The Origins of AIDS (26 page)
Read The Origins of AIDS Online
Authors: Pepin
These findings represent the best available data concerning the chronology of the introduction of HIV-1 into the Americas. They were contested by Haitian researchers, and one can understand that the wounds of the anti-Haitian stigmatisation of twenty-five years ago have left permanent scars, especially considering that these were superimposed on centuries of domination and exploitation of Haitians by white westerners. However, their arguments were refuted by the authors’ reply published in the same journal.
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There is now little doubt that HIV-1 subtype B was exported from central Africa to Haiti around 1966, from where it was re-exported to the US a few years later. Among the 4,500 Haitians who worked in the
Congo, one of them acquired HIV-1, probably through heterosexual intercourse, and later initiated a chain of transmission upon returning to the Caribbean island, during vacations or at the end of his contract. As in any population of 4,500 adults, there must have been a small minority who were sexually promiscuous and bought sex once in a while. The same behaviours that facilitated acquisition of HIV-1 within the heart of Africa must have contributed to its early spread in Haiti, the returning technical assistant infecting one or more Haitian women, perhaps a sex worker.
Congo, one of them acquired HIV-1, probably through heterosexual intercourse, and later initiated a chain of transmission upon returning to the Caribbean island, during vacations or at the end of his contract. As in any population of 4,500 adults, there must have been a small minority who were sexually promiscuous and bought sex once in a while. The same behaviours that facilitated acquisition of HIV-1 within the heart of Africa must have contributed to its early spread in Haiti, the returning technical assistant infecting one or more Haitian women, perhaps a sex worker.
Molecular biology and phylogenetics aside, we can be relatively certain of the number of Haitians who introduced HIV-1 into the Americas: a single individual. That is because subtype B, the exclusive subtype present among Haitians and Americans in the early stage of the epidemic, is very uncommon in central Africa where it represents less than 0.5% of all HIV-1 strains that circulate. Thus, it is virtually impossible statistically that more than one Haitian working in the Congo got infected with the same subtype in the early 1960s and brought it back home. This is an extraordinary example of what evolutionary biologists describe as a
founder event
.
founder event
.
But why was the introduction of HIV-1 into Haiti so epidemiologically successful rather than just another dead end infection, as with the
Norwegian sailor and the Belgian expatriates infected in the Congo in the 1960s? How was it possible for a virus imported in 1966, by only one individual, to infect 8% of mothers attending an under-five clinic in the
Cité Soleil slum of
Port-au-Prince merely a decade and a half later, bearing in mind that such an expansion required more than fifty years in Léopoldville/Kinshasa? There must have been a very effective amplification mechanism early on, but was it sexual or parenteral? This will be the topic of the
next chapter
.
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Norwegian sailor and the Belgian expatriates infected in the Congo in the 1960s? How was it possible for a virus imported in 1966, by only one individual, to infect 8% of mothers attending an under-five clinic in the
Cité Soleil slum of
Port-au-Prince merely a decade and a half later, bearing in mind that such an expansion required more than fifty years in Léopoldville/Kinshasa? There must have been a very effective amplification mechanism early on, but was it sexual or parenteral? This will be the topic of the
next chapter
.
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The blood trade
The blood trade
In this chapter, we will examine the possibility that, during the early stage of the Haitian epidemic, a commercial enterprise in Port-au-Prince exponentially and parenterally amplified the number of HIV-1-infected individuals and allowed the virus to thrive. More generally, we will review the role of the blood trade in the globalisation of HIV-1. But first, we need to understand how viruses can be transmitted, not only from donor to recipient, but also from one donor to another during the handling required to prepare certain blood products. The word ‘donor’ is somewhat misleading here because we are talking mostly about people paid for their ‘donations’.
Blood is made of cells (red blood cells, white blood cells and platelets) and plasma, its liquid component. Plasma is made of water and proteins: antibodies, clotting factors and albumin. When a donation is made, the various components are separated to maximise their use. Patients with anaemia or acute blood loss need only receive the red blood cells, those with a low platelet count will be given the platelets and so on. Plasma is highly valuable as it contains many proteins. Therapeutic use of plasma started during WWII as an expander of intravascular volume, to increase quickly blood pressure in patients with serious bleeding. Subsequently, other uses of plasma components were developed, which required the selective processing of specific proteins: albumin (to expand intravascular volume or to patients with low albumin levels),
coagulation factors (haemophilia or other coagulation disorders) and
immunoglobulins (patients with immune deficiencies or to protect travellers against
hepatitis A)
.
coagulation factors (haemophilia or other coagulation disorders) and
immunoglobulins (patients with immune deficiencies or to protect travellers against
hepatitis A)
.
Plasma was also used for the production of the early generation of hepatitis B vaccines, made from the chemical inactivation of the virus present in blood and the purification of its surface antigen. Sources of hepatitis B-positive donors included gay men and
prisoners in developed countries, and the general population of Third World nations, where up to 15% of adults chronically carry HBV in their blood. At
least 30 million doses of such crude vaccines were administered before being replaced with genetically engineered vaccines.
prisoners in developed countries, and the general population of Third World nations, where up to 15% of adults chronically carry HBV in their blood. At
least 30 million doses of such crude vaccines were administered before being replaced with genetically engineered vaccines.
As the amount of the specific proteins of interest is small in each individual donor’s plasma, commercial plasma derivatives must be prepared by pooling plasma from several donors. In particular, the fabrication of coagulation factor concentrates required the pooling of plasma from thousands of donors, such that an infectious agent present in a single donor could make the entire pool infectious and be transmitted to many recipients. Prior to their discovery, transmission of HIV-1 and
HCV from coagulation factor concentrates infected thousands of haemophiliacs worldwide, resulting in the tragic death of a large portion of this population. Since then, the infectious risk from coagulation factors has been drastically reduced through the development of sensitive screening assays for donors and better methods for eliminating viruses
.
HCV from coagulation factor concentrates infected thousands of haemophiliacs worldwide, resulting in the tragic death of a large portion of this population. Since then, the infectious risk from coagulation factors has been drastically reduced through the development of sensitive screening assays for donors and better methods for eliminating viruses
.
The risk of transmitting HIV was much lower, indeed probably near zero, when the plasma was processed to prepare albumin, because ethanol was used in the fractionation, after which the product was pasteurised by heating
. And fortunately, no transmission through immunoglobulins has ever been reported, even if many batches contained antibodies against HIV: again, the ethanol fractionation process inactivated HIV
. The early hepatitis B vaccines were not incriminated in the transmission of HIV either; presumably, the methods used to inactivate HBV were effective against HIV as well
.
1
–
2
. And fortunately, no transmission through immunoglobulins has ever been reported, even if many batches contained antibodies against HIV: again, the ethanol fractionation process inactivated HIV
. The early hepatitis B vaccines were not incriminated in the transmission of HIV either; presumably, the methods used to inactivate HBV were effective against HIV as well
.
1
–
2
In the late 1960s and 1970s, before HIV and HCV were known, the demand for plasma-derived products had escalated rapidly. There was not enough excess plasma from volunteer whole blood donors and paid donors had to be recruited. In order to get more plasma from these paid donors, a technology called ‘plasmapheresis’ was developed: whole blood was taken from the donor, the plasma quickly separated from the blood cells and the cells re-infused in the donor along with replacement fluids. Thus the donor did not become anaemic and could sell plasma repeatedly, not just twice a year as with donors of whole blood. However, before and even after the infectious risks were understood, viruses could be transmitted not only to the ultimate recipients of the blood products but also between donors participating in plasmapheresis. This required only one breakdown in some component of the process, for instance the re-use of pieces of plastic tubing that had been designed for single use. If a donor with unrecognised HIV infection
entered the process and if some precaution was disregarded, this person could infect subsequent plasma donors whose blood was processed by the same machine on the same or following days. In settings where paid donors repeatedly sold their plasma week after week, this would increase the number and proportion of HIV-infected individuals among those selling plasma, further enhancing the risk for the other donors. This vicious circle would result in exponential propagation of HIV between donors, arguably the most effective method for HIV transmission.
entered the process and if some precaution was disregarded, this person could infect subsequent plasma donors whose blood was processed by the same machine on the same or following days. In settings where paid donors repeatedly sold their plasma week after week, this would increase the number and proportion of HIV-infected individuals among those selling plasma, further enhancing the risk for the other donors. This vicious circle would result in exponential propagation of HIV between donors, arguably the most effective method for HIV transmission.
The infectious risks for donors in plasmapheresis centres had been known for some time before the HIV epidemic. In 1973, donors at a South Carolina commercial plasmapheresis centre contracted the
hepatitis A virus, a microbe which remains present in the bloodstream for only a short period of time. This was caused by the pooling of plasma from multiple donors during its extraction from the cells, allowing the reflux of pooled plasma into the bags of red cells re-infused in the donors. In 1977–8, four outbreaks involved plasma donors who developed ‘non-A non-B hepatitis’ (later renamed
hepatitis C after its aetiological agent was discovered) in plasmapheresis centres in
Austria, Germany and
Poland, apparently from contamination with plasma of the plastic bags used for re-infusing red blood cells. In the US, paid donors were often recruited in prisons, a substantial percentage of whose populations were previous or current drug addicts at high risk of being infected with HBV or HCV: a chain of transmission could easily be initiated
.
3
–
5
hepatitis A virus, a microbe which remains present in the bloodstream for only a short period of time. This was caused by the pooling of plasma from multiple donors during its extraction from the cells, allowing the reflux of pooled plasma into the bags of red cells re-infused in the donors. In 1977–8, four outbreaks involved plasma donors who developed ‘non-A non-B hepatitis’ (later renamed
hepatitis C after its aetiological agent was discovered) in plasmapheresis centres in
Austria, Germany and
Poland, apparently from contamination with plasma of the plastic bags used for re-infusing red blood cells. In the US, paid donors were often recruited in prisons, a substantial percentage of whose populations were previous or current drug addicts at high risk of being infected with HBV or HCV: a chain of transmission could easily be initiated
.
3
–
5
The first well-documented epidemic of HIV-1 among paid plasma donors occurred in a poor suburb of Mexico City where, in 1986, 281 donors were found to be HIV-infected, especially those that sold plasma ten or more times each month. Re-utilisation of blood collecting material was blamed. At the time there were thirteen plasmapheresis centres in the country, mainly in Mexico City and in states near the Texan border. Most donors were young men living in the peri-urban shanty towns. They could sell their blood as often as every two to three days. By the time that the sale of plasma was prohibited nationwide in 1987, 7% of 9,100 paid donors were HIV-infected. In one of the plasmapheresis centres, HIV prevalence increased from 6% in June to 54% in November 1986
. Other outbreaks of HIV transmission among paid plasma donors were reported in
Valencia,
Spain and
Pune,
India. In the latter city, among commercial plasma donors, HIV prevalence was 0%
in November 1987 but 78% seven months later, illustrating the exponential transmission of HIV through unhygienic plasma collection practices.
6
–
11
. Other outbreaks of HIV transmission among paid plasma donors were reported in
Valencia,
Spain and
Pune,
India. In the latter city, among commercial plasma donors, HIV prevalence was 0%
in November 1987 but 78% seven months later, illustrating the exponential transmission of HIV through unhygienic plasma collection practices.
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These outbreaks, although tragic in their own right, were dwarfed by what happened in China in the early 1990s, several years after the risk of HIV transmission via plasmapheresis was understood, and a decade after the transmission of
HCV had been documented in the same Chinese centres. In rural areas, poor farmers were recruited by ‘
plasma pimps’, to sell plasma to increase their meagre income. They received $6 per donation, which could be repeated twice a month in theory, more often if donors attended more than one collection centre. There were several hundred plasma collection stations set up by blood product companies. In the most-heavily affected provinces of Henan, Anhui, Shanxi, Hubei, Hebei, Shandong and Jilin, approximately 250,000 paid donors (a quarter of a million!) acquired HIV.
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HCV had been documented in the same Chinese centres. In rural areas, poor farmers were recruited by ‘
plasma pimps’, to sell plasma to increase their meagre income. They received $6 per donation, which could be repeated twice a month in theory, more often if donors attended more than one collection centre. There were several hundred plasma collection stations set up by blood product companies. In the most-heavily affected provinces of Henan, Anhui, Shanxi, Hubei, Hebei, Shandong and Jilin, approximately 250,000 paid donors (a quarter of a million!) acquired HIV.
12
–
14
In several plasma collection centres, blood from multiple ABO-matched donors (who were not screened for HIV) was combined for ‘more efficient’ large volume plasma separation, and then the pooled cell fraction was returned to the donors, along with any infectious agent that had been present in the blood of any of the donors at a given session. The re-use of needles and tubing also facilitated transmission. In some regions, between 9 and 17% of plasma donors became HIV-infected while up to 28% were infected with
HCV. It is remarkable that such a high HIV prevalence was reached despite most donors reporting fewer than ten donations per year. Among the small number who sold plasma more than twenty times per year, half became HIV-infected
.
12
,
15
HCV. It is remarkable that such a high HIV prevalence was reached despite most donors reporting fewer than ten donations per year. Among the small number who sold plasma more than twenty times per year, half became HIV-infected
.
12
,
15
What do all these stories have in common? Poor people looking for a quick source of income and willing to sell their blood repeatedly. Profit-driven blood collection centres where a small number of entrepreneurs try to make as much money as possible by cutting costs, re-using needles, syringes and tubings, while being unaware of or not caring about the risk of transmitting blood-borne viruses. A lucrative market for these blood products, either locally or internationally. Finally, a ‘patient zero’ who introduces the pathogen.
The vampire of the CaribbeanNow back to the Caribbean, where the potential for a quick profit in the blood trade had been exploited as well. In Port-au-Prince, a large
plasmapheresis centre operated from May 1971 to November 1972 under the name Hemo-Caribbean.
This was a joint venture between Joseph Gorinstein, a Miami businessman and stockbroker, a few other American investors and a well-known Haitian politician, Luckner Cambronne.
plasmapheresis centre operated from May 1971 to November 1972 under the name Hemo-Caribbean.
This was a joint venture between Joseph Gorinstein, a Miami businessman and stockbroker, a few other American investors and a well-known Haitian politician, Luckner Cambronne.
Luckner Cambronne was born in 1929, the son of a poor Protestant preacher. Starting out as a bank teller, he eventually found a job in the entourage of François Duvalier (Papa Doc), the country doctor elected president in 1957. Initially just a messenger, he then became a bagman. Duvalier liked him and Cambronne quickly rose to become the regime’s chief extortionist. He held various ministries (public works, customs, etc.), all of which provided ample opportunity for corruption. His speciality was to intimidate businessmen into making large ‘donations’, and those who refused had a much shorter life expectancy. Ostensibly, these funds were to be used to rebuild a slum or pave a road but most of it ended up in Duvalier’s and Cambronne’s bank accounts. This was also the main destination for the funds (deducted from the pay of civil servants) allocated to building a new city,
Duvalierville. Only a few bungalows were erected, far from the promised Caribbean Brasilia.
16
Duvalierville. Only a few bungalows were erected, far from the promised Caribbean Brasilia.
16
Cambronne was the most feared man in Haiti after his boss for good reason: he was the leader of the infamous
Tontons Macoutes, Duvalier’s militia, who assassinated thousands of opponents. He became famous for saying that a good Duvalierist is prepared to kill his own children for Duvalier, and also expects his children to kill their parents for him. Cambronne developed many business interests: part-ownership of Air Haiti (which had a monopoly on transportation to Miami)
, taxi companies, the Ibo Tours travel agency specialising in quick all-inclusive $1,200 divorces for Americans (conveniently, a new divorce law facilitated this enterprise – it was no longer necessary for both parties to be present), fishing facilities, fruit and coffee exports, a supermarket, cannabis plantations and so on. Cambronne also made money by exporting corpses to American medical schools. His plasma commerce would earn him the nickname ‘Vampire of the Caribbean’. He became a habitué of the upmarket brothels in Port-au-Prince, a high-stakes poker player in the flashy casinos and a lover of expensive sharkskin suits, hence his other nickname, ‘The Shark’.
Tontons Macoutes, Duvalier’s militia, who assassinated thousands of opponents. He became famous for saying that a good Duvalierist is prepared to kill his own children for Duvalier, and also expects his children to kill their parents for him. Cambronne developed many business interests: part-ownership of Air Haiti (which had a monopoly on transportation to Miami)
, taxi companies, the Ibo Tours travel agency specialising in quick all-inclusive $1,200 divorces for Americans (conveniently, a new divorce law facilitated this enterprise – it was no longer necessary for both parties to be present), fishing facilities, fruit and coffee exports, a supermarket, cannabis plantations and so on. Cambronne also made money by exporting corpses to American medical schools. His plasma commerce would earn him the nickname ‘Vampire of the Caribbean’. He became a habitué of the upmarket brothels in Port-au-Prince, a high-stakes poker player in the flashy casinos and a lover of expensive sharkskin suits, hence his other nickname, ‘The Shark’.
In January 1972, the
New York Times
reported that Hemo-Caribbean was exporting up to 6,000 litres of plasma to the US each month. Hemo-Caribbean could accommodate 350 donors per day at its
two-storey centre on Rue des Remparts, and was building a second facility to increase capacity to 850 donors per day. Run by an Austrian biochemist, Hemo-Caribbean initially had a staff of 110 employees and was open six days a week from 6.30 to 22.00. After the expansion, its payroll doubled to 200 employees including nine full-time medical doctors. Paid donors were among the poorest of a very impoverished nation, described by the
New York Times
as ‘many in rags, without shoes’. Most were illiterate. They would show up once a week and receive between $3 and $5 per donation, a process described by some as ‘plasma farming’. A local doctor commented: ‘The plasma cows are rather tired, but they don’t have a job anyway.’ When sold in the US, the same quantity of plasma would fetch around $35. An author estimated that ultimately around 6,000 Haitians sold their plasma to Hemo-Caribbean. That seems reasonably accurate because Gorinstein claimed that in late 1972 Hemo-Caribbean was paying donors an average of $70,000 each month: at $4 per donation, this corresponds to 700 different donors each day and about 4,200 through an average week.
17
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26
New York Times
reported that Hemo-Caribbean was exporting up to 6,000 litres of plasma to the US each month. Hemo-Caribbean could accommodate 350 donors per day at its
two-storey centre on Rue des Remparts, and was building a second facility to increase capacity to 850 donors per day. Run by an Austrian biochemist, Hemo-Caribbean initially had a staff of 110 employees and was open six days a week from 6.30 to 22.00. After the expansion, its payroll doubled to 200 employees including nine full-time medical doctors. Paid donors were among the poorest of a very impoverished nation, described by the
New York Times
as ‘many in rags, without shoes’. Most were illiterate. They would show up once a week and receive between $3 and $5 per donation, a process described by some as ‘plasma farming’. A local doctor commented: ‘The plasma cows are rather tired, but they don’t have a job anyway.’ When sold in the US, the same quantity of plasma would fetch around $35. An author estimated that ultimately around 6,000 Haitians sold their plasma to Hemo-Caribbean. That seems reasonably accurate because Gorinstein claimed that in late 1972 Hemo-Caribbean was paying donors an average of $70,000 each month: at $4 per donation, this corresponds to 700 different donors each day and about 4,200 through an average week.
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–
26
Of course, only plasma was utilised and the red cells were re-infused in the donor to enable him/her to come back quickly for a further donation. The frozen plasma was exported on Air Haiti, Cambronne’s company, and sold to four American enterprises (according to the
New York Times
:
Armour Pharmaceutical,
Cutter Laboratories,
Dade Reagents and
Dow Chemical) as well as to clients in
Germany and
Sweden.
17
New York Times
:
Armour Pharmaceutical,
Cutter Laboratories,
Dade Reagents and
Dow Chemical) as well as to clients in
Germany and
Sweden.
17
After the death of Papa Doc in 1971
, when nineteen-year-old
Jean-Claude (Bébé Doc) succeeded his father, Cambronne was the most powerful man on the island as minister of interior and national defence. The following year, he fell into disgrace and had to flee from Haiti. Whether this was related to the fact that he had allegedly been the lover of Simone Duvalier (Manman Simone) after the death of Papa Doc remains unclear. He also had a conflict with Marie-Denise, Jean-Claude’s powerful eldest sister, who helped to oust Cambronne while Manman Simone happened to be in
Miami.
Jean-Claude Duvalier was afraid that Cambronne wanted the top job, and unhappy with the bad publicity generated by the
New York Times
report, not just outside but also within Haiti (the
Haitian Catholic Church had issued a pastoral letter condemning the trade as unjustified exploitation of a poor people). In November 1972, he ordered Hemo-Caribbean to be closed
and the divorce law was modified so that both parties had to be represented in Port-au-Prince. Gorinstein tried to relocate his plasma business into
Puerto Rico. Cambronne ended up in Miami where he died peacefully in 2006
.
, when nineteen-year-old
Jean-Claude (Bébé Doc) succeeded his father, Cambronne was the most powerful man on the island as minister of interior and national defence. The following year, he fell into disgrace and had to flee from Haiti. Whether this was related to the fact that he had allegedly been the lover of Simone Duvalier (Manman Simone) after the death of Papa Doc remains unclear. He also had a conflict with Marie-Denise, Jean-Claude’s powerful eldest sister, who helped to oust Cambronne while Manman Simone happened to be in
Miami.
Jean-Claude Duvalier was afraid that Cambronne wanted the top job, and unhappy with the bad publicity generated by the
New York Times
report, not just outside but also within Haiti (the
Haitian Catholic Church had issued a pastoral letter condemning the trade as unjustified exploitation of a poor people). In November 1972, he ordered Hemo-Caribbean to be closed
and the divorce law was modified so that both parties had to be represented in Port-au-Prince. Gorinstein tried to relocate his plasma business into
Puerto Rico. Cambronne ended up in Miami where he died peacefully in 2006
.
Although it has been stated that no case of HIV infection in Haiti was ever found among the thousands of people who had sold their plasma, it is far from clear that the first cohorts of Haitian AIDS patients, diagnosed in Port-au-Prince or in the US, were ever asked this question. Since Hemo-Caribbean was closed in 1972, and since the interval between HIV infection and death is generally around ten years, perhaps slightly less in impoverished countries, the opportunity to document such an association did not last long
.
27
.
27
The earliest reports of AIDS among Haitians merely described the new disease, the variety of opportunistic infections and the immunological findings. When the HIV aetiological agent was identified, investigators started looking for risk factors, but many of the early Haitian AIDS studies lacked a comparison group. Factors investigated were those already identified in the US: homosexuality, bisexuality, intravenous drug use, transfusions, haemophilia and contaminated injections, heterosexual promiscuity, sex with prostitutes or past STDs. To these were added potential factors of local interest: the use of medicinal roots or herbs, history of malaria, travel to the US or sex with Americans. Men accounted for three-quarters of these early patients, and many lived in
Carrefour, a poor suburb of Port-au-Prince known to be a hotbed of prostitution. The 1982 Spartacus
Gay Guide recommended that travellers to Haiti should, ‘above all, avoid any establishment’ in the crowded slum area of Carrefour, where theft was rampant, sometimes accompanied by violence
. The preponderance of males among early cases of AIDS could reflect either homosexual transmission, heterosexual transmission in which a small number of female prostitutes infected a large number of male clients, or perhaps a preponderance of men among the paid donors of Hemo-Caribbean. Elsewhere in the world, the sex distribution of paid plasma donors varied: in
Mexico, three-quarters were men while in
China it seemed more evenly distributed between genders.
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36
Carrefour, a poor suburb of Port-au-Prince known to be a hotbed of prostitution. The 1982 Spartacus
Gay Guide recommended that travellers to Haiti should, ‘above all, avoid any establishment’ in the crowded slum area of Carrefour, where theft was rampant, sometimes accompanied by violence
. The preponderance of males among early cases of AIDS could reflect either homosexual transmission, heterosexual transmission in which a small number of female prostitutes infected a large number of male clients, or perhaps a preponderance of men among the paid donors of Hemo-Caribbean. Elsewhere in the world, the sex distribution of paid plasma donors varied: in
Mexico, three-quarters were men while in
China it seemed more evenly distributed between genders.
28
–
36
In the first study in which AIDS cases diagnosed between 1979 and 1984 were compared to controls (same-sex siblings or friends), researchers asked questions about homosexuality, bisexuality, transfusions, intravenous drug use, number of IM injections in the last five years,
source of injections (medical personnel versus non-qualified
piquristes
), level of education, place of residence, income, occupation and foreign travel. But apparently they did not ask any questions about the sale of plasma. One third of the men with AIDS acknowledged having had homosexual intercourse, which indicated that this mode of transmission was significant. Heterosexual promiscuity and receiving injections, especially from a non-medical source, were also more common in cases of AIDS than in controls.
37
source of injections (medical personnel versus non-qualified
piquristes
), level of education, place of residence, income, occupation and foreign travel. But apparently they did not ask any questions about the sale of plasma. One third of the men with AIDS acknowledged having had homosexual intercourse, which indicated that this mode of transmission was significant. Heterosexual promiscuity and receiving injections, especially from a non-medical source, were also more common in cases of AIDS than in controls.
37
A similar study was conducted in 1984 among Haitians diagnosed with AIDS in
Miami and
New York, and healthy seronegative Haitians of the same age and sex as controls. Among forty-three men with AIDS, having bought sex from prostitutes, a history of gonorrhoea, a positive serological test for
syphilis, low socioeconomic status and a recent arrival in the US were more common than in controls, but only one admitted to having had sex with another man. Whether, as was alleged later, this reflected a cultural barrier between patients and interviewers is doubtful as the questionnaire was administered in Creole by Haitian interviewers. It is certainly possible, however, that some men were reluctant to acknowledge their homosexuality. The small group of women with AIDS was more likely than controls to have been offered money for sex and to have a friend who was a voodoo priest! Cases and controls did not differ for a long list of factors: transfusions, drug use, prostitution with tourists, education, occupation, area of residence in Haiti before coming to the US, travel to central Africa, receiving injections in Haiti, going to an injectionist, self-injections, sharing a razor, tattoos, voodoo practices, history of malaria, animal bites, use of folk healers, etc. No data were collected about the sale of plasma. Nor was such information collected in a survey of pregnant women in the
Cité Soleil slum area of Port-au-Prince.
38
,
39
Miami and
New York, and healthy seronegative Haitians of the same age and sex as controls. Among forty-three men with AIDS, having bought sex from prostitutes, a history of gonorrhoea, a positive serological test for
syphilis, low socioeconomic status and a recent arrival in the US were more common than in controls, but only one admitted to having had sex with another man. Whether, as was alleged later, this reflected a cultural barrier between patients and interviewers is doubtful as the questionnaire was administered in Creole by Haitian interviewers. It is certainly possible, however, that some men were reluctant to acknowledge their homosexuality. The small group of women with AIDS was more likely than controls to have been offered money for sex and to have a friend who was a voodoo priest! Cases and controls did not differ for a long list of factors: transfusions, drug use, prostitution with tourists, education, occupation, area of residence in Haiti before coming to the US, travel to central Africa, receiving injections in Haiti, going to an injectionist, self-injections, sharing a razor, tattoos, voodoo practices, history of malaria, animal bites, use of folk healers, etc. No data were collected about the sale of plasma. Nor was such information collected in a survey of pregnant women in the
Cité Soleil slum area of Port-au-Prince.
38
,
39
In follow-up studies, the proportion of AIDS patients diagnosed in Haiti who admitted to homosexuality decreased from 50% in 1983 and 27% in 1984, to as little as 8% in 1985, 4% in 1986 and 1% in 1987. That was a very quick drop indeed, one very hard to explain and never seen elsewhere in the world. Again, no mention was made of the sale of plasma as a risk factor. During the same interval, the proportion of cases seemingly acquired during a transfusion decreased from 23 to 7%.
In a 1991 review article about AIDS in Haiti, the risk of transmission via the Red Cross and public blood banks was
discussed, without any mention of the past activities of Hemo-Caribbean.
40
–
42
In a 1991 review article about AIDS in Haiti, the risk of transmission via the Red Cross and public blood banks was
discussed, without any mention of the past activities of Hemo-Caribbean.
40
–
42
To summarise, the Hemo-Caribbean plasmapheresis centre in Port-au-Prince could have been the perfect venue for the rapid parenteral amplification of a strain of HIV-1 subtype B recently imported from the Congo, and potentially for its re-export to other countries through the international trade in blood products. Hemo-Caribbean operated in 1971 and 1972, at exactly the right time, a few years after the virus had been imported into Haiti. The examples of India, Mexico and China suggest that if HIV-1 was introduced into the cohort of the Port-au-Prince paid donors, transmission could have been swift. Most of these individuals would have died before or shortly after AIDS was recognised in Haiti, and unfortunately the early epidemiological studies did not look for this specific risk factor.
Would it be possible to verify this hypothesis epidemiologically, assuming that some of the paid donors who did not get HIV were infected with HCV instead? Unfortunately, the chaotic situation of the last twenty-five years made it very difficult to conduct medical research in this small country, and those dedicated and courageous enough to do so have focused, quite rightly so, on the treatment of HIV-1 infection. The catastrophic earthquake may have buried definitively any possibility of sorting this out
.
.
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