Reprinted from July 17, 2002
AIDS in Britain: Why Complacency is Justified
Dr Michael Fitzpatrick, MD
"For 15 years, authorities have been manipulating AIDS
statistics to inflate popular fears of an imminent heterosexual
epidemic. They are reluctant to let declines in AIDS interfere with
their moralizing message."
According to public health supremo Dr Angus Nicoll, "None of
us can afford to be complacent about HIV - the safer sex message
applies to everyone (1)."
The good news that is worrying the medical moralists is that, after
all the doomsday scenarios - and not forgetting the devastation
it is causing in parts of Africa - AIDS is a declining problem in
Britain. The figures show that, some 20 years after the first cases
of AIDS in Britain, it remains confined to well-recognized high-risk
While "safer sex" makes sense for those at high risk,
everyone else can indeed afford to be complacent and enjoy an active
sex life without worrying about the dangers of AIDS.
When I joined my current practice in Hackney some 15 years ago,
there was a general expectation that we would soon be looking after
large numbers of AIDS cases. It is a large inner London practice
in which the main risk groups for HIV - gay men, drug users, immigrants
from Africa - are well represented.
My first patient with AIDS died shortly after I started; I well
remember talking to his mother, who had come over from Northern
Ireland to make the simultaneous discoveries that her son was gay
and that he was dying of AIDS. My colleagues dutifully registered
for courses on the management of AIDS and its complications.
But the anticipated influx of AIDS cases has never happened. We
have had a few more over the years and a slowly rising number of
patients who are HIV positive. (One early case who appeared wearing
a t-shirt proclaiming his HIV positivity, and had received diverse
benefits and services on the strength of this, and was a regular
attendee at several specialist hospital clinics, subsequently turned
out to be negative.)
Yet, even though Britain's HIV/AIDS epidemic remains highly concentrated
in London, it has yet to make much of an impact on general practice,
even on a practice like ours. We try to keep abreast of the new
treatments, but have gained little practical experience of using
One reason for the dearth of AIDS cases in general practice is that,
given the slow growth of the epidemic, specialist centers - at most
of the major London hospitals - are inclined to hang on to their
AIDS patients. Special units that handed patients back to their
General Practitioners would soon face a declining workload, with
the resulting loss of funding and ultimate risk of closure.
The epidemic explosion among heterosexuals has never happened
Given the relatively high level of resources available to AIDS care,
with its privileged access to celebrity fund-raising as well as
dedicated health and social care revenues, patients too prefer to
attend the superior facilities provided in specialist centers.
However, the most important reason for our lack of AIDS patients
is the simple fact that the epidemic in Britain has turned out to
be much smaller than predicted. Far from spreading rapidly to affect
wider and wider sections of the population, it has remained highly
Furthermore, after reaching a peak in the mid-1990s, the epidemic
has subsequently sharply declined. In the early 1990s, new cases
passed 1,000 a year, to reach a peak of 1,853 in 1994; in 2001 some
558 new cases were recorded. The total of deaths from AIDS follows
a similar course, reaching a peak of 1,531 in 1994 and declining
to 221 in 2001.
There are a number of reasons for the decline in size and virulence
of the AIDS epidemic in Britain. Community activism among gay men,
still the main group affected by AIDS, has undoubtedly helped to
slow the spread of HIV, while new drug regimes have dramatically
improved the outlook of people who are HIV positive. The spectre
of widespread dissemination of HIV through needle-sharing by drug
abusers has never materialized. This may be partly attributable
to needle-exchange schemes, but also reflects the small scale and
highly localized character of intravenous drug use in Britain.
The big untold story of AIDS in Britain is that the epidemic explosion
among heterosexuals that was anticipated in the 1980s has never
happened. This story is partly obscured by the conflation of cases
of HIV and AIDS acquired through heterosexual contact in countries
with large-scale epidemics (notably in Africa) and cases in which
infection has been acquired in Europe. Let's look first at the extension
of the African AIDS problem into Britain.
During the 1990s I attended several meetings of doctors in East
London at which alarming statistics were presented about the high
prevalence of HIV infection that had been discovered in antenatal
screening testing at Newham General Hospital. These figures –
"1 in 64" has stuck in my mind – were used to illustrate
the spread of HIV in a population of confirmed heterosexual activity,
in which no other risk factor was declared. They were held to confirm
that HIV was spreading at a terrifying rate among heterosexuals
in Britain, even in a nondescript east London borough like Newham,
hence justifying an alarmist "everyone is at risk" safer
Discreet inquiries revealed that the relatively high rate of HIV
recorded in Newham was virtually entirely attributable to a small
pocket of refugees from Uganda. In other words, the figures told
nothing about HIV spread among British heterosexuals; they merely
confirmed the presence in the capital of a small sample of the AIDS
epidemic in Africa. (Given the traditional inhospitality of the
citizens of Newham towards newly arriving immigrants, the risks
of wider spread must be regarded as remote.)
In recent weeks, the particular plight of patients who have acquired
HIV infection overseas (usually in Africa) and are now presenting
at London hospitals, have received some media coverage. There can
be no doubt that their problems are serious and need special attention.
My main concern here, however, is with the way these cases are used
to boost the statistics of heterosexual transmission of HIV in Britain
to bolster the flagging AIDS scare.
For 15 years, the authorities have been manipulating AIDS
If we look, for example, at the figures for heterosexually acquired
HIV infection in 2001, we find a total of 2,226. This has been widely
quoted to illustrate the rising tide of heterosexual transmission
at a time when spread among gay men is declining. Yet closer scrutiny
reveals that more than 1500 of this total refers to HIV infection
acquired in Africa. Add another 163 cases of infection acquired
in other non-European countries and these cases make up more than
75 percent of the heterosexual total.
How many people became HIV positive as a result of heterosexual
contact with a partner who became infected in Europe? This figure
- the key statistic of the indigenous heterosexual epidemic - is
52 (2.3 percent of the total).
It is noteworthy that this number has remained remarkably steady
over the past decade.
Looking at AIDS cases reveals even more starkly the small size of
the British epidemic among heterosexuals. In 2001, the number of
cases of AIDS in which infection was acquired by heterosexual contact
with a partner who had become infected in Europe was 13. This marks
a decline from an average of 19 cases a year through the 1990s (the
peak year was 1994 with 28 cases).
In the whole of the 1980s there were 20 cases. Heterosexual AIDS,
the great bogey launched with the government's "tombstones
and icebergs" campaign in 1987, has remained a mercifully rare
disease - and it is getting rarer.
For 15 years, medical and political authorities have been manipulating
AIDS statistics to inflate popular fears of an imminent heterosexual
epidemic. Having invested so much in this strategy, it seems they
are reluctant to let the good news about the decline of the epidemic
interfere with their moralizing message. Thus Dr Nicoll quotes with
alarm surveys that report an "increase in numbers of sexual
partners, lower age at first sexual intercourse, increasing levels
of heterosexual anal sex and payment for sex. All of these,"
he insists, "are known to be associated with HIV transmission."
These may all be activities of which Dr Nicoll disapproves, but
in communities in which the prevalence of HIV is likely to be negligible,
they can be indulged in with impunity without risk of HIV transmission.
Dr Nicholl is entitled to his sexual preferences, but he is not
entitled to inflate risks of serious diseases to scare the public
into following them.
Dr Michael Fitzpatrick is the author of The Tyranny of Health: Doctors
and the Regulation of Lifestyle, Routledge,