The Origins of AIDS

by Pepin

  In 1947, the CRC brought to the Congo the country’s first paediatrician, Claude Lambotte, along with his wife Jeanne Legrand, also medically qualified. They convinced the CRC to build a 100-bed paediatric hospital, which was inaugurated in 1953. Unfortunately, this facility proved very expensive to operate, which threatened the very survival of the CRC. As the city’s endless expansion created a need for more STD clinics, the charity decided rather to withdraw completely from this field and handed over its two clinics to the government. It had also become uncomfortable with the coercive nature of the STD clinics. Reluctant patients being forcibly brought in by the police was inconsistent with the values of the international Red Cross movement.

  In 1957, the Croix-Rouge opened a blood transfusion centre in Léo, with a pool of volunteer donors, which was certainly more in line with its traditional responsibilities. Until then, blood had to be given by relatives or friends of the recipient and was transfused within minutes of collection. One of the CRC board members in Belgium, Professor Albert Dubois, warned that strict measures would need to be taken to avoid transmitting diseases such as malaria, trypanosomiasis and viruses during transfusions. ‘Don’t worry,’ he was told, ‘our medical officers in Léo will take care of that.’ Legrand became the first director of the transfusion centre, but she was caught up in a series of conflicts with doctors at the main hospital (who accused her of stealing their own blood donors), with the volunteer directors of the Léopoldville branch of the CRC, and others. In those days, women working as professionals did not have an easy time. She was fired by the CRC, went into a depression and died in Léo in 1960, with a request to be buried alongside the Africans. It is unlikely that this blood bank contributed to the early dissemination of HIV in Léo because the prevalence among donors must have been rather low and many of the recipients were young children who, had they acquired HIV, would have died before reaching sexual maturity. A year after independence, the Brussels-based CRC disbanded and the blood bank was transferred to other institutions.49

  However, a specialised institution which warrants greater attention is the Dispensaire Antivénérien (STD clinic). It may have played a crucial role in the iatrogenic transmission of HIV-1 in Léopoldville because it was the main provider of care for free women, all of whom had to show up for the regular examinations necessary for their health card to be stamped. In 1929, the CRC opened a STD clinic in Léo-Est (Barumbu district). Like many such clinics, its official name was later changed to the more innocuous Centre de Médecine Sociale (patients preferred being seen by relatives and neighbours going to a social medicine centre than a venereal disease clinic). Eventually, a smaller satellite clinic was opened in Léo-Ouest. While the annual reports of the CRC provided nice photographs of its leprosarium and hospital in Province Orientale and its paediatric facilities in Léopoldville, the charity was more discreet about its STD clinics.50,51

  The STD clinics provided free care to women or men who presented spontaneously with a genital complaint (generally a discharge or ulcer) and whose employers did not provide medical care. For men, these would be recent arrivals, the few who were unemployed and all those working for small enterprises or for individuals (domestic staff). As very few women worked in the formal sector, for them the Dispensaire Antivénérien was the only accessible institution. In practice, most free women of Léopoldville, fiscally defined as financially independent adult women not living with a husband, attended at least a few times per year. Contact tracing also generated part of the caseload. Males presenting with an STD had to refer their recent sexual contact(s), otherwise a visiting nurse would come to their compound for this purpose, potentially causing embarrassment. Furthermore, male migrants to Léopoldville had to show up at the same clinics upon arrival in order to comply with health regulations and obtain their permis de séjour (they were also required to attend the tuberculosis centre nearby).

  The statistics presented in Figure 18 tabulate the totals for the two clinics together, but in practice the Léo-Ouest clinic never got off the ground and 95% of the total number of cases and number of injections correspond to the work done in Léo-Est. The bulk of the caseload consisted of thousands of asymptomatic free women who came for screening because they were required to do so by law, in theory every month. At its peak, 32,000 such visits took place each year.

  Number of new cases of gonorrhoea and syphilis, injections of various drugs and number of visits for free women at the Dispensaires Antivénériens of Léopoldville.

  Data on the incidence of new cases of syphilis or gonorrhoea, the number of women and men seen at least once during the year, the number of serological assays for syphilis and the number of injections administered were provided in the annual reports of the Croix-Rouge du Congo, as well as in health service reports. The number of new cases of syphilis or gonorrhoea diagnosed each year varied substantially, reflecting the expansion of the capital’s population and changes not just in diagnostic strategies but also in the efforts made to screen free women.47,51

  Given that those treated for syphilis or gonorrhoea had to attend repeatedly for prolonged courses of injectable drugs but also for a long follow-up, by the early 1950s, as the population of Léo had increased dramatically, up to 1,000 patients attended the Léo-Est Dispensaire Antivénérien each day. The medical officers estimated that they were providing more or less regular check-ups to 3,500 free women. The clinic, which held only four rooms, opened at 4.30 a.m. so men could receive their treatments before going to work. This extremely high turnover of patients made it impossible for syringes and needles to be sterilised properly. In 1952, the Léo-Est facility was enlarged: syphilitics on one side, those with gonorrhoea on the other. STD screening of migrants was abandoned as it was deemed to provide little in the way of results. The blood samples were sent to the Institute of Tropical Medicine for testing. In 1954, 85,654 serological tests for syphilis were performed.

  In retrospect, it is extraordinary that the treatment received by most patients of the Dispensaire Antivénérien was useless: wrong diagnoses, ineffective drugs. The reports suggest that, in the late 1940s, the medical officers began to wonder whether these efforts were a waste of time. In the 1949–54 reports, tables show that, of 7,204 new diagnoses of syphilis, only 111, 97 and 29 patients had signs compatible with primary, secondary or tertiary syphilis respectively. All of the others, 97% of patients with so-called syphilis, were given IV or IM drugs merely because they had a positive serology. Even today, the serological assays for syphilis do not discriminate between this latter infection and yaws, the non-venereal disease caused by a closely related bacterium. With both infections, the serological assays remain positive at a low titre for a very long period of time and even for life with some of the best assays. At the time, the medical thinking was that patients needed to be treated repeatedly with rather ineffective drugs until their serology came back completely negative. In 1952, 22% of a random sample of 1,000 adults living in Léo had a positive serology for syphilis/yaws, compared to 34% of free women. Given the high incidence of yaws in the preceding decades in the rural areas where many of these individuals originated, most of these cases with a positive serology probably corresponded to a past episode of yaws, which the patient could not recall because it had occurred in childhood. However, if that person was a free woman or male migrant and happened to be tested at the STD clinic, she/he was always considered to be syphilitic and received long courses of drugs containing arsenic or bismuth until penicillin was introduced around 1954. Even with this wonder drug, half of the patients remained seropositive for ‘syphilis’.51

  The precision of the diagnoses among free women was no better for gonorrhoea. In men, diagnosing gonorrhoea (or chlamydia) is straightforward: pus drips out of the penis. Among women, it is the opposite: most remain asymptomatic and less than 10% of those presenting with a vaginal discharge have gonorrhoea. The STD dispensaries could not cultivate the gonococcus, and did simple stains of the vaginal secretions. Such tests are not very
good at identifying those infected as there are non-pathogenic bacteria within the normal vaginal flora that look the same as the gonococcus. Patients thought to have gonorrhoea were treated for up to two months with drugs that aimed to combat the infection by triggering a high fever. They received injections of milk(!), typhoid vaccine(!), a product called Gono-yatren, etc. Starting in 1951, effective antibiotics such as penicillin, sulphonamides or streptomycin were given but only at the end of this ‘preparatory’ course.

  As a result of these debatable diagnostic and therapeutic approaches, during the 1930s and 1940s the STD clinics administered 50,000 injections per year on average (95% of these at the Léo-Est site). About 60% of these injections were given IV. In the 1950s, during the post-war demographic boom, the number of injections fluctuated around 100,000 per year, peaking at the extraordinary level of 154,572 by 1953. This number decreased rapidly thereafter as penicillin was introduced, a course of which required fewer injections than the arsenicals.

  It is generally difficult to gather information about the procedures used for the sterilisation of syringes and needles during the colonial era. In this case, however, it is illuminating to read a paper about hepatitis in Léopoldville written in 1953 by Dr Paul Beheyt, the internal medicine specialist at the Hôpital des Congolais. The author distinguishes epidemic hepatitis from inoculation hepatitis, the latter being defined as a patient developing hepatitis between 45 and 150 days after having received IV injections or transfusions. Inoculation hepatitis must have corresponded mostly to hepatitis B, because acute infection with hepatitis C rarely causes a disease severe enough for the patient to develop jaundice. Of sixty-nine cases of inoculation hepatitis diagnosed during 1951–2, thirty-two had received IV arsenical drugs at the Léo-Est STD clinic, corresponding to 0.9% of the patients treated during the same period by this institution. This measure of risk was greatly underestimated because the reference hospital diagnosed only a fraction of all cases of inoculation hepatitis occurring in Léopoldville, and the iatrogenic infection could only occur among patients who had not been infected with HBV earlier in their lives, at most 5% of adults in central Africa.52

  It is worth quoting at length from what Beheyt wrote about how his patients were infected:

  The Congo contains various health institutions (maternity centres, hospitals, dispensaries, etc.) where every day local nurses give dozens, even hundreds, of injections in conditions such that sterilisation of the needle or the syringe is impossible. At the Dispensaire Antivénérien de la Croix-Rouge in Léopoldville, on average 300 injections are administered each day. The large number of patients and the small quantity of syringes available to the nursing staff preclude sterilisation by autoclave after each use. Used syringes are simply rinsed, first with water, then with alcohol and ether, and are ready for a new patient. The same type of procedure exists in all health institutions where a small number of nurses have to provide care to a large number of patients, with very scarce supplies. The syringe is used from one patient to the next, occasionally retaining small quantities of infectious blood, which are large enough to transmit the disease.52

  In September 1955, the Croix-Rouge abruptly withdrew from running the STD clinics and the colony took over its clients, nurses and other workers. This must have involved some heated argument because in that year’s annual report it appears that the Croix-Rouge transferred responsibility for this activity to the Léopoldville Department of Hygiene following some mutual agreement, while at the receiving end the latter made it clear in its own annual report that the running of the STD clinics had been dumped on it at very short notice.53

  Nevertheless, the department did its job. By the end of 1957, 3,761 free women were registered, on whom a total of 26,123 screening examinations had been performed. The following year, 4,384 free women were registered, a rather substantial percentage given that the medical officers estimated that there were around 5,000 of them in the city. The number of injections, however, was drastically reduced. Long-acting penicillin completely replaced arsenicals for patients with syphilis, and the indications for such treatment were tightened as physicians acknowledged that it was unnecessary to treat those who probably carried only a ‘serological scar’ due to a past episode of yaws or a past syphilis which had been adequately treated.54

  The department of health also ran the annual medical census of the whole population of Léopoldville, for which each and every inhabitant was examined summarily to look for sleeping sickness and leprosy. This represented a substantial effort: between 148,584 (1949) and 322,198 (1958) individuals were examined, all to detect less than 100 cases of sleeping sickness and a few lepers annually. During the last years before independence, in a never-to-be-repeated population measure of the prevalence of symptomatic STDs, the health agents running the medical census required every adult male to drop his pants: of 99,446 men seen in 1958, 163 were found to have gonorrhoea, 335 to have non-gonococcal urethritis (presumably, in retrospect, chlamydia) while only 44 had a chancre suggestive of syphilis.47,55

  It is remarkable that throughout this period the incidence of other tropical diseases, for which injectable drugs were massively used in the rural areas, including those around Léopoldville, remained minimal in the Belgian Congo’s capital. After 1930, there were generally fewer than 100 cases of sleeping sickness diagnosed each year, mostly in migrants from endemic areas, and similar numbers of cases of yaws. To some extent, this was a result of the systematic screening of migrants arriving in Léo so that a large proportion of sleeping sickness cases were identified and treated, which reduced the risk of transmission of the parasite within Léo. This was very good news for its large Belgian population as the risk of being bitten by an infectious tsetse fly was reduced accordingly. Yaws remained uncommon, reflecting an easier access to health care (treatment shortened the duration of infectiousness) and hygienic conditions which, even if far worse than those of the Europeans, were healthier than in rural areas. In the African suburbs, water was readily available, not in each house but at a shared tap for several compounds. Consequently, in Léo the treatment of STDs, especially ‘syphilis’, provided the best opportunity for the iatrogenic transmission of infectious agents through syringes and needles.

  The perfect storm

  Less than 0.1% of the total population of the central chimpanzee inhabited the Belgian Congo, so it is unlikely that ‘patient zero’, the one who started the pandemic, lived there. However, Léo was the most dynamic city in the region, a commercial hub which attracted large numbers of migrants and traders. A SIVcpz-infected cut hunter moving to the city or an HIV-1-infected trader wishing to spend some time in the capital would have to present himself at the STD clinic upon arrival, where he would receive treatment for syphilis if his serological assay was positive, either because of prior syphilis or much more often because of prior yaws. Alternatively, one can imagine that a first HIV-infected free woman sexually infected by one of her patrons would be treated with IV drugs, also because of a positive serology.

  Once the virus was introduced within the Léopoldville–Brazzaville conurbation, it would have found an extraordinary opportunity for its amplification through non-sterile syringes and needles at the Dispensaire Antivénérien in the Barumbu district of Léo-Est. There, the caseload of patients was extreme due to the obsession of local physicians with treating anybody with a positive ‘syphilis’ serology. Iatrogenic transmission of another blood-borne virus, HBV, was well documented in 1951–2 to have occurred as a consequence of the inadequate sterilisation of injection equipment. It does not take much imagination to deduce that if HBV was transmitted iatrogenically, the same must have occurred with SIVcpz/HIV-1 once it was introduced into the cohort of patients treated for presumed STDs at the same Dispensaire Antivénérien. Many of the iatrogenically infected cases would have been free women who had concomitant sexual relationships with several men: it was indeed the perfect storm.

  Those free women infected parenterally could then transmit the vi
rus sexually to some of their regular clients, who in turn infected other sex workers, or later other women, eventually allowing the virus to move out of the sexual core group. This second part of the amplification process, this time sexual, could proceed at a much faster pace when, during the chaotic years that followed the country’s accession to independence in 1960, the face of Léopoldville changed abruptly, with massive migrations, high unemployment rates and the emergence of a different type of prostitution in which some women might entertain up to 1,000 clients per year.

  10 The other human immunodeficiency viruses

  Although they contribute little to the overall burden of AIDS in the world, the other HIVs (HIV-1 groups O, N and P, and HIV-2) can provide useful insight into the events that led to the emergence of pandemic HIV-1 group M. How was it possible for HIV-2, a different virus that originated from a different simian host, to spread in a different region of Africa at roughly the same time (give or take a few decades) as HIV-1, only to disappear quietly thereafter? And why was HIV-1 group M so successful compared to the others?

  HIV-1 groups O, N and P

  Highly divergent strains of HIV-1 were described in the 1990s. The first, now known as HIV-1 group O (‘O’ for outlier), has only 50–65% homology in nucleotide sequences compared to HIV-1 group M, which is why it is considered as a different ‘group’ rather than a different ‘subtype’ (subtypes differ by about 20%; in other words, they have 80% homology). The original isolates of HIV-1 group O had been obtained from two Cameroonians living in Belgium, a young woman and her husband. Additional cases were documented among Cameroonians living in France, and in Cameroon itself. Further studies confirmed that Cameroon was the epicentre of HIV-1 group O, where it accounted for 2% of all HIV-1 infections, versus 1% in adjacent Gabon and Nigeria. A few cases were found in other African countries. Within Cameroon, regional variations were noted, with group O representing 6% of all HIV-1 positive sera in Yaoundé but only 1% in northern provinces. When stored sera were tested, group O represented 21% of all HIV-1 positive sera in 1986–8, 9% in 1989–91, 3% in 1994–5 and only 1% in 1997–8. It then remained rather stable at 1–2%.1–7