HIV is a slow-moving time bomb.
Unlike Ebola, which infects and kills people quickly — and then disappears just as quickly — the HIV epidemic has become so good at killing people in part because it moves so very slowly, says journalist Craig Timberg.
"In vaginal sex, you can have sex with hundreds of people and not transmit [HIV], it turns out," he says. "And that's part of the reason it's still with us today. It has spread very slowly. It makes people ill very slowly. ... And that's one of the reasons why it's been so difficult for the world to understand it. ... It's been hard to make sense of this epidemic because of the way it moves. It's not obvious."
Timberg, the former Johannesburg bureau chief for The Washington Post, with his co-author Daniel Halperin, an AIDS expert currently at the University of North Carolina, explores the history of the HIV virus and efforts to fight the AIDS epidemic in his book Tinderbox: How the West Sparked the AIDS Epidemic and How the World Can Finally Overcome It.
The History Of HIV
Timberg tells Fresh Air's Dave Davies that the simian version of HIV — which is called SIV — has been around for thousands of years. It was only when colonial powers migrated across parts of Africa — where the SIV virus existed among the chimps — that the virus started to spread among humans.
"It was only with the introduction of these new transport routes, of these human movements, that HIV popped out of the chimpanzee population and starts an epidemic among the human population and became what we see today," he says.
In the past 100 years, 99 percent of all of the world's deaths from AIDS have come from a strain of the virus called HIV-1 group M, which first appeared in remote parts of Cameroon, where African porters worked a century ago cutting paths across dense brush in places where humans had never before traveled.
"The best theory is that a human caught a chimp, was butchering a chimp — which is a very bloody business — and in the process of that cut his hand, and the virus mutated as it went into the human bloodstream," says Timberg. "... [There was] human movement in areas where humans didn't live in great density before colonialism arrived — you had the arrival of the rubber trade and the ivory trade, and suddenly you had to go into these very deep parts of the forest that were not hospitable to humans before and since."
From Cameroon, strains of HIV migrated down into other parts of central Africa and then into Leopoldville, which is now called Kinshasa. Leopoldville was a Belgian territory and by 1920 had become the capital of the Belgian Congo — complete with factories, shipyards, railways and single-sex dormitories for the workers, who were thrust into urban living conditions.
"You had the kind of human movement that could really get an epidemic moving," says Timberg.
In 1960, the Belgians gave up Congo, which then became an independent country again. At that point, 1,000 to 2,000 people likely had HIV, says Timberg.
"But you have to bear in mind, when HIV progresses into AIDS, it looks like a lot of other diseases," he says. "You have diarrhea, you have fevers, you have wasting. So there's not much evidence that anybody at the time had any evidence that there was a new sickness."
The unknowingly infected inhabitants of Kinshasa mingled with U.N. aid workers who were flown over from Haiti to work as physicians and civil servants. It is almost certainly the case, says Timberg, that one of the Haitian aid workers caught HIV in Leopoldville and then flew back to Haiti.
"From Haiti, it brews up for a few years and then it makes its way into the United States, and from the United States it comes back and infects Europe through airline traffic," he says. "So every HIV virus in the United States or Europe or the Caribbean can be traced to a single ancestor, a single virus that came over from Kinshasa in the 1960s."
Fighting AIDS In Africa
In the 1980s in the United States, there was a large resistance to the idea that HIV and AIDS could spread widely among a heterosexual population — in part, says Timberg, because it didn't happen in many places. But across Africa, he says, it was a different story.
"The first researchers who began to look into the HIV epidemic in Africa found these unbelievable rates of infection that frankly horrified them and terrified them," he says. "When they began to write their papers about this, the peer-reviewed medical journals were like, 'You're crazy. You can't have HIV spreading like this.' But in Africa, it did."
Many African countries initially ignored the AIDS crisis, but some nations — like Uganda and Zimbabwe — were successful in providing public health information and slowing the spread of the disease. Timberg says when Western countries later became serious about fighting the African AIDS epidemic, international AIDS groups didn't follow Uganda's model — and overlooked some relatively simple and inexpensive approaches proven to stem the spread of HIV.
One of their errors, he says, was overlooking the effectiveness of male circumcision. Circumcised men are at a much lower risk of becoming infected with HIV through sexual transmission.
"When you look at the parts of not just Africa but the world where HIV is worse, it is almost inevitably societies that don't circumcise," he says. "The science on this began emerging in the 1980s and it became terribly politicized. People were uncomfortable with the subject, and the whole discussion became incredibly controversial. It took almost 20 years for the scientific community and the community of policymakers to really do enough science and enough research to realize how important this was."
In other places, like South Africa, prevention programs funded by Western charities focused on messages that Timberg says were "stunningly off point" and puzzled their intended audiences. One initiative, called loveLife, was designed to get South Africans to talk about sex more openly, but their billboard campaigns left many South Africans scratching their heads.
"Again and again, as the Western world took over these HIV prevention campaigns, truly frank conversation about sex drained out of these societies," says Timberg. "And fascinatingly, the places that were kind of left alone [like] Zimbabwe — which is north of South Africa, has a horrible government, political collapse — did way better on preventing HIV than South Africa did. Because Zimbabweans didn't have all of the heavy-handed Western messages [and] they watched lots of people die."
In Uganda, he says, the HIV rate went up when Western organizations began pumping money into the country.
"There was this remarkable five-year period where [Uganda] literally saved hundreds of thousands of lives by heading off the spread of HIV [themselves]," he says. "A few years later, when Uganda became this hot nation to give AIDS money to, it went in reverse. HIV started going back up. The HIV [infection rate] is higher than it was 10 years ago. ... It stopped being something that Ugandans themselves felt like they owned."
On sexual culture and epidemics
"The ability for a society to grasp the connection between sexual culture and the spread of this epidemic is just essential to reversing it. And it seems like the more the United States or other Western nations get involved, the farther societies get away from that kind of moment of reckoning."
On the legacy of colonialism
"One of the really pernicious legacies of colonialism in Africa is a bunch of rich governments come in — a bunch of European and American governments come in — and tell people what to do, and lots of people listen. Money talks. You come in with billions of dollars into societies that don't have access to those means or anything else, and you can hire the best doctors, the best thinkers, you can invite journalists out to clinics and tell them the story that you think works, and the usurping of the authentic local response can be very profound."
On the spread of HIV
"Whether it spreads quickly or slowly depends on a lot of factors: among them, whether either partner has sexually transmitted diseases, but also, the kind of society that people are living in, particularly in societies where men and women or men and men have one partner at a time or more than one partner. Those variations in sexual culture have an enormous difference in how quickly the virus spreads. And additionally, men who are circumcised are much less likely to get HIV, and that can really affect how quickly the virus spreads."
On the origins of HIV
"This remarkable biologist at the University of Arizona had found a piece of virus that had been circulating in the capital of Congo back in 1960, and he compared it to a second piece that existed from that same era. And when you look at how different those pieces of virus are, you can sort of do the math and figure out what the origin is. And by looking at the pace with which viruses evolved, you can reverse engineer your way back into a date range. His research suggests that the key year was around 1908, but the range is a bit wider — 1884 to 1924. Somewhere in there, the first HIV is loose in the world, has come out of the chimp population and is infecting humans."
On Patient Zero from And the Band Played On
"Randy Shilts talks about the CDC's fixation on this one airline steward who was Canadian, and he traveled back and to Europe, and he clearly infected plenty of people. There's no reason to minimize that, but what is now clear that wasn't clear when Randy Shilts was writing, was by the time that happened in the late '70s and early '80s, HIV is already all over parts of the United States and, increasingly, parts of Europe as well."
On why HIV spread rapidly in the gay community in the early 1980s
"One of them was that anal sex, when condoms aren't involved, is a very efficient way to spread this virus, much more so than vaginal sex or oral sex. And in addition, you had a fast-lane gay culture in some American cities, where men were having lots of partners in a given year. You had the bathhouses around. That's very consequential in how all sorts of STDs move, not just HIV, sadly."