “purified virus”. When Montagnier was asked if Gallo isolated HIV he replied: "I do not believe so". If there were no retrovirus-like particles in Montagnier’s "purified" virus, then obviously Montagnier and his colleagues could not claim to have isolated a specific exogenous retrovirus HIV nor the protein constituents of such a virus. Including a p24 protein.
Significantly, in 1992 Jorg Shupbach, the principle author of one of the first four 1984 papers published by Gallo's group on HIV isolation, reported that the whole blood cultures of 49/60 (82%) of "presumably uninfected but serologically indeterminate individuals and 5/5 seronegative blood donors were found positive for p24".17
In March 1997 Bess and his colleagues published the first EM of “purified HIV”, that is, an EM of sucrose density gradient banded culture supernatant taken from an “infected” cell line culture. They also published a similar EM from a “non-infected” cell line as well as electrophoretic data from both. In the EM of the “infected” cell line supernatant none of the particles possessed the two principle morphological characteristics of a retrovirus, that is, a diameter of 100-120 nM and surface spikes, (knobs). In fact the particles which Bess and his colleagues claimed were HIV had an average diameter of 236 nM, twice the diameter that defines retroviral particles. The authors did not note or explain this discrepancy as they “were much more focused on showing the mixture of particles in the preparations as opposed to their actual diameters”. The majority of the material in the “purified HIV” was cellular material including microvesicles with diameters of a "range in size from about 50 to 500 nm". Such particles also formed the majority of the “non-infected” cell line banded supernatant.
If the banded supernatant material from the infected cells contained HIV particles then that material should contain proteins which are not present in the banded supernatant from uninfected cultures. However, the only differences between the electrophoretic patterns of “infected” and “non-infected” banded supernatants are quantitative. That is, “purified HIV” contains the same proteins as the banded material obtained from uninfected cells. Although the authors labeled three proteins of molecular weight lower than 30,000 as p24CA, p17MA, and p6/p7NC and claimed these were "major bands of viral proteins”, they later admitted “these labels were added when one of the reviewers asked for them. He felt it would help orient readers when looking at the figure - the reviewer is correct. We did not determine the identities of the bands in this particular gel”. More significantly, the same proteins, including the p24 protein was present in the non-infected material albeit in lesser amounts. This can be explained on the basis of the history of the preparations of both sets of cultures.
Both at and after the July 2000 Presidential AIDS Panel meeting Professor William Makgoba objected to our interpretation of the Bess data:
"The Perth Group themselves in our correspondence recognised that own deficiencies and were critised by several members for living [sic] and present outdated data eg Dr. Carolynn Williamson and Dr Lynn Morris [these delegates made no comments in relation to the Bess data]. If the recordings are correct [sic] that is what you will find. I do not use rhetoric but I equally cannot be deceived by presented electrophoretic patterns that are completely wrong as they attempted to do. My whole PhD thesis was based on doing and reading minute differences in electrophoretic patterns on cell lysates [sic], so I know what I am talking about here".
We contacted Dr. Bess who responded:
“I would like to answer any questions you have about my work. However, I do not understand the quote…Was it spoken in another language and translated directly into English? Please read it carefully. It has significant syntax problems. Also, I suggest that you re-read my manuscript. You will discover that I presented no data on cell lysates. As to how the electrophoretic patterns can be "completely wrong" - you will have to get that one answered by the questioner. I have no clue how they could be wrong. It is possible that the questioner is not aware of what material was electrophoresed (e.g. a cell lysate vs. microvesicles). If the questioner thinks these are cell lysates, he will likely come to an erroneous conclusion”.
In a subsequent email Dr. Bess affirmed “We agree that you can come to the conclusion from gel electrophoresis patterns that there are only quantitative differences between HIV and microvesicles” (non-infected cell culture, banded supernatants).
1. There is no proof that the p24, p41, p120 and p160 antigens used in the ELISA or Western blot test are retroviral. In fact there is ample proof they are cellular.
2. It is impossible to determine the specificity of an antibody test using the method Gallo et al applied to the ELISA test employed in the Mandela/HSRC study.
3. In the developed world no citizen would be diagnosed HIV infected on the basis of an ELISA test.
4. No matter how well designed and executed, the Mandela/HSRC study does not provide any conclusion in regard to the prevalence of HIV infection in South Africa. The present HIV prevalence estimate amongst persons aged two years and older may be 11.4% or it may be zero.
5. Although there is no proof a positive antibody test is caused by HIV infection, studies such as that by Mulder and colleagues18 have shown a positive test predicts morbidity and mortality, both AIDS and non-AIDS related. Thus the Mandela/HSRC study has the potential to identify and stratify risk for a positive test and possibly arrive at strategies to minimise this risk. However, at present there is no scientific proof antibody associated morbidity and mortality is related to a retroviral infection. Although to some it may seem “curious indeed”,19 a non-retroviral correlation between seropositivity and morbidity, mortality and AIDS in Africa 18 is eminently possible. Clinical practitioners are no strangers to tests of significant utility and predictive ability which are nonetheless devoid of specificity. Arguably the test which provides the best example is the erythrocyte sedimentation rate (ESR) because it, like the HIV antibody tests, is associated with elevations of antibodies and acute phase reactant proteins. Indeed, there is evidence that an elevated ESR is a superior predictive marker for the development of the clinical AID syndrome than is a decrease in the CD4 cell count,20 although the latter is said to be the cause of the syndrome. A positive antibody test, like the ESR, may indicate a propensity to the development of particular diseases without necessarily being linked to HIV infection.
6. Fulfilling the recommendations of the Presidential AIDS Advisory Panel Report would resolve the issues related to antibody testing and HIV infection.
1. The Mandela/HSRC study included children as young as two years of age. However,
according to the manufacturers of the OraSure collection device:
OraSure® HIV-1 Oral Specimen Collection Device is intended for use in the collection of oral fluid specimens for testing for antibodies to the Human Immunodeficiency Virus-Type 1 (HIV-1) in subjects 13 years of age and older”.
2. On page 23 of the Mandela/HSRC study one reads:
“Regarding testing, all children between 2 and 14 years of age were asked for their verbal consent to take a saliva sample, regardless of whether or not they personally gave consent for participation in the study or proxy consent was given by their parent or guardian”.
Thus it is not clear whether children were tested using oral mucosal transudate or saliva. The test is not licensed for testing saliva.
3. On page 63, under “Findings requiring further research”, (underlining ours) one reads:
The observation that the estimated HIV prevalence among children aged 2-14 years is 5.6%(CI:3.7-7.4%) was unexpected. Once HIV prevalence was identified to be high in this group, a record review was undertaken to determine how many could have been infected through vertical transmission. The analysis was done focusing on those 2-11 years of age, as they are less likely to be sexually active. Analysis of the mother-child and father-child pairs revealed that of the 86 HIV positive children aged 2 to 14 years,27 could be matched with a biological parent, and 20 of the parents selected in the study had an HIV test result. Of these 20,only five (25%)were HIV positive (four females and one male)and 15 (75%)were HIV negative. This raised the question of whether the biological parents of these children were alive or dead. The results found were that only seven (6.1%) of the 86 children had a biological mother who had died and a similar percentage (7%) had a biological father who had died. It remains unclear as to how these children could have been infected. An emerging theory that warrants further investigation is that there is unexplained HIV prevalence in children who have had no sexual exposure, or have parents with HIV negative mothers. In addition between 20-40%of HIV infections in African adults are associated with injections (Gisselquist et al.2002). Given this unexplained high prevalence in children aged 2-14 years, it is necessary to test this theory in South Africa. Possible factors to be investigated include sexual abuse and unsterile needles”.
“In addition between 20-40%of HIV infections in African adults are associated with injections (Gisselquist et al.2002)”.
The Gisselquist paper21 argues, albeit from a different perspective from our Group, that heterosexual and mother to child transmission cannot account for the high rates of HIV seropositivity in sub-Saharan Africa.22-24 Gisselquist and his colleagues argue the African statistics are explicable in terms of an iatrogenic mechanism involving unsterile injections. This presents at least two difficulties. First, if this is the case, given that many infectious agents existed in Africans prior to the AIDS era and survive in needles and syringes longer than HIV, and are more readily transmitted,25 such agents should be more prevalent than HIV. Second, their view that HIV can survive for “more than four weeks”, is not shared by other HIV experts including the CDC: “…drying of HIV-infected human blood or other body fluids reduces the theoretical risk of environmental transmission to that which has been observed--essentially zero".26
An alternative and in our view more plausible explanation is found in an examination of the specificity of the antibody tests.22
“The observation that the estimated HIV prevalence among children aged 2-14 years is 5.6%(CI:3.7-7.4%) was unexpected”.
This figure is 12 times less than the seroprevalence rate amongst 75 healthy Ugandan children reported in 1985 by Gallo but on sera collected and stored in 1972/73. In a paper entitled “Evidence for exposure to HTLV-III in Uganda before 1973”, blood samples were collected from “a subsistence-farming environment” in the West Nile district of Uganda. The samples were obtained from healthy children selected as controls for a study of Burkitt's lymphoma, predominantly a disease of young children. In 1985 Gallo tested these samples with the HIV ELISA and Western blot and found that from 75 children of average age 6.4 years, 50 (67%) were positive.27 Since:
(a) the HIV theory of AIDS requires mother-to-child transmission as the cause of HIV antibodies in young children;
(b) African AIDS is said to be spread by heterosexual intercourse;
(c) the development of AIDS following infection “may be about 1-2 years shorter than in the developed world”;
(d) barrier contraception is problematic even today in Africa;
(e) there is no cure for AIDS;
(f) untreated AIDS is fatal within one to two years even with the best medical intervention;
(g) there was no AIDS in Uganda in 1973;
(h) the children were healthy and not treated for AIDS;
how is it possible to claim the antibody tests are proof of a sexually transmitted, immune suppressing infectious agent if there any Africans alive in Uganda 30 years later?
Significantly, “The target population for this study were all people in South Africa, excluding persons in so-called special institutions (e.g.hospitals, military camps, old age homes, schools and university hostels)”. That is the Mandela/HSRC study did not target AIDS patients or those at risk or unhealthy individuals. Given the 1972/73 Ugandan data, why was the estimated 5.6% HIV prevalence among children aged 2-14 years “unexpected”? Or why is it not 100%?
Criteria defining a
positive HIV Western blot
AFR=AFRICA;1 AUS=AUSTRALIA;2 FDA=US FOOD AND DRUG ADMINISTRATION;3 RCX=US RED CROSS;3 CDC=US CENTER FOR DISEASE CONTROL;3 CON=US CONSORTIUM FOR RETROVIRUS SEROLOGY STANDARDIZATION;3 GER=GERMANY; UK=UNITED KINGDOM; FRA=FRANCE; MACS= US MULTICENTER AIDS COHORT STUDY 1983-1992. * Bands not in electrophoretic order
I. “The Association of Public Health Laboratories now recommends that patients who have minimal positive results on the WB, eg p24 and gp160 only, or gp41 and gp160 only, be told that these patterns have been seen in persons who are not infected with HIV and that follow-up testing is required to determine actual infective status”.4
II. In February 1993 the US Food and Drug Administration relaxed their criteria in order to “reduce the number of HIV-1 seroindeterminate Western blot interpretations”, that is, to increase the number of HIV positive individuals.5
1. WHO. (1990). Acquired Immunodeficiency Syndrome (AIDS). Proposed criteria for interpreting results from Western blot assays for HIV-1, HIV-2 and HTLV-I/HTLV-II. Weekly Epidemiological Record 65:281-298.
2. Healy DS, Maskill WJ, Howard TS, et al. (1992). HIV-1 Western blot: development and assessment of testing to resolve indeterminate reactivity. AIDS 6:629-633.
3. Lundberg GD. (1988). Serological Diagnosis of Human Immunodeficiency Virus Infection by Western blot Testing. Journal of the American Medical Association 260:674-679. (Data presented in this paper reveal that when the FDA criteria are used to interpret the HIV Western blot less than 50% of US AIDS patients are HIV positive whereas 10% of persons not at risk of AIDS are also positive).
4. Mylonakis E, Paliou M, Greenbough TC, Flaningan TP, Letvin NL, Rich JD. Report of a false-positive HIV test result and the potential use of additional tests in establishing HIV serostatus. Archives of Internal Medicine 2000;160:2386-8.
5. Keinman S, Busch MP, Hall L, et al. (1998). False-positive HIV-1 test results in a low -risk screening setting of voluntary blood donation. Journal of the American Medical Association 280:1080-1083.
NOTE: Each horizontal band
on the left represents a protein with which an antibody can react. Serum from a
patient is added to a strip and the strip develops. Where there have been
antibodies reacting a dark band occurs. The number and location determining a
positive test, for the same virus, varies all over the world.
1. "Four of the five study authors are employees of Epitope Inc and hold stock options and stock holdings. All own stock in the company and all, except Dr. Hindahl, who is no longer with Epitope, currently have stock options". From reference 8.
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3. Muller WEG, Bachmann M, Weiler BE, Schroder HC, Uhlenbruck GU, Shinoda T, et al. Antibodies against defined carbohydrate structures of Candida albicans protect H9 cells against infection with human immunodeficiency virus-1 in vitro. J. Acquir. Immun. Defic. Syndr. 1991;4:694-703.
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7. Papadopulos E, Turner V. Presentation to the Presidential Panel AIDS Advisory Meeting 3 & 4 July Johannesberg, South Africa. 2000. www.theperthgroup.com/aids
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14. Layne SP, Merges MJ, Dembo M, Spouge JL, Conley SR, Moore JP, et al. Factors underlying spontaneous inactivation and susceptibility to neutralization of human immunodeficiency virus. Virol. 1992;189:695-714.
15. Pinter A, Honnen WJ, Tilley SA, Bona C, Zaghouani H, Gorny MK, et al. Oligomeric structure of gp41, the transmembrane protein of human immunodeficiency virus type 1. J. Virol. 1989;63:2674-9.
16. Tahi D. Did Luc Montagnier discover HIV? Text of video interview with Professor Luc Montagnier at the Pasteur Institute July 18th 1997. Continuum 1998;5:30-34. www.virusmyth.com/aids/data/dtinterviewlm.htm
17. Schupbach J, Jendis JB, Bron C, Boni J, Tomasik Z. False-positive HIV-1 virus cultures using whole blood. AIDS 1992;6:1545-6.
18. Mulder DW, Nunn AJ, Kamali A, Naklylngi J, Wagner HU, Kengeya-Kayondo JF. Two-year HIV-1-associated mortality in a Ugandan rural population. Lancet 1994;343:1021-1023.
19. Dondero TJ, Curran JW. Excess deaths in Africa from HIV: confirmed and quantified. Lancet 1994;343:989.
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24. Papadopulos-Eleopulos E, Turner VF, Papadimitriou JM, Alfonso H, Page BA, Causer D, et al. Global voices on HIV/AIDS. Heterosexual transmission of HIV in Africa is no higher than anywhere else. Brit. Med. J. 2002;324:1035. http://bmj.com/cgi/content/full/324/7344/1034#resp3
25. Simonsen L, Kane A, Lloyd J, Zaffran M, Kane M. Unsafe injections in the developing world and transmission of bloodborne pathogens: a review. Bull. World Health Organ 1999;77:789-800.
26. CDC. Fact sheet on HIV transmission. Fact sheet on HIV transmission 1994;January. www.cdc.gov/hiv/pubs/facts/transmission.htm
27. Saxinger WC, Levine PH, Dean AG, de The G, Lange-Wantzin G, Moghissi J, et al. Evidence for exposure to HTLV-III in Uganda before 1973. Science 1985;227:1036-8.