The Origins of AIDS

by Pepin

  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’.

  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.17–26

  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

  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.

  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

  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.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

  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

  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 a
cquired 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

  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.

  The red gold

  Meanwhile, at the receiving end of the plasma equation, technological advances contributed to the dissemination of the virus. Haemophiliacs have a genetic deficiency in a coagulation factor (usually, factor VIII) which, in the absence of treatment, leads to their early death, generally from bleeding inside the brain. Blood transfusions and, in the 1950s, administration of plasma were not very effective because they contained little of the missing coagulation factor. Starting in the mid-1960s, ‘cryoprecipitates’ were used: the freezing and thawing of plasma led to some concentration of factor VIII, which was recuperated after such cycles. One treatment required cryoprecipitates obtained from three to six donors. Unfortunately, the titre of factor VIII in cryoprecipitates varied substantially from lot to lot. Furthermore, they had to be stored at −40oC and thawed slowly before being administered.

  These shortcomings were solved around 1972 with the marketing of factor VIII concentrates, in which the quantity of the coagulation factor was high and fixed, and the product conserved as a dry powder, a revolution in the treatment of haemophilia. From the mid-1970s, concentrates were even used preventively and administered regularly (forty to sixty times per year) to some high-risk haemophiliacs. However, the production of factor VIII concentrates required the pooling of plasma obtained from between 2,000 and 25,000 donors, implying that the recipients would be potentially exposed during each treatment to any infectious agent present in the plasma of thousands of individuals. A given lot would be administered to dozens of recipients. Even if much diluted through this pooling process, HIV which had been present in a single donor would be found in many of the vials prepared: in Scotland, eighteen of thirty-two haemophiliacs who had been exposed to a single HIV-infected batch developed HIV infection.43–46

  It is likely that some of the plasma sent to the US by Hemo-Caribbean was used to produce albumin and immunoglobulins (products whose manufacturing processes inactivated HIV, in contrast with coagulation factors), and the Port-au-Prince company was shut down before factor VIII concentrates became widely used. It could have been worse.17

  When Hemo-Caribbean was forced out of business, plasma traders used other sources, one of which was Managua, Nicaragua, where one centre was owned by the dictator Anastasio Somoza and a Cuban entrepreneur. For a few years, the Compania Centroamericana de Plasmaferesis was the largest plasma collection centre in the world. With two dozen doctors and a few hundred employees, it could process plasma from up to 1,000 donors per day. Somoza ordered the 1978 killing of the editor of a local newspaper, Pedro Joaquin Chamorro, also a prominent opponent of Somoza’s rule, who had dared to criticise this blood trade. At the latter’s funeral, a riotous crowd burned down the plasma centre and that was the beginning of the end for Somoza. Chamorro’s widow later became president of the country.22,23

  In the 1970s, about 20% of the plasma produced in the US came from the Third World. A considerable proportion of commercial plasma used in North America and Western Europe was bought and sold by brokers. The largest plasma brokers were a Montreal company called Continental Pharma Cryosan, and Brandenberger AG in Zurich. During the heyday of the plasma trade in the early 1970s, plasma was bought in at least twenty-five developing countries to be exported to pharmaceutical companies in the industrialised world. Apart from those already mentioned, the list included Belize, Brazil, Colombia, Costa Rica, the Dominican Republic, El Salvador, Guatemala, Puerto Rico, Taiwan, Thailand and even African countries such as Lesotho. In Latin America, blood became known as el oro rojo, the red gold.47

  A large and respected French company had another interesting idea: extracting plasma from placentas, which came from France but were also imported from other countries. All of this slowed down after 1975 when the WHO’s annual assembly of health ministers unanimously adopted a resolution condemning such practices and urging member states to enact legislation to protect blood donors and blood recipients. Plasma trafficking became illegal in some countries, and the traders who continued risked fines and/or jail terms. These did not deter everybody, given the anticipated hefty profits. For instance, plasma was exported from South Africa to Belgium, Austria, China and India well into the 1980s and 1990s.47–49

  Such wheeling and dealing necessarily meant that the ethical standards of non-profit corporations were not respected. Following investigations by the Royal Canadian Mounted Police, Continental Pharma Cryosan pleaded guilty in 1980 to charges that it had mislabelled the source of some plasma that it traded. An internal draft memo written in 1977 by a Health Canada official had commented, concerning the same company: ‘It is evident we are dealing with more than technical violations, but rather a calculated and deliberate business designed to take advantage of legal loopholes providing possibly hazardous products on the world market.’ This was referring to the fact that Canadian regulations did not apply to blood products that were to be re-exported from the country. The Krever Commission inquiry into Canada’s blood supply established that Continental Pharma Cryosan had bought plasma from American prisoners in 1983 and resold it to a number of clients, including Connaught Laboratories in Toronto, the sole Canada-based plasma fractionator. Such practices were discouraged by the US Food and Drug Administration (FDA) because prisoners were already thought to be at greater risk of being infected with the putative aetiological agent of AIDS. In June 1983, Health Management Associates, a company buying plasma from prisoners in Arkansas, informed Continental Pharma Cryosan that thirty-eight units of plasma had been obtained from four prisoners who had previously tested positive for HBV antigen and should have been excluded, even if their more recent test was negative.50,51

  As a measure of the ongoing international circulation of plasma two years into the AIDS crisis, four of these thirty-eight units had been sold by Continental Pharma Cryosan to Connaught, while the other thirty-four had been vended to companies in Switzerland, Spain, Japan and Italy. Continental Pharma Cryosan did not inform Connaught of the problem. Eventually Health Management Associates recalled the thirty-eight units and informed the FDA, which then informed Health Canada, which in turn informed Connaught. Up to that time, Connaught apparently did not know that it was processing plasma obtained from prisoners. Because the process required the pooling of a large number of donations, small quantities of plasma from the four HBV-infected donors was now present in 2,409 vials of coagulation factor concentrates, only 417 of which could be retrieved. The others had already been administered.

  Then, a fifth Arkansas donor was found to have been HBV-positive in the past. This prisoner had sold plasma th
irty-four times over ten months. Only twenty-seven out of 1,968 vials that included plasma from this man could be recalled. That was too much for the Canadian Red Cross, the national distributor of blood products, which cancelled its contract with Connaught. The Krever Commission also revealed that Connaught had earlier processed plasma from inmates in four Louisiana prisons. There, prison plasma collection centres were exploited by Community Plasma Center Inc., which sold the plasma to Health Management Associates, which resold it to Continental Pharma Cryosan, which then resold it to Connaught between November 1982 and January 1983.51

  A class action lawsuit initiated by HCV-infected haemophiliacs against the Canadian Red Cross, Connaught Laboratories and Continental Pharma Cryosan was eventually settled as part of a larger arrangement that included several other parties, after the defendants collectively agreed to pay a multi-million dollar compensation to the plaintiffs, most of which had been raised by the Canadian Red Cross selling some of its assets.

  We will never know for sure how often and from what sources HIV entered this transcontinental network. However, the point is that, throughout the 1970s and the early 1980s, any virus present in plasma samples could have travelled thousands of miles in all directions within days or weeks of being collected, and ended up in the veins of many recipients.

  13 The globalisation