Debunking Denialism

Defending science against the forces of irrationality.

When HIV/AIDS Activism Goes Wrong

virus

A few days ago, a guest post by HaifischGeweint appear on the Crommunist blog over at the Freethought Blogs network. It is about the stigma attached to individuals with HIV/AIDS and focuses on laws requiring individuals that are HIV positive to let their sexual parters know before engaging in sex. HaifischGeweint appears to label these laws “institutionalized HIV/AIDS discrimination”.

Just so there are no misunderstandings

Just to make sure that we are reducing the risk of misunderstandings, let us get some things clear. HaifischGeweint clearly states that he or she “very strongly disagree with engaging in unprotected sex without first having an honest conversation about STIs and safer sex (no matter what your status)”. HaifischGeweint is also careful to point out that he or she “cannot stand by someone who lies about their status when asked about it or who (regardless of their status) deliberately avoids getting tested and/or practising [sic] safer sex. Full stop.”

Second, people with HIV/AIDS experience a lot of stigma. A lot of people just assume that HIV+ individuals have been sexually promiscuous without using protection, even if the HIV infection was the result of rape, having sex with a long-term partner that cheated on you or getting contaminated blood during surgery. We should do everything within reason to work together against irrational stigma against people with HIV/AIDS. But no matter how noble the goal is, we should not promote scientific falsehoods in order to achieve it (see below).

HIV, sex and informed consent

I am not going to spend a whole lot of text on the main issue here, because there are other serious problems with the blog post (see below), but I think it is clear that informed consent is important when it comes to sex (and most other serious human activities). In a perfect world, everyone would get tested, ask their partner about sexually transmitted infections and tell them if they have any as well as use protection. Unfortunately, this is a fantasy. It does not exist, and it does not appear to be reachable within the foreseeable future. So how should society protect people from being at uninformed risk of being infected by HIV? One avenue is via the legal system, where a person with HIV/AIDS is punished when he or she has sex with another person who has been denied informed consent. Should the punishment be 25 years in prison if there was no intention? That seems a bit excessive, but then again, I am not a legal scholar.

I find it quite ironic that HaifischGeweint seems to put a lot of responsibility onto the other person to ask about HIV status compared with the responsibility of the person with HIV telling about his or her status. In reality, how much different, in terms of emotional difficulty, is it to say that one has HIV compared with answering “Do you have HIV?”? Although I do not know for sure what the difference is in terms of emotional impact, I think it is safe to say that both are emotionally difficult. But let’s flip the situation over. Imagine having HIV and that your partner has another sexually transmitted infection that will substantially decrease your health and quality of life as well as the capacity of your immune system. Surely, you would want him or her to tell you? So the value of informed consent really goes both ways. This would lead me to conclude that both the person with HIV/AIDS and the other person both have a moral responsibility to have an open and honest conversation about sexually transmitted infections before having sex.

So what is the main problem? I think it has to do with the concept of intention in the legal system. Clearly, having HIV and having sex with someone with the intention of giving them HIV is very different from the same process but without that intention. From what I can tell, it is fairly uncontroversial that former group should be brought to justice. So the conversation seems to be about whether or not it is possible to unintentionally deny informed consent to one’s sexual partner (the other perspective being the rejection of informed consent when it comes to sex, which I think few people hold) and if so, how hard should the punishment be. I have no definite answers to these questions at this time.

As a final comment, I must object to the “but he/she was not infected!” argument. This is because whether or not you are infected is a probability game. Whether or not the partner got infected or not, the same actions was performed by the person with HIV/AIDS (i.e. denying informed consent by not telling). In that sense, it is difficult for me to count it as a mitigating factor. I find it very unsafe to base the bulk of legal decisions on the results of a probabilistic processes, although I do realize that it has, and should have, some influence.

Instead, let us move on to the meat of this article, namely a harsh criticism of some scientific errors in the post written by HaifischGeweint. As it turns out, HaifischGeweint contributes to the spread of misinformation over HIV/AIDS. This is particularly sad and harmful considering that HaifischGeweint is an HIV/AIDS activists, that presumably should know better.

Infection is a legitimate scientific concept

HaifischGeweint writes that:

Most people who are poz [HIV+ positive - Emil's note] aren’t walking around with such an active and excessively contagious infectious process coursing through their circulatory system that it is in any way appropriate to refer to them as “infected”. And in fact, even for those who are so unfortunate to be dealing with a hyperbolic bloom of the virus in their system, this is usually a temporary state, often associated with the earliest phases in conversion (which can easily go unnoticed for many newly converted) or the final stages of AIDS (in which case, they are unlikely to just be out for a casual stroll like anyone else).

The point is that words like “infected” and “infection”, when talking about people who are poz, carries a connotation of uncleanliness, filth, and/or viral transmission [...]

I do appreciate the argument that the term “infected” can have negative connotations. That means that we should be careful in our usage of the term and show thoughtfulness and respect towards people with HIV/AIDS. The term “infection” should ideally not produce any more negative connotations when associated with HIV/AIDS than with the common cold.

However, the term infection is scientifically legitimate in this context. Having an infection simply means that a pathogen has entered a host, is replicating and is interacting with the host in various ways. While it is true that HIV hides inside cells, there is still viral replication going on (both when the cell divides and when free virus particles go through their infectious cycle). Disallowing the term “infection” would, strictly speaking, make it wrong to say that HIV is a sexually transmitted infection. This would, of course, be absurd.

So to sum up, we should be careful about the connotations of the words we are using, but we should not arbitrarily delegitimize valid scientific concepts just because we think they have bad connotations. There has to also be a scientific argument. I will examine one such argument in the next section, but from a different perspective.

“Undetectable viral load” does not mean “non-transmissible”

HaifischGeweint continues:

The point is that words like “infected” and “infection”, when talking about people who are poz, carries a connotation of uncleanliness, filth, and/or viral transmission — again, medical intervention has actually advanced to the point that many poz people are no-transmissible or even un-detectable (I’ve seen it with my own eyes while working for a doctor whose only poz patient had been non-transmissible for 13 years and started testing un-detectable). You don’t personally have to agree with this argument, but I do, so I will be referring to people as becoming converted (or at risk thereof) unless I’m quoting a source that uses different language, such as the Supreme Court of Canada.

It appears that HaifischGeweint is suggesting that individuals with an undetectable viral load cannot transmit HIV. It is not explicitly stated, but it is a possible interpretation from the text.

While having an undetectable viral load decreases the risk of spreading HIV, I have found three arguments for why “undetectable viral load” does not imply “non-transmissible”:

(1) The viral load in e. g. semen might be higher from blood: Politch (2012) published in AIDS showed that 25% of the men who have sex with men in their study who had an undetectable viral load in their blood had HIV in their semen, up to a copy number of over 2500. So having an undetectable viral load is not a guarantee that you cannot spread HIV.

(2) Risk factors for HIV infection: the partner may have another sexually transmitted infection that makes it more likely to be infected with HIV, such as genital herpes.

(3) Change in viral load: the viral load might have changed since last measurement do to a variety of factors, perhaps such as non-compliance.

The claim that having an undetectable viral load means that you cannot transmit HIV is an incredibly dangerous myth.

HIV can be transmitted via oral sex

HaifischGeweint makes the following astounding claim:

For instance, if you aren’t having penile sex, how do you protect yourself (obviously condoms are out) and what is your risk of inheriting or transmitting something like HIV or chlamydia from the different activities you are engaging in? (Hint: enzymes in human saliva eliminate the HIV virus but not chlamydia; some infectious processes such as heat blisters from herpes or aphthous ulcerations from bad oral hygiene or smoking can compromise either your lips or gingiva, increasing your risk of inheriting even infections that your saliva would normally eliminate.)

Does HaifischGeweint really believe that HIV cannot be transmitted through oral sex unless there are blisters or ulcerations? This is perhaps one of the most destructive myths that HaifischGeweint has promoted.

Hladik (2008) notes that it is estimated that approximately 1.5 million people have been infected by HIV via oral sex. The oral portions of he pharynx and the esophagus has a squamous epithelium and the stomach and small intestine has only a single layer of columnar epithelial cells. These are sites of mucosal invasion by HIV and can occur without there having to be listers or ulcerations. These makes it easier to become HIV infected, but it is wrong to state that HIV cannot be transmitted via oral sex if you do not have them. While the probability per exposure event is low, improbably things happen every day.

This is another dangerous myth spread by HaifischGeweint.

Conclusions:

HIV/AIDS activists have a special moral and intellectual responsibility. They surely know that there are a lot of harmful and destructive myths around about HIV/AIDS. Therefore, it is so much worse when someone like HaifischGeweint decides to spread some of these around. Clearly, as an HIV/AIDS activist, HaifischGeweint should know better.

We should do everything within reason to remove the stigma attached to being HIV+ positive, but we should not delegitimize valid scientific concepts and we should certainly not spread dangerous myths about the transmission of HIV.

Having an undetectable viral load does not mean that you cannot transmit HIV as the viral load in semen is higher, the partner may have other sexually transmitted infections that makes it more likely for HIV transmission to occur and the viral load might be different than when it was measured.

HIV can be transmitted through oral sex, even without wounds or blisters.

References and further reading:

Hladik, Florian, & McElrath, M. Juliana. (2008). Setting the stage: host invasion by HIV. Nat Rev Immunol, 8(6), 447-457.

Politch JA, Mayer KH, Welles SL, O’Brien WX, Xu C, Bowman FP, Anderson DJ. (2012). Highly active antiretroviral therapy does not completely suppress HIV in semen of sexually active HIV-infected men who have sex with men.
AIDS. 26(12):1535-43.

13 responses to “When HIV/AIDS Activism Goes Wrong

  1. NeuraltNätverk December 11, 2012 at 00:36

    The important thing to remember is that the science doesn’t really matter on Free from Thought Blogs. To the extent that they agree with it at all, it is largely incidental. That is to say, when it aligns with their overarching belief system.

  2. putinreloaded December 11, 2012 at 10:57

    “…Infection is a legitimate scientific concept…

    In the context of HIV and legality, “infection” means “person infected”, and “person infected” means “person positive to the HIV test”.

    In the same context, “tranmission ” means “person becoming positive to the HIV test” where the cause is attributed to contact with a “person positive to the HIV test”.

    The baseline here is the HIV test. What is being tested for? Not for the infective particle, but for antibodies presumed to have been induced by the infective particle.

    Problems wit the tests:

    1. presence of antibodies does not imply active infection,
    2. antibody specificity is low (have multiple epitopes that match many antigens),
    3. HIV tests are not calibrated against the actual presence of the particle itself, but using clinical panels.

    Problem with transmission:

    1. The “person becoming positive to the HIV test” may have acquired the reactinve antibodies in multiple ways. There are more than 60 documented conditions, including pregnancy and the flu, shown to induce antibodies reactive in the HIV tests.
    2. The official transmission rate in unprotected sex is 1:1,000, raising doubts about the sexual path being the actual way of acquiring the antibodies.

    As a result, HIV positive people who can put a good defence, based on the above, are being acquitted of charges. See for example: Fort Bragg NC-Soldier diagnosed with HIV acquitted of aggravated assault.

  3. putinreloaded December 11, 2012 at 11:32

    “…Having an undetectable viral load does not mean that you cannot transmit HIV…

    The VL test (PCR) is the least specific of all HIV tests, to such an extent that the manufacturers warn against its use for neither diagnosis of infection nor confirmation:

    COBAS AMPLICOR HIV-1 MONITOR,

    Intended Use

    The COBAS AMPLICOR HIV-1 MONITOR Test, v1.5 is not intended to be used as a screening test for blood or blood products for the presence of HIV-1 or as a diagnostic test to confirm the presence of HIV-1 infection.

    Read carefully: not intended to be used as a screening test…. or as a diagnostic test to confirm… NONE OF BOTH.

    The reason for the disclaimer? When PCR is applied to HIV negative, low-risk people (e.g. blood donors), VL is still detected in a percentage high enough to render the test useless. This problem is not exclusive of HIV-PCR, it apples to other viral PCR test kits as well:

    False-positive nucleic acid test results for HIV RNA and hepatitis C virus RNA: an underappreciated problem

    The VL is just another spurious measure that only superficially correlates with HIV or AIDS. It should not be used for convicting anybody of a crime.

  4. putinreloaded December 11, 2012 at 16:02

    “..“Undetectable viral load” does not mean “non-transmissible”..

    The objections above to VL notwithstanding, and assuming VL always correlates with actual infection by the pathogen, “undetectable” means that the presence of the pathogen can’t be scientifically demonstrated.

    If the person is also asymptomatic, then no objective reason exists to continue labelling it as “infected”.

    Even Montagnier, co-discoverer of HIV, publicly admitted that HIV infection can be cleared. There are just too many “undetectable” and asymptomatic HIV-positive people around to keep pretending antibodies to HIV are the exception to the rule and always mean active infection.

  5. Emil Karlsson December 11, 2012 at 17:37

    putinreloaded, almost everything you asserted is scientifically wrong.

    1. Infection is not the same as being tested positive by an HIV test. This is because of things like the small but intrinsic fail rate of any medical test, the window period and because infection is a biological state whereby the pathogen has entered the host, is replicating and interacting with the host in various ways. This is a biological process independent of test results.

    2. Transmission is about the transfer of HIV from one person to the next. This is also not the same as testing positive by an HIV test.

    3. There is no such thing as “the HIV test”. There are many different tests that can look at antibodies, viral proteins and viral nucleic acids.

    4. The presence of HIV-specific antibodies is a good indicator of HIV infection, but a diagnosis of HIV is never done solely based on ELIZA results, but only after a confirmatory western blot (this handles your criticism that some medical conditions can give an ELIZA false positive). If you still need extra accuracy, you can do a PCR. The combined specificity and sensitivity is extremely high. The chance of a false positive or false negative is therefore very low.

    5. You claim that the “official transmission rate in unprotected sex is 1:1,000″. This is wrong. If you read the Nature Review Immunology article I linked to earlier, you would have seen that the transmission probability per exposure event (not the same as “official transmission rate”) between 1 in 200 and 1 in 2000.

    6. You also misunderstand basic immunology. Mainstream science shows that HIV is transmitted through e. g. unprotected sex, not antibodies. Antibodies are produced by the immune system and not sexually transmitted.

    7. You also misunderstand basic probability theory. Here is a simple example for you: have you ever played bridge? Imagine that I deal you a hand of 13 cards. Now look at them. What is the probability that you got this exact hand? Since the order does not matter, the number of possible bridge hands are c(52,13), which is approximately 635 billion. So the probability that you got the hand you got was 1 in 635 billion. If you reject 1 in 1000 as too low probability, then you must clearly reject this extremely low probability as well, so you cannot, according to your faulty logic, have gotten the hand you got in front of you! Do you see why your argument against HIV being sexually transmitted fail?

    8. Judges are not professional scientists. They can therefore easily be mislead by professional-sounding pseudoscience.

    9. RT-PCR is among the most accurate HIV tests there are, because it directly detects viral nucleic acids.

    10. The test you linked, COBAS AMPLICOR HIV-1 MONITOR, is a test used to quantify viral load, not to diagnose an HIV infection. It is quite silly to complain that a test does not do X, if the stated purpose of the test is to do Y. You need to read up on RT-PCR if you want to discuss the merits of PCR tests for HIV diagnosis.

    11. The first article you linked to (“False-positive nucleic acid test results for human immunodeficiency virus RNA and hepatitis C virus RNA: an underappreciated problem”) is only for pooled-samples and for screening blood donations. Clearly, a false positive in this area is not a big deal.

    12. Your second link is to the exact same paper.

    13. Having an undetectable viral load in the blood plasma means just that. The viral load in the semen or vaginal fluid can be, and is, higher. Therefore, having an undetectable viral load in blood plasma does not imply that there can be no HIV transmission.

    14. It is possible to be infected even if you are asymptomatic. Most diseases have an incubation time where no symptoms are experienced, yet this period clearly falls under what is meant by “infection” in a scientific context.

    15. The percentage of long-term non-progressors is really low and this argument has been discussed on this blog before.

    16. Your claim that “Even Montagnier, co-discoverer of HIV, publicly admitted that HIV infection can be cleared” is wrong. He was quoted out of context in the HIV/AIDS denialist pseudodocumentary House of Numbers.

    Let’s see if you can actually address my arguments this time. Keep in mind that my patience with your ramblings is already stretched thin.

    • putinreloaded December 11, 2012 at 18:53

      “..This is a biological process independent of test results….

      Tell me something new.

      What I said is the abstract concept of infection is moot, because a judge deals with persons, and the only way to claim “Person X is infected” are the HIV tests.

      Still don’t get it?

      “..Transmission is about the transfer of HIV from one person to the next….

      The same reasoning.

      A judge deals with persons, and the only way to claim “There has been HIV transmission” are the HIV tests.

      Still don’t get it?

      “..There is no such thing as “the HIV test..

      I refer to them all as “The HIV test” for simplicity, meaning the diagnostic procedure (local in nature adn not standardized) to claim “Person X is infected”.

      Another moot point.

      “..The presence of HIV-specific antibodies is a good indicator of HIV infection..”

      They’re a good dindicator of 60+ conditions as well. There’s a comprehensive referenced list here: Factors Known to Cause False Positive HIV Antibody Test Results

      These antibodies are so abundant, that 32% of the “low risk” population carry at least one “specific HIV antibody” reactive to “HIV antigens”. See:

      Frequency of indeterminate western blot tests in healthy adults at low risk for human immunodeficiency virus infection.

      “…blood specimens were collected from 168 healthy adult volunteers at minimal or no risk for becoming infected with human immunodeficiency virus… 32% had indeterminate Western blot tests, most of which demonstrated a single band of low intensity. The most common bands were p24 (47%), p55 (34%), and p66 (36%); envelope bands were unusual (gp41, 2%; gp120, 2%). …”

      “..HIV is never done solely based on ELIZA results, but only after a confirmatory western blot …

      It’s spelled ELISA. You obviously haven’t studied this subject much.

      It matters little because the pretended higher specificity of this testing sequence is the product of a wrong assumptions. I cite:

      “…Care must be taken, however, when interpreting the results from a sequence of tests. Assays are generally not strictly independent, since one source of bias may simultaneously affect multiple laboratory techniques. For example, EIA, W B and IFA are all techniques that detect antibodies to HIV, as opposed to techniques that detect viral antigens of viral RNA directly (see below). Pure Bayesian analysis, which assumes strictly independent tests, will typically therefore lead to overestimation of predictive values with most supplementary tests (see Table 8.1):”

      — Source: 2004, Gary P. Wormser, AIDS and other manifestations of HIV infection, 4th edition, Elsevier Academic, ISBN 0127640517. , Chapter 8, page 156, “Persons at Low Risk”

      “..If you still need extra accuracy, you can do a PCR….

      Read AGAIN: “not intended to be used as a screening test for blood or blood products for the presence of HIV-1 or as a diagnostic test to confirm the presence of HIV-1 infection.”. No PCR test is apporved for diagnosis or confirmation purposes. It’s an improper use of a laboratory technique.

      But still you grossly mistake consistency for accuracy. Having twenty tests give similar results doesn’t imply accuracy at all, only consistency – which is a completely different animal.

      Accuracy can only established by comparison against the actual demonstration of the viral particle in subjects with a positive test outcome and its absence in subjects with a negative outcome.

      But this is not the way HIV tests are calibrated. Not by far!

      From the disclosures of the FDA and the CE approval requirements (see http://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=OJ:L:2009:039:0034:0049:EN:PDF pages L 39/40 to L 39/42) the positive and negative references used for hiv-test calibration and licensing are based on assumptions and mutual comparisons. The calibration references used are these:

      Positive referents: Clinical AIDS patients. Negative outcomes in these referents are considered “false negatives” and affect the specificity of the test.

      Because there’s no clinical differential diagnosis of AIDS without an HIV test, these referents are simply assumed to be infected. Alternatively, they have been diagnosed using a different HIV test which suffers from exactly the same lack of calibration against the actual virus as the test being licensed.

      Negative referents: Blood donors, pregnant women and other “low risk” persons. Positive outcomes in these are considered “false positives” and affect the sensitivity of the test.

      These referents aren’t controlled for the actual absence of HIV either, just assumed uninfected for being “low risk” (another axiom). This causes gross contradictions, such as a “positive” pregnant woman considered “false positive” in a panel setting, but the very same woman being “true positive” if tested in a clinical setting.

      Neither ELISA nor WB nor PCR are verified against the real presence of the virus. As a consequence, these tests might be detecting “feature X” with good consistency (they are panel-beaten agsisnt each other), but still we have no clue on how close “feature X” is to “HIV”. We can never know the accuracy because HIV is left out of the calibration process.

      “…the transmission probability per exposure event (not the same as “official transmission rate”) between 1 in 200 and 1 in 2000…..

      Again, this level is too low compared to a true STDs. It’s most likely “assumption noise” because the clinical trials claim transmissions based on simple observation of seroconversions, which are not enough proof. It’s like claiming diabetes is an STD because 1 in 1,000 people who have diabetic sexual partners became diabetic themselves after some time.

      For actual proof of transmission, a genetic characterization of the transmitted virus is necessary, proving the HIV in both individuals actually match. This is never done, so the number is just noise.

      “..Mainstream science shows that HIV is transmitted through e. g. unprotected sex, not antibodies. …

      Wrong, mainstream only assumes sexual transmission but lacks the proof, which would be showing the viral RNA in both partners match. This is never done. As I said, 60+ conditions can give you a nice set of “HIV antibodies” to sport on your baseball cap. You have a 32% of having at least one yourself.

      “…If you reject 1 in 1000 as too low probability…

      It is too low compared to any other STD, so HIV would be an “exceptional” STD. Exceptional claims require exceptional evidence. Instead, those estimates are obtained from cohort studies with 300-400 people at most, and based on assumptions as I already noted, rather than proof of match between the presumed transmitter’s bug with the receiver’s bug.

      Too much wish-wash in Mainstream claims.

      “..RT-PCR is among the most accurate HIV tests there are, because it directly detects viral nucleic acids….

      Tests are not “accurate”, they can only be X% specific and Y% sensitive. More obvious ignorance of the subject.

      Accuracy applies to diagnoses.

      There are two kinds of accuracy: Positive Predictive Value (PPV) and Negative Predictive Value (NPV). Both depend on specificity, sensitivity AND most importantly, the prevalence of the condition among the population tested.

      PCR is the most sensitive, because it amplifies a single strand of DNA. However, sensitivity is achieved at the cost of specificity, because a very small error will produce a false positive result. That’s why PCR is the worst tool for diagnosis and the manufacturer warns it’s not the intended use.

      “…COBAS AMPLICOR HIV-1 MONITOR, is a test used to quantify viral load, not to diagnose an HIV infection….

      COBAS AMPLICOR HIV-1 MONITOR is the most widely used HIV PCR test kit. There are no PCR kits approved to diagnose or confirm HIV infection. They’re used “off label” anyway, especially to diagnose newborns, which should be a crime.

      “…Having an undetectable viral load in the blood plasma means just that. The viral load in the semen or vaginal fluid can be, and is, higher.

      If you can prove it, go ahead. It is not done in most people with undetectable plasma viral load. They’re considered infected for life, without evidence of the virus and no one even cares to look for it.

      “..The percentage of long-term non-progressors is really low and this argument has been discussed on this blog before….

      It can’t be low at all, because there’s an estimate 207,600 people in the USA (2009) whose infections had not been diagnosed. An incubation period of 10 years would mean a yearly “surprise” of 20,000 AIDS unexpected cases from these non-medicated people. This is just not happening. It seems “long-term non-progressors” must then be the rule, rather than the exception.

      “..It is possible to be infected even if you are asymptomatic. …

      It’s possible to be possessed by a devil even if you behave well. But there’s no way to prove it.

      If you can’t prove neither the infectious agent nor the disease, you have no right to label a person as infectious for life.

      “..He was quoted out of context in the HIV/AIDS denialist pseudodocumentary House of Numbers….

      Why do you claim it was “out of context”? Even Montagnier hasn’t retracted his words. More wishful thinking?

    • Emil Karlsson December 11, 2012 at 19:59

      1. Infection is not an abstract concept. I’m sure you have not been living in a sterile bubble all your life so you have at least had a cold. Nothing “abstract” about it.

      2. No, you typically show that HIV transmission has occurred by sequencing the HIV strains of the two individuals and show that the best explanation is that one infected the other.

      3. A very poor argument. Saying “The HIV test” compared with “HIV tests” is not easier. In fact, the latter is conceptually clearer and requires fewer letters to type.

      4. You completely ignored this argument. A positive ELISA test is always followed up by a western blot. So your rebuttals are moot. You also did not reply to the argument that the specificity and sensitivity of ELISA is very high. Contrary to your assertion, the paper you link does not show that “32% of the low risk population carry at least one specific HIV antibody reactive to HIV antigens”. The study shows that for people in a trial for a vaccine against HIV/AIDS, 32% of western blots were inconclusive. In other words, it shows that this particular vaccine candidate was not very good. Also, the study is over 20 years old, hardly relevant.

      (As for the spelling of ELISA, you are correct. I sometimes mix letters up (and have a family history of dyslexia). In this case, it is probably because I mixed up ELISA and Eliza Jane Scovill, the daughter of the HIV/AIDS denialist Christine Maggiore).

      You may be able to argue that some HIV tests are not completely independent, but that is a fast mathematical correction for that, which does not undermine the general argument that the more tests that point to the same conclusion, the stronger it becomes.

      You also ignored what I wrote about how a specific quantitative test for viral load is not the same as a RT-PCR used for detection. You are basically complaining that thermometers suck for measuring temperatures because they do not measure weight.

      I have never claimed that consistency in itself implies accuracy, only that consistent results using many different, highly accurate tests, imply extremely high accuracy.

      - Positive referents: Clinical AIDS patients. Negative outcomes in these referents are considered “false negatives” and affect the specificity of the test.

      Because there’s no clinical differential diagnosis of AIDS without an HIV test, these referents are simply assumed to be infected. Alternatively, they have been diagnosed using a different HIV test which suffers from exactly the same lack of calibration against the actual virus as the test being licensed.

      You are confusing diagnosis of HIV with the clinical definition of AIDS, the latter having a very low CD4+ T cell count plus AIDS defining illnesses. Furthermore, there is no intellectual or scientific problem by calibrating a new test against an old test that we know works.

      And again, you can use an RT-PCR test to make sure.

      5. You failed to address this argument. Transmission is not determined by simply observing seroconversion. It is possible to isolate and sequence the HIV and determine from who the person got HIV from. Your analogy with diabetes fails because we know that diabetes is not an infectious disease, whereas HIV has fulfilled Koch’s postulate many times.

      6. You did not address this argument either. Do you now accept that it is the virus, not the antibodies that are being transmitted?

      7. You neglected to respond to my probability argument.

      8. You did not respond to this argument.

      9. Actually, having a high sensitivity and high specificity is what is meant by the term “accurate”. Your claim that RT-PCR is flawed “because a very small error will produce a false positive result”, yet you provide no scientific reference to support that claim. I can save you the trouble, because it is wrong. This is because RT-PCR uses primers and because you can sequence the end product. Thus, it is not the case that “a very small error will produce a false positive”. What exactly do you think can be confused with viral RNA?

      10. You failed to respond to this argument. The test is a viral load test, not an RT-PCR used for detection. See above about thermometer and weight.

      11-12. You did not respond to this argument.

      13.

      If you can prove it, go ahead. It is not done in most people with undetectable plasma viral load. They’re considered infected for life, without evidence of the virus and no one even cares to look for it.

      I referenced the paper in the blog post (check the reference section). Did you not read it? Having an undetectable viral load is not the same as “no evidence for the virus”. Viral load refers to the copy number of free virus particles, most often in the blood plasma. But you can isolate any infected CD4+ cell and find the virus.

      14.

      It can’t be low at all, because there’s an estimate 207,600 people in the USA (2009) whose infections had not been diagnosed. An incubation period of 10 years would mean a yearly “surprise” of 20,000 AIDS unexpected cases from these non-medicated people. This is just not happening. It seems “long-term non-progressors” must then be the rule, rather than the exception.

      No, that figure is for people with HIV that have not been diagnosed (i.e. people with HIV that has not had a health check up, probably because they cannot afford it), not the number of long-term non-progressors (LTNPs). This latter group, who do not progress to AIDS, are about 0.2%. LTNPs probably have certain mutations in HLA or FUT2.

      15. You did not reply to this argument. How can you? It is fairly obvious that every disease have an incubation time where you are infected, but not displaying symptoms. The fact that you refuse to acknowledge this leads me to conclude that you are not a serious debater.

      16.

      Why do you claim it was “out of context”? Even Montagnier hasn’t retracted his words. More wishful thinking?

      Because quoting out of context is the tactic that many HIV/AIDS denialists must stoop to in order to defend their beliefs.

      You can read a detailed justification and explanation of how Montagnier was taken out of context here.

      All in all, I think you are not really listening or responding to the arguments I make. Instead, you are ignoring them and continuing to spread the same errors you did in the last post.

      So tell me, why should I continue to have patience with you? In what way can you contribute to a productive discussion about this topic? Also remember that this comment section is about what I wrote in the blog post. I have little interest in letting you derail it.

  6. putinreloaded December 11, 2012 at 21:11

    “..Infection is not an abstract concept. I’m sure you have not been living in a sterile bubble all your life so you have at least had a cold. Nothing “abstract” about…”

    Red herring. You and I have over 30,000 species of “bugs” in our bodies, is that an “infection”? , The concept is abstract, an interpretation of facts. Evidence of infection (antibodies, bugs etc) are the facts. It’s these facts that are relevant in a “HIV crime” trial. In this case, the only fact is the HIV test.

    You keep banging on the idea of “infection” as if it was something provable by itself independently of any diagnostic method. It’s not. You’re hitting a concrete wall, and you’re loving it.

    “..You completely ignored this argument. A positive ELISA test is always followed up by a western blot. So your rebuttals are moot….”

    This is what the citation from ISBN 0127640517 calls “a sequence of tests”, so my rebuttal just flew over your head (or you pretend it did).

    “..you typically show that HIV transmission has occurred by sequencing the HIV strains of the two individuals and show that the best explanation is that one infected the other….

    A single refecence of this, please. I won’t take your word for it because you can’t even spell ELISA, so you’re not in your field or expertise,.

    “… A very poor argument…”

    Your opinions against my sources, I can live with your whines.

    “…in a trial for a vaccine against HIV/AIDS…

    And you point would be? None of the low-risk subjects were vaccinated, so: moot again. Similar frequencies of “HIV” antibodies in low-risk populations (35%) have been reported in other studies:

    Antibodies to human immunodeficiency virus (HIV-1) in autoimmune diseases

    “…At least one band was shown on immunoblotting in 26% of patients with autoimmune diseases and 35% of controls…”

    “…the specificity and sensitivity of ELISA is very high…

    What is “very high”? Realtive to what?

    The most specific and sensitive test fails miserably if the prevalance is low. Does this concept escapes you too?

    If ELISA is 99,9% specific, it will always claim, at least 1 positive out of 1,000 persons. If the prevalence is lower, say 1:10,000, then the PPV of ELISA in this population is a mere 10% Error rate of a positive diagnosis: 90%, because there’s actually only 1 true positive out of 10.000, 9 positives out of 10 are false.

    We’re not yet considering the error introduced by the random antibodies of the HIV vaccine study. According to its data on antibody frequency, the chances of a spurious positive ELISA combination (gp41) is a whopping 0.32 x 0.02 = 0.64%. This means the actual PPV in a positive ELISA is more like 0.0001 / 0.0064 = 1.6%; actual error rate of a positive ELISA diagnosis: 98.4%

    Now we know why most HIV-positives are asymptomatic at the time of hearing their diagnoses, HIV tests are a case of massive misdiagnosis.

    “…the more tests that point to the same conclusion, the stronger it becomes….

    Reincidence: concordance does not imply accuracy. The surrogate for “HIV” in test validation is a mixture of illnesses, assumptions about risk, and tests validated against the same mixture of illnesses and assumptions about risk. No combinatino of such tests can be closer to “HIV” than the mixture of illnesses and assumptions about risk, and the closeness is unknown because no AIDS disease is exclusive of HIV. It’s a stupid “Circulus in probando”.

    Shame on Mainstream for allowing this! IT seems no serious scientist works with HIV. Test manufacturers know better and refrain to claim their tests prove infection with HIV.

    • Emil Karlsson December 11, 2012 at 22:52

      You and I have over 30,000 species of “bugs” in our bodies, is that an “infection”?

      Actually, those microorganisms live in the gut and the gut lumen is actually considered to be the outside of the body, not the inside. So only those pathogens, like Shigella, that penetrates the gut mucosa, can be classified as an infection. Imagine if all the gut bacteria were to trigger inflammation! Then the entire digestive system would be in utter chaos. A form of chronic gut inflammation is know as inflammatory bowel disease (IBD).

      A single refecence of this, please. I won’t take your word for it because you can’t even spell ELISA, so you’re not in your field or expertise,.

      Actually, I have taken two advanced university courses in immunology and received the highest grade in both. As I said before, I have a family history of dyslexia.

      You want a reference? Sure. I happen to have one right in my bookshelf: Stearns and Hoekstra (2005, pp. 309-311):

      Who transmitted HIV to a rape victim? Systematics can help to identify criminals

      The methods of systematics are not limited to basic questions about the Tree of
      Life. They can be applied to very practical problems. Suppose you are a detective
      asked by the police to identify which of two suspects transmitted the HIV
      virus to a rape victim who developed AIDS after the rape was committed. You take blood samples from the victim, the two suspects, and an AIDS patient
      whom you are certain had nothing to do with the rape case. From those blood
      samples you isolate the RNA genome of the HIV virus and confirm that all four
      persons are infected. From the RNA you prepare a DNA copy that you
      sequence. The critical part of the four sequences is 30 bases long and is shown
      in Table 13.1.

      Using a computer program, you prepare a phylogenetic tree based on these
      four sequences. The program examines all the possible trees and delivers the one
      that implies fewer mutations in nucleotides than any other (Figure 13.7).
      This tree suggests that the second suspect infected the rape victim. The
      conclusion is supported by four changes in sequence that are shared by the
      second suspect and the victim: A → G at position 1, A → T at position 2, G →
      A at position 12, and A → G at position 20. HIV is an RNA virus that evolves
      rapidly, and since the rape occurred, the virus has continued to evolve in both
      suspect and victim. In the suspect, there has been a change at position 25, C →
      T, and in the victim there have been two changes, at position 21, T →C, and at
      position 28, A → G.

      This example is artificial, but similar methods were used to identify the sailor
      that introduced HIV to Scandanavia, the dentist with HIV who infected several of his patients in Florida (both the sailor and the dentist died before this was discovered),
      and in criminal cases to show that a gastroenterologist injected his
      girlfriend with blood taken from a patient with HIV (Metzker et al. 2002) and
      that cases of encephalitis in New York and New England were caused by the
      first strains of West Nile virus to appear in the western hemisphere (Lanciotti
      et al. 1999).

      The chapter with the relevant section is available at Oxford University Press here.

      At any rate, you continue to cite 15-20 year old papers, misunderstand then and quote them out of context. Again, it is about inconclusive immunoblottings, not a false positive western blots.

      The most specific and sensitive test fails miserably if the prevalance is low. Does this concept escapes you too?

      The point here is that the relevant prior probability is not the population prevalence, but the prevalence in your particular risk group. And as always, an ELISA test is just the start, not the end of the tests. I have explained this in more detail in my blog post called How HIV/AIDS Denialists Abuse Bayes Theorem. Been there, done that.

  7. putinreloaded December 11, 2012 at 21:15

    “…Your claim that RT-PCR is flawed “because a very small error will produce a false positive result”, yet you provide no scientific reference to support that claim….

    So what was this, then? <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1537-2995.2010.02884.x/full"False-positive nucleic acid test results for human immunodeficiency virus RNA and hepatitis C virus RNA: an underappreciated problem
    .
    See Table 1: false positive rate of HIV PCR (NAT) is 83%. The most “accurate” HIV test indeed!

    Pay attention to the manufacturer’s warnings and stop being more popist than the Pope himself.

    • Emil Karlsson December 11, 2012 at 22:57

      As I have explained to you before, that is only for pooled-samples and for screening blood donations. It is no problem with a high level of false positives in those areas.

      You are just repeating arguments I have debunked already. You show little or no serious effort at a productive discussion. I have given you enough space to lay out your position.

      You are done here.

    • Snout December 22, 2012 at 00:46

      “See Table 1: false positive rate of HIV PCR (NAT) is 83%. The most “accurate” HIV test indeed!”

      Try reading the paper. The “false positive rate” they are talking about refers to the seven samples out of 1,051,701 antibody negative samples they tested that returned positive (discordant) NAT results. The other 1,051,694 samples were negative on both antibody and NAT.

      Out of those seven they retested six, and five of those turned out to be false positives. Assuming the sample that wasn’t retested was also a false positive, that makes six false positives out of a total of 1,051,700 truly negative samples tested. They identified one truly infected sample that was missed by antibody screening but picked up on the NAT.

      Six false positives per million truly negative samples is a very specific test. The actual false positive rate for this NAT was 0.00057%, not 83%. You are out by five orders of magnitude.

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