Perhaps the only thing known with certainty in trying to understand the Acquired Immune Deficiency Syndrome, AIDS, is that there are more questions than answers. The questions only begin with trying to define AIDS itself. The question in defining AIDS is compounded by the fact that different AIDS definitions are used. The World Health Organization has its own definition, and the Centers for Disease Control in the United States has a definition for surveillance purposes. This latter definition has changed since the beginning of the AIDS epidemic in 1981. Two important changes are the list of indicator and opportunistic infectious diseases associated with AIDS this number went from 14 in 1982 to 29 in 1993. These opportunistic infectious diseases are the result of infection by different microorganisms. But not all these diseases are infectious some are various cancers with no established etiology or cause. More importantly in 1993 one disease was added that is gender specific effecting women invasive cervical cancer The second important change was that in 1982 a person had to have no known cause for diminished resistance for immune suppression and in 1987 a person could have a known cause for diminished resistance for immune suppression. From 1983 to 1984 there were three claims of discovery by three different groups and three different names were given to the virus that is said to be the cause of AIDS. In 1986, the virus was renamed HIV, human immunodeficiency virus.
We have to see what AIDS is, AIDS is not a disease entity, AIDS is a whole bag of old diseases under a new name. (Adams, AIDS: The HIV Myth, p.130)
One could justifiably argue that the AIDS epidemic is due at least partially to the grouping of two dozen causes of death under one rubric, rather than to a new disease. (Root-Bernstein, Rethinking AIDS: The Tragic Cost of Premature Consensus, p. 67)
In other words, AIDS is new not only in the sense that it was only recently recognized; AIDS is also new in the way that biomedical researchers have defined it. These are important points to remember when we try to determine what AIDS is, what causes it, and whether its causes are in fact new. After all, if the biomedical tools and concepts did not, as Grmek asserts, exists twenty years ago for recognizing AIDS, how could it have been observed even if it had existed? (Root-Bernstein, Rethinking AIDS: The Tragic Cost of Premature Consensus, p. 65)
As mentioned in the Introduction, AIDS is the acronym for acquired immunodeficiency syndrome’ and was a term coined early on in the history of the disease. AIDS is by definition, the end-stage disease manifestation of an infection with a virus called human immunodeficiency virus (HIV). The virus infects mainly two systems of the body, the immune system and the central nervous system, and disease manifestations are consequent on damage to these two systems. (Schoub, AIDS and HIV in Perspective, p. 20)
The cause of this tumult is said to be a microbe unknown until 1983. Even before its discovery, the powers conferred on this minute entity rivaled archetypal legends of pollution and plague. It is said to be the cause of not one, but three, then 16, then 25, and now 29 diseases - an unprecedented feat for any microbe in the history of human illness. (Caton, The AIDS Mirage, p.10)
Essentially the classification systems for AIDS consist of three major features: firstly, laboratory test for HIV infection as well as immunosuppression; secondly, demonstration of what are called indicator diseases, that is the specific opportunistic infections or tumors which predict that the individual is at least significantly immunosuppressed; thirdly, the cerebral manifestations of AIDS as well as the other direct effects of the virus such as wasting." (Schroub, AIDS and HIV in Perspective, p. 36)
Full-blown HIV-related disease, AIDS, is currently defined as related to one or more of the following indicator disease (a) Kaposi’s sarcoma, a cancer of the blood vessel walls; (b) Pneumocystis carinii pneumonia, an otherwise rare form of pneumonia; (c) a variety of other opportuntistic infections including, cytomegalovirus and candidiasis (thrush); (d) HIV wasting syndrome (emaciation, slim disease); or (e) HIV encephalopathy (also called HIV dementia or AIDS dementia) (Centers for Disease Control, 1987e) (Zimmerman, AIDS: Social Causes, Patterns, Cures’, and Problems, p. 292 in Human Sexuality: The Societal and Interpersonal Context. Kathleen McKinney and Susan Sprecher)
AIDS is a syndrome of about thirty diseases, not a disease. It displays no unique combination of diseases in the patient. Clinically, it is identified by the diagnosis of specific diseases known to medical science for decades or centuries. The CDC has several times increased-but never decreased-the official list: of AIDS indicator diseases, most recently on January 1, 1993 (See Table 2).
The list now includes brain dementia, chronic diarrhea, cancers such as Kaposi’s sarcoma and several lymphomas, and such opportunistic infections as Pneumocystis carinii pneumonia, cytomegalovirus infection, herpes, candidiasis (yeast infections), and tuberculosis. Even low T-cell counts in the blood can now be called "AIDS," with or without real clinical symptoms. Cervical cancer has recently been added to the list, the first AIDS disease that can affect only one gender (in this case, women). The purpose behind adding this disease was entirely political, admittedly to increase the number of female AIDS patients, creating an illusion that the syndrome is "spreading" into the heterosexual population. Originally the AIDS diseases were tied together because they were all increasing within certain risk groups, but today they are assumed to derive from the common basis of immune deficiency. The overlap between AIDS and certain risk groups still holds true but, as pointed out in Table I, a significant number of these diseases are not products of weakened immune systems. (Duesberg, Inventing the AIDS Virus, p. 209)
* The United States Center for Disease Control’s defining of AIDS chronologically
In 1982 and subsequently in 1985 and 1987, the American Centers for Disease Control (CDC) introduced a case definition for AIDS, as a cluster of conditions seen in the early part of the HIV outbreak. This definition consisted of a list of infections, malignancies and constitutional illnesses that signified immunodeficiency in these previous healthy people. (Murphy, Brook, Birchall, HIV Infection and AIDS, p.5)
Mid 1981: a person who 1) has either biopsy -proven KS or biopsy-proven life threatening opportunistic infection, 2) is under age 60, 3) no history of either immunosuppressive underlying illness or immunosuppressive therapy.
September1982: a disease at least moderately predictive of a defect in cell-mediated immunity, occurring in a person with no known cause for diminished resistance to that disease. 1) Kaposi’s sarcoma (KS) (< 60 years of age) 2) Pneumocystis carinii pneumonia (PSP) 3) a specific list of other opportunistic infections (a list which which the CDC has amended over the years). This was a list of 14 different opportunistic diseases.
In 1982, the CDC developed a surveillance case definition for this syndrome focusing on the presence of opportunistic infections; it initially received case reports directly from both health care providers and state and local health departments. (Smith, Encyclopedia of AIDS, p.33-34)
June 1985: After discovery of HIV and its identification as the cause of AIDS the CDC once again revised the definition of AIDS. It added 7 more diseases to the previous list of 14 different opportunistic infectious diseases. The list now included 21 diseases. Also, this new AIDS definition included a person who was HIV seropostive by any test.
The AIDS case definition was expanded in 1985 to include a total of 20 conditions. Four of these conditions were cancers: Kaposi’s sarcoma and three distinct types of lymphoma. The remaining conditions were opportunistic infections - those caused by bacteria, fungi, protozoans, and other infectious agents - that an intact immune system can usually manage but which take advantage of the opportunity provided by weakened immunity to proliferate in the body. (Smith, Encyclopedia of AIDS, p.34)
August 1987: The number of opportunistic infectious diseases on the AIDS definition list was increased from 21 to 24. Of particular interest was a change that one set of 12 opportunistic infectious diseases were diagnostic for AIDS regardless of whether there was any evidence of HIV infection. Thus, if a person had one of these 12 opportunistic infectious disease, even without any other indication of a relationship to being infected with HIV, (including a negative HIV test) the person was classified as having AIDS. Included in this first set of 12 opportunistic infectious diseases was Pnueumocystis pneumonia, Kaposi’s sarcoma, disseminated cytomegalovirus infection, and esophageal candidiasis. A second set of 12 other diseases were diagnostic for AIDS only in conjunction with a positive HIV antibody test. The September 1982 definition included required no known cause for diminished resistance to that disease, but the August 1987 definition now included persons with known causes for diminished resistances to this second set of 12 specific diseases.
Ongoing evidence about the inadequacy of the case definition prompted another revision in 1987 and the inclusion of three additional conditions. One of the new conditions was an opportunistic infection, tuberculosis (TB), but only the extrapulmonary (outside the lungs) type. The other conditions were not opportunistic infections, but rather conditions resulting from the direct effects of infection by HIV in cells of the digestive system (wasting syndrome) and the central nervous system (encephalopathy or dementia). (Smith, Encyclopedia of AIDS, p.34)
In other words, acquired immune deficiency syndrome attributed to HIV infection is now diagnosed even among people who were born with congenital immune deficiencies; who have demonstrable, preexisting, or coexisting causes of immune suppression due to chemotherapy, radiation treatment, or corticosteroid use; among transplant patients who are on regimens of immunosuppressive drugs for life; and so forth. (Root-Bernstein, Rethinking AIDS: The Tragic Cost of Premature Consensus, p. 63)
January 1993: This definition change retained the previous list of 24 diseases and added 3 additional diseases, one of which, invasive cervical cancer is gender specific. It affects only women. The other 2 diseases are pulmonary tuberculosis and recurrent pneumonia in persons with documented HIV infection. The list of indicator and opportunistic infectious diseases has grown from 14 to 29. Also, more significant any person was considered to have AIDS if they had developed a significant loss of a particular white blood cell, called T-helper lymphocytes. The person’s T-helper cell count was to below 200 per cubic millimeter of blood if the individual is HIV seropositive, even if they did not have any opportunistic infectious diseases.
In November 1992, the CDC announced that it was expanding the surveillance definition, effective January 1, 1993, to include the three conditions from the community proposal and any HIV positive individual with a CD4+ cell count of 200 or less or whose CD4+ cells represented less than 14 percent of all lymphocytes. Evidence for HIV seropositivity could be obtained by any means of an HIV-antibody test, direct identification of the virus in tissues, an HIV-antigen test, or another highly specific licensed test for HIV. (Smith, Encyclopedia of AIDS, p.35)
* Western (HIV-1) / African AIDS (HIV-2)
AIDS is a different disease according to geographic location. The differences may be seen regarding the infected groups of people within the population. Also, differences are how the HIV virus is transmitted and the risk factors for acquiring AIDS. In Western countries AIDS is closely linked with male homosexual behavior and intravenous drug use. AIDS in Africa is found effecting males and females alike, as a result of malnutrition and parasitic diseases.
In 1984, the transmissible agent was identified and finally named as human immunodeficiency virus type 1 (HIV-1). In 1985, a second human immunodeficiency virus (HIV-2) was identified in Western Africa, which gave rise to a clinically similar disease.
There are different strains of HIV-1 known as subtypes’ or ‘clades’ and designated A to H. Subtype B is the most common strain in the UK and USA, subtype A in Africa and subtype E in Thailand. (Murphy, Brook, and Birchall, HIV Infection and AIDS, p. 1)
The distinction between Western AIDS and African AIDS, as the two forms of the disease became known, was based primarily on epidemiological differences, especially with regards to the groups of people within the population who were mainly affected and how the virus was predominately transmitted. (Schoub, AIDS and HIV in Perspective, p. 22)
HIV is the only microbe that behaves differently according to the geographic location of its host. In Africa it acts like other infectious agent, attacking male and females alike. But in North America and Europe it is sociotropic, seeking out adult gay men and intravenous drug users. Moreover, the risk factors vary by geography. In Africa, they are not receptive anal intercourse and drug use, but parasitic diseases and malnutrition. (Hiram, The AIDS Mirage, p.11)
Classification systems have been modified for specific circumstances; for example, in 1986 the WHO at a meeting in Bangui, in the Central African Republic, proposed a working definition for Africa which soon became known as the Bangui definition. This classification was tailored for African conditions where the spectrum of opportunistic infections is different from that in the USA and Europe, and it also makes provisions for the inadequacies in laboratory testing facilities in many African countries, both for HIV as well as for a number of the opportunistic infections. (Schoub, AIDS and HIV in Perspective, p. 36)
* The World Health Organization’s 3 patterns of AIDS
In 1988, the WHO proposed that the global epidemiology of AIDS be divided into three patterns. (Schoub, AIDS and HIV in Perspective, p. 22)
Within the global community three general patterns of HIV transmission have been identified by the World Health Organization and the U.S. Communicable Disease Center: Patterns I, II, III. (Stine, Acquired Immune Deficiency Syndrome, p. 181)
The following ‘patterns’ are from the book by Gerald J. Stine, Acquired Immune Deficiency Syndrome, p. 181-182
1. Industrialized parts of the world: US, Canada, Western Europe, Australia, New Zealand and some Latin American countries such as Brazil, Mexico, & Puerto Rico.
2. HIV introduced in the late 1970s
3. Principal modes of transmission are through homosexual sex, bisexual sex, injection drug use, and sex with a drug user.
4. Ratio of male to female AIDS cases is 10:1 to 15: 1
Thus, an essential component of Pattern 1 HIV epidemiology is that infection is concentrated in so-called high-risk groups, mainly homosexual and bisexual men and intravenous drug abusers, where the prevalence of infection may be up to 50% or more. (Schoub, AIDS and HIV in Perspective, p. 22)
1. Developing countries in Africa, Caribbean, (Haiti and the Dominican Republic) and parts of South America.
2. HIV was introduced in the late 1970s.
3. Heterosexual intercourse
4. Ratio of male to female AIDS cases is 1:1
Early in 1994, the World Health Organization stopped using the term Pattern II to describe regional differences in transmission because this was no longer a useful way to describe all countries where heterosexual contact is a major mode of HIV transmission. (Stine, Acquired Immune Deficiency Syndrome, p. 181)
Now the category is risk not reported or identified.
Occurs in countries of Eastern Europe, the Middle East, North Africa, Asia, and the Pacific.
* Consequences of how AIDS is defined
One result of this changing definition for AIDS is the increasing number of groups of people who are said to have AIDS as the definition is broadened. As the number of new groups is included so does the number of people who are said to have AIDS increases. In some cases, this increase in the number of people with AIDS has been a result definitional fiat that is just by changing the definition of AIDS itself.
There does not even exist a single proper definition of AIDS on which discourse or statistics can reliably be based. Indeed, certain practices of the Centers for Disease Control (CDC) obstruct a scientific appraisal of the AIDS situation. The CDC definition of AIDS is circular. It involves a list of 24-29 diseases (depending on the year), about 60% of which have to do with immunodeficiency (including tuberculosis), and 40% have to do with other types of diseases, some of which are of cancer type, such as cervical cancer (included in 1992-1993), or Kaposi’s sarcoma. The CDC calls these diseases AIDS only when antibodies against HIV are confirmed or presumed to be present. If a person tests HIV negative, then the diseases are given another name. Statistics based on such a definition are very misleading, because the definition assumes correlation. Furthermore, some statistics from some sources are based on the CDC definition, while others are not. (Lang, HIV and AIDS: Have We Been Misled? p. 274 in AIDS: Virus- or Drug Induced, Peter Duesberg editor)
To my knowledge, I am the first writer to compile a numbered list of the official AIDS-indicator diseases or conditions. It is a very mixed bag. Many of the diseases are caused by funguses: for example, candidiasis, coccidiodomycosis, cryptococcosis, histoplasmosis, and Pneumocystis carinii. Others are caused by bacteria, like salmonella. Others, by mycobacteria, like tuberculosis. Still others, by viruses, like cytomegalovirus or herpes. And still others, like the various cancers and neoplasms, including lymphoma and Kaposi’s sarcoma, have no established etiology. And still others, like dementia or wasting, are poorly defined and can have many different causes" (Lauritsen, The Incidence Quagmire, p. 337 in AIDS: Virus- or Drug Induced, Peter Duesberg editor)
Moreover, the existence of multiple causes of immune suppression unique to or unusually common among those at high risk for AIDS must also cause us to reconsider the definition of AIDS itself. Recall that AIDS was defined in 1987 as a syndrome characterized by significant immune suppression leading to opportunistic disease in previously healthy people without identified causes of immune suppression. But every AIDS patient for whom complete records exist can be shown to have had multiple causes of immune suppression other than HIV and to have been ill or unhealthy prior to developing either HIV or AIDS. These pre-AIDS health problems were ignored, and generally continue to be ignored, in considering the causes of AIDS and in carrying epidemiological studies of risk factors for AIDS. Until they are recognized and the definition is altered to reflect their existence, we may never understand AIDS because we will be utilizing an inaccurate and misleading guide. (Root-Bernstein, Rethinking AIDS: The Tragic Cost of Premature Consensus, p. 114-115)
Thus, a number of groups that had previously been excluded from diagnoses of AIDS, such as certain cancer patients and elderly men with Kaposi’s sarcoma, were suddenly potential AIDS patients despite previously demonstrated risks for opportunistic diseases. (Root-Bernstein, Rethinking AIDS: The Tragic Cost of Premature Consensus, p. 61-62)
In other words, the number of AIDS cases may double with one fell swoop, not because of AIDS has suddenly spread to new risks groups or even because it has spread within acknowledged risks groups, but by definitional fiat. (Root-Bernstein, Rethinking AIDS: The Tragic Cost of Premature Consensus, p. 64)
The effects of the definition changes go far beyond mere questions of who has AIDS or how it is to be diagnosed. Much of our public health policy rests upon calculations of how fast AIDS is growing and into what groups it seems to be spreading. Each time the definition of AIDS changes; all these calculations change as well. Previously excluded people suddenly qualify as AIDS patients. Diagnoses skyrocket. The 1985 definition change resulted in about a 4 percent increase in the number of diagnoses, a small enough fraction that translates into 2,000 additional cases a year in the U.S. The 1987 revision resulted in about 30 percent increase in diagnoses, or some 10,000 cases in 1988 and some additional cases during 1991. The proposed 1992 definition may double the number of diagnoses overnight. In consequence, a significant proportion of the continued explosive growth of AIDS throughout the past decade has been fueled not by transmission of AIDS to new groups of people but rather by the inclusion of previously excluded groups of people into the category of AIDS. People fitting these revised definitions of AIDS have always existed, but they were not counted as AIDS cases. (Root-Bernstein, Rethinking AIDS: The Tragic Cost of Premature Consensus, p. 67-68)
Almost all AIDS statistics for the United States come from CDC publications. The number of AIDS cases has increased over time, partly because the definition of AIDS has been expanded. In particular, the number of conditions that meet the CDC’s criteria for AIDS changed in 1993, resulting in a substantial increase in the number of cases. (Rushing, The AIDS Epidemic: Social Dimensions of an Infectious Disease, p. 3)
Each time the definition of AIDS has been altered by the CDC, it has led to an increase in the number of AIDS cases. In 1985, the change in definition led to a 2% increase over what would have been diagnosed prior to the change. The 1987 change led to a 35% increase in new AIDS cases per year over that expected using the 1985 definition. The 1993 change resulted in a 52% increase in AIDS cases over that expected for 1993. Such rapid changes altars the baseline from which future predictions are made and makes the interpretations of trends in incidence and characteristic of cases difficult to process. (Stine, Acquired Immune Deficiency Syndrome, p. 27)
As AIDS survivor Michael Callen writes in his in his inspirational book, Surviving AIDS, long-term AIDS survival does occur, but no one, once diagnosed definitely with AIDS, has ever been taken off the lists kept by the CDC except at death. This makes AIDS the first disease that no can survive, by definition. Not only is this description of AIDS logically bankrupt, it sends the demoralizing and an inaccurate message to people with HIV or AIDS that they have a disease that is not worth fighting. A more legitimate, and more hopeful, definition must be devised. (Root-Bernstein, Rethinking AIDS: The Tragic Cost of Premature Consensus, p. 68)
The Centers for Disease Control HIV/AIDS Surveillance Reports notes, “ Acquired Immune Deficiency Syndrome (AIDS) is a specific group of diseases or conditions which are indicative of severe immunosuppression related to infection with the human immunodeficiency virus (HIV). The precision of this medical definition obscures the fact that has been essential to the public understanding of AIDS: most people with AIDS are gay men or injection drug users (IDUs). (Donovan, Taking AIM: target Populations and the Wars on AIDS and Drug