C. McCarthy, P.D. Welsby
Infectious Disease Unit
Western General Hospital
Crewe Road
Edinburgh
EH4 2XU
Abstract
The prevalence of HIV in the general population of Edinburgh and seven other European cities was compared. Edinburgh University students’ perceptions of the HIV problem in Edinburgh and in the seven major European cities were ascertained using a questionnaire.
Edinburgh is not the AIDS capital of Europe
(Barcelona, most likely, deserves this accolade). Reasons why Edinburgh has
retained its unjustified reputation are suggested.
In 1979, HIV was introduced into the intravenous drug using (IVDU) population of Milan.1-3 At much the same time, HIV was introduced into Barcelona, and throughout Southern Europe.1-6 By 1986, 70 percent of all European AIDS cases attributable to IVDU were from Italy, Spain or France.1, 2
Later, in 1983, HIV was introduced into the
intravenous Edinburgh drug using population.2, 7 In the following
years most of those IVDUs died of AIDS.8, 9. Edinburgh responded by
creating a Community Drugs Problem Service, providing oral methadone to minimise
the need for intravenous use of drugs, and initiating needle exchange schemes so
that needle sharing was minimised. Currently, the risk group with highest number
of newly diagnosed HIV infection in Edinburgh is homosexual Men.8
Edinburgh was first labelled the "Aids [sic]
capital of Europe" in the Sunday Telegraph in April 198610. In
subsequent years HIV/AIDS became a more standard medical problem and relatively
less newsworthy. However, Edinburgh managed to retain this accolade and is still
widely perceived to be suffering from a disproportionate HIV/AIDS epidemic –
indeed the current Lonely Planet™ Britain guide11 referred to
Edinburgh’s “serious drugs scene and the distressing AIDS problem"
without mentioning similar or worse problems elsewhere.
We investigated the prevalence of HIV in eight
European cities (Amsterdam, Barcelona, Edinburgh, Glasgow, London, Milan, Paris
and Rome) which might compete for the title of “AIDS Capital of Europe”
(Capital in the sense of leading city for HIV, rather than the political
capital).
Prevalence of HIV in pregnant women in the eight
cities was obtained from the European Centre for the Epidemiological Monitoring
of AIDS, Saint-Maurice, France.12 This provides a reflection of HIV
prevalence in the general heterosexually active population but, as this
obviously excludes homosexual men, we also obtained overall AIDS national
statistics for the country in which each city was located.13 The
rankings should remain unaffected if it is assumed that the homosexual
population of each city studied was approximately proportional to its total
population..
Identical questionnaires were given to 100 Edinburgh
University students. After giving their initial answers, the respondents were
presented with correct data and changes in their opinions and the reasons
provided were analysed.
Table 1
(adapted from reference 12) gives the HIV prevalence in the eight cities,
derived from pregnancy studies in 1997, and Table
2 (adapted from reference 13) gives the incidence of AIDS per million in the
countries containing the eight cities.
One hundred mostly fourth year University students of
age range of 18 to 26 (mean 21) years were asked the following questions.
Which European cities have, or have had, major problems with HIV/AIDS?
For the purposes of this study, a major problem was
defined as one which involved a significant number of a select population
relative to the city’s entire population or one which required specific extra
funding and required public health interventions.
Students identified London, Edinburgh, Glasgow and Amsterdam as having a major problem (Fig.1) and indicated a high level of ignorance -via “don’t know” of problems elsewhere. Only three percent of students correctly believed that Glasgow had the lowest ranking of HIV prevalence.
Students
ranked the highest risk groups for HIV infection in Edinburgh in 2002 (Fig.
2) and the correct data are shown in Figure
3.8
Students ranked the eight cities in the order with which they believed they had the highest proportion of their general population infected with HIV/AIDS (Fig. 4).
Were students aware that Edinburgh had a significant HIV and drugs problem before reading the book or seeing the film “Trainspotting”?
Eighty respondents had read the book or seen the film
"Trainspotting." Of these, 62 were aware that Edinburgh had a drug and
HIV problem before seeing the film.
Thirty three reported that it increased their estimate of the extent of the
problem in Edinburgh.
It might be argued that HIV data derived from screening of pregnant women does not reflect the general population prevalence and might give false rankings between cities, especially as some countries test in the ante-natal clinics and others at delivery.12, 13. However the national AIDS statistics for the country of each city (Table 2) were consistent with these rankings.
Most students were comprehensively unaware of the relative prevalence of HIV in the eight European cities. And yet they “knew” that Edinburgh (and London) had more problems (Fig. 1) and “knew” that new infections in Edinburgh were more common in IVDUs (Fig. 2). If students resident in Edinburgh are not accurately informed, it is difficult to criticise others for lack of knowledge.
So what factors caused the misapprehensions?
Media
portrayals of Edinburgh.
Books and films, notably Trainspotting, reinforce the myth of Edinburgh as the
AIDS capital of Europe - 33 out of
the 80 responders who had read this book or seen the film reported that it had
caused them to overestimate the extent of the Edinburgh problem.
A
lack of media coverage concerning Europe-wide patterns of HIV and AIDS. In
this age of rapid information transfer it is disappointing that parochial news
is so predominant.
The
rapid identification of, and vigorous response to, the HIV problem in Edinburgh.
It was
recognised that HIV (then known as HTLV-III) had been acquired by 15
haemophiliacs in the Lothian region during 198415 and by the December
of that year, all Scottish National Blood Transfusion Service factor
VIII concentrates were heat-treated.
There is little doubt that, in Europe, Edinburgh was
first with the HIV "bad news" despite the fact that there was
(unpublicised) worse news elsewhere. The quantity and quality of Edinburgh-based
HIV research2, 7 and early interventions,16 some of which
were controversial, generating publicity such as “Anger at moves to give
needles"17 all contribute to the misunderstanding. Similar
publications and interventions based on Italian, Spanish or French cities were
either not produced or received little publicity either locally or in Edinburgh.
The lack of data from the initial years of the epidemic in at least one other
European cities has been acknowledged.4
Edinburgh does not have the worst HIV/AIDS problem.
It seems that those who ask “when and where was the alarm first sounded?”
assume that the “First will be Worst.”
The
previous reputation of Edinburgh as a city of old-fashioned virtue. There seems to be a delight in downgrading
high status accolades. Edinburgh might have been “the Athens of the North”
but now it is “the AIDS Capital of Europe” is a memorable, if misleading,
juxtaposition.
Despite Amsterdam’s reputation as a city where drug
abuse and prostitution are tolerated “therefore they must have lots of HIV”;
the public health measures instituted minimised HIV problems. Amsterdam - like
Edinburgh - recognised and dealt with their drug problems early and the
Amsterdam initiated a methadone dispensing Programme18 in 1980,
which, although initially intended to minimise the effects of drug abuse, almost
certainly reduced their HIV problem
Conclusions
Students could not accurately rank European cities that had the highest prevalence of HIV, they did not know which sub-groups of the population were most at risk for new HIV infection in the city where they currently resided and a third overestimated the extent of the drugs/HIV problem in Edinburgh after reading the book of seeing the film "Trainspotting".
Edinburgh's undeserved and inappropriate
accreditation as "AIDS capital of Europe" should be corrected. This
dubious accolade almost certainly belongs to Barcelona.
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