The HIV controversy – To test or not to test

by J. Yorke, B. Rapatski, F. Suppe

Yorke’s home page

In September 2006, the Centers For Disease control made a change in policy, asking for wide-spread population screening to detect earlier people in the U. S. who are infected with HIV. See the lead article in the Washington Post September 22, 2006; A01. “All adolescents and adults should routinely be tested for HIV infection in hospitals, clinics and doctors' offices, the federal government said yesterday, signaling a radical shift in the public health approach to the 25-year-old epidemic.”

Why is this radical shift occurring now and not ten years ago when effective antiretroviral treatment became available? Perhaps the medical establishment was fooled by research published in 1994 and 1997 indicating that broad testing would be ineffective at stemming the epidemic. Did those papers make absurd assumptions to prove their point? Is it really possible that gay men choose sex partners whose age differs from theirs by a median of 0.4 years? If they could, why would they bother?

James Koopman et al (1) assert that in sexual contacts HIV-1 is most infectious when the infected partner is in the “first” stage of infection, the initial two-month period before developing antibodies to HIV. Hence the standard antibody detection tests will not work during that stage. For an epidemic that is nearly level as in the United States, their estimates imply that about 3/4 of all infections are caused by people in stage 1. Our paper (2) asserts that the third stage is most infectious. Since the third stage typically begins after about seven years of infection, there is sufficient time for population screening to identify many infected individuals. The third stage (excluding the AIDS stage) is typically about 12 times as long as the first stage so infected individuals have more time to spread the disease in that stage than in the primary stage.

If an infected person is detected, he or she will, with high likelihood, begin treatment with anti-retroviral drugs, and his or her infectiousness will plummet.

We believe that if the screening policy is implemented effectively, many chains of infection, from person to person to person ... will be stopped and the rate of new infections in the US will be decrease significantly.

(1) Papers by Koopman et al.

Jacquez, JA, Koopman, JS, Simon, CP, & Longini, IM. Jr., Role of the primary infection in epidemics of HIV infection in gay cohorts. JAIDS 7, 1169-1184 (1994); and

Koopman JS, Jacquez JA, Welch GW, Simon CP, et al. The role of early HIV infection in the spread of HIV through populations. JAIDS 14, 249-258 (1997).

(2) Brandy L. Rapatski, Frederick Suppe, and James A. Yorke, HIV Epidemics Driven by Late Disease-Stage Transmission, J. AIDS, 38, 2005, 241-253.

This paper asserts that late stage (stage 3) is more important than stage 1 for transmission.

(3) Letter to JAIDS editor by Koopman & Simon has a vicious attack on above paper (2), with over 20 criticisms.

The strong phrasing on this page is necessitated by the phrasing in (3).

(4) JAIDS response (in press) by Rapatski, Suppe, & Yorke to the Koopman & Simon attack (3).

This paper observes that Koopman & Simon believe their criticisms (though R-S-Y do not). These criticisms are equally valid for attacking the K-S work. “Koopman and Simon ... seem to severely criticize their own paper and choose not to defend it against our remarks.” Does Dr. Koopman believe that hypotheses should be changed and shifted until the results are those he wants, even if it is necessary to make absurd hypotheses?

Excerpts from a Washington Post article by Susan Levine, Washington Post Staff Writer
published Saturday, June 24, 2006; A01

Excerpts:

The District will launch a campaign next week urging every resident between the ages of 14 and 84 to be tested for HIV, an ambitious undertaking that public health officials say is critical to reversing rates of infection that are among the worst in the country.
The citywide campaign, which appears to be unprecedented in its breadth, will target 400,000 men, women and teenagers and encourage them to learn their HIV status through an oral swab that delivers results in 20 minutes.
Organizers want the rapid test to become as common a part of any medical exam as blood-pressure monitoring or a cholesterol check. The hope is that the results, especially if positive, would influence a person's sexual behavior and motivate him or her to seek treatment.
Nationally, the CDC estimates, 25 percent of the more than 1 million Americans living with HIV are unaware they are infected.
Appleseed Executive Director Walter Smith applauded the campaign yesterday. "I don't think you'll find routine citywide testing anywhere in the country," he said. "It's an important and bold step forward, and we welcome it."

A monograph that created a theoretical underpinning for US policy on gonorrhea population screening policy:

H. W. Hethcote and J. A. Yorke,

Gonorrhea Transmission Dynamics and Control,

Springer-Verlag Lecture Notes in Biomathematics #56, 1984.

(Out of print; copyright now retained by the authors)

Co-author

Brandy Rapatski, Ph.D.
Richard Stockton College of NJ
Natural Sciences and Mathematics
Pomona, NJ 08731