《艾滋病的蔓延：流行病学碰撞政治正确性》（第九章）翻译实践报告

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翻译专业学位硕士论文《Ｘ孅爲的筻泛，洗行禹嗲麇積政飨炙确钳》ｆ第先幸Ｊ｜？磚素我裁鲁黎妮指导教师一：曹顺发教授ｆ？ｉｌｋ￥称？拥译硕士ｉｆ＆＃＆英语笔译论文提交时间论文答辩时丨苟：２０１７年６月＾＾２０１７３８２ AReportontheTranslationofTheAidsPandemic:TheCollisionofEpidemiologywithPoliticalCorrectness(Chapter9)ByLiNiAThesisSubmittedtotheGraduateSchoolofSichuanInternationalStudiesUniversityInPartialFulfillmentoftheRequirementsfortheDegreeofMasterofTranslationandInterpretationUndertheSupervisionofProfessorCaoShunfaMay2017 i 《艾滋病的蔓延：流行病学碰撞政治正确性》（第九章）翻译实践报告摘要本篇翻译项目所涉及的原文《艾滋病的蔓延：流行病学碰撞政治正确性》（TheAIDSPandemic:TheCollisionofEpidemiologywithPoliticalCorrectness）由资深医生、医学教授JamesChin(詹姆斯·钦)撰写，并于2016年6月由CRC出版社出版。原文主要从三个方面入手，详述了导致艾滋病毒流行传播的主要决定性因素，人们对于艾滋病毒传播动力学的误解于错误观念，以及作者如何逆主流机构而上表达自己的新观点。本翻译项目不仅为相关专业人士提供了理论和实践参考，笔者通过这篇科普文章的翻译，还丰富了自身专业领域的理论和实践，且对艾滋病也有了全新的科学认识，受益匪浅。笔者对整个翻译报告做了简单介绍之后，对原文进行了介绍和分析。然后在诺德的文本分析理论指导下，笔者对此翻译项目中的难点，提出解决办法。此翻译项目中主要的翻译难点存在于长难句和术语翻译。长难句主要通过顺译法、拆分法、倒置法等翻译方法来解决。而此项目中的对于术语翻译的处理方法，仍需讨论。关键词：艾滋病；政治正确性；诺德；文本分析ii AReportontheTranslationofTheAIDSPandemic:TheCollisionofEpidemiologywithPoliticalCorrectness(Chapter9)AbstractThistranslationreporton“TheAIDSPandemic:TheCollisionofEpidemiologywithPoliticalCorrectness”(Chapter9)iswrittenbyaexperienceddoctorandmedicalprofessorJamesChinandispublishedbyCRCPressonJune2016.Thesourcetextcontainsthreemajorparts,elaboratingthemajordeterminantsofepidemicHIVtransmission,gloriousmythsormisconceptionsofHIVtransmissiondynamics,andhowtheauthorswimsupstreamagainstmainstreamAIDSagencies.Thistranslationprojectreportprovidestheoreticalandpracticalreferencefortherelatedprofessionals.Moreover,thetranslationofthispopularscienceworkhasenrichedthetheoreticalandpracticalexperienceofthetranslator，andhasprovidednewscientificviewpointsofAIDSforthetranslator,whichisverybeneficial.Aftergivingabriefintroductiontothewholereport,thetranslatorpresentsthemaincontentofthesourcetextandconductstextanalysistoit.UndertheguidanceoftheChristianeNord'stextanalysis,thetranslatorputsforwardsolutionstothedifficultiesencounteredduringtranslationprocess.Aslonganddifficultsentencesandabbreviationsperplexthetranslatorthemost,thetranslatorexploitssequentialtranslation,division,inversionandsoontosettlelonganddifficultsentences.Asfortheterminology,thetranslationapproachisstillopentodiscussion.Keywords:AIDSpandemic;politicalcorrectness;Nord;Textanalysisiii AcknowledgementsFirstofall,Iwouldliketoextendmysinceregratitudetomysupervisor,ProfessorCaoShunfa,forhisinstructiveadviceandsuggestionsonthistranslationreport.Iamgratefulforhisguidanceinthecompletionofthisreport,whichcouldnothavebeenachievedwithouthisconsistentinstructionandilluminativesuggestions.What’smore,Iamindebtedtotheothertutorsandprofessorsintranslationstudiesfortheirdirectandindirectguidanceandhelp.AndImustexpressmyspecialthankstomyfriendswhohavedevotedtheirconsiderabletimeandeffortstocommentingonthedraftandgivingmesuchgreatsupportandusefuladvice.Lastbutnottheleast,Iwouldliketoappreciatethesupportandencouragementfrommyparents.iv CONTENTS摘要................................................................................................................................iiAbstract.......................................................................................................................iiiAcknowledgements.......................................................................................................ivChapter1Introduction....................................................................................................11.1BackgroundInformationoftheTranslationProject................................................11.2SignificanceoftheTranslationProject.......................................................................21.3StructrueoftheTranslationProject.............................................................................3Chapter2IntroductiontotheSourceText......................................................................42.1BriefIntroductiontotheAuthors.................................................................................42.2MainContentoftheSourceText..................................................................................42.3LinguisticFeaturesoftheSourceText........................................................................5Chapter3TheoreticalBasisfortheTranslationProject.................................................63.1IntroductiontoNord’sTextAnalysis...........................................................................63.2AnalysisoftheSourceTextType.................................................................................73.3Translation-orientedAnalysis............................................................................8Chapter4TranslationDifficultiesandSolutions..........................................................104.1TranslationDifficulties.................................................................................................104.2TechniquesEmployedintheProcessofTanslating...............................................114.2.1SequentialTranslation................................................................................................114.2.2Division.......................................................................................................................124.2.3Inversion...................................................................................................................14Chapter5Conclusion...................................................................................................165.1LessonsandEnlightenments.......................................................................................165.2ProblemstoBeSolved..................................................................................................17Reference......................................................................................................................18AppendixISourcetext.................................................................................................20AppendixII中文译文................................................................................................33v Chapter1Introduction1.1BackgroundInformationoftheTranslationProjectAIDS,shortforAcquiredImmuneDeficiencySyndrome,isanincurablepandemiccausedbyinfectionofHIV.Owingtoimmunodeficiency,AIDSpatientssufferfromaseriesofopportunisticinfectionsandtumors,whichhaveafairchanceoftakingtheirlives.ThestatusquoshowsthatAIDShasbeenoneofthebiggestthreatstothehealthandwell-beingofmankind.Toaddressthisworld’stoughestproblem,scientistsandphysicians,aswellaspoliticiansandthemedia,havemadelotsofeffort.However,thepublicdon’tseemtohaveknowledgeenoughoforaccurateinformationaboutthisdisease.Withthisregard,thepublicationofTheAIDSPandemic:TheCollisionofEpidemiologywithPoliticalCorrectness(Chapter9)mayhelpclearsomedeep-rootedmisconceptionsofAIDSandgivestheEnglishreaderscorrectepidemiologicalinformation.NowthetranslationprovidesanaccesstothelatestscientificcomprehensionofAIDSpandemicfortheChinesereaders.Underthiscircumstance,thetaskforthetranslatoristoconvertthesourcetextinaunderstandableandfluentmanner.UNAIDSandothermainstreamAIDSagenciesandactivistscontinuetoacceptanduseseveral“glorious”mythsandmisconceptionsaboutHIVepidemiology.Toavoidstigmatizingthealreadymarginalizedpopulation,theUNAIDSparadigmclaimsthat,withoutaggressiveAIDS/HIVpreventionprograms,especiallydirectedtoyouth,it’sjustamatteroftimebeforetheheterosexualHIVepidemicsbreakoutinthegeneralpublic.Butthisparadigmisn’tsupportedbyepidemiologyandavailabledata.HIVepidemicswon’tbreakoutinthegeneralpubliclikeanypandemicinfluenza.Sobyfocusingonexplainingthosemisconceptions,thepresentstudycangiveabetterandfullunderstandingofHIV/AIDSpandemics.Inaddition,althoughHIV/AIDSisalsoathornyproblemfacingtheworld,fewrelevantmonographscanbefoundaccessibletothegeneralpublicormedicalpractitionersinChina.WorkswithbasicinformationofHIV/AIDSarenotavailabletothegeneralpublic,letaloneanynewconclusionssupportedbythelatestresearchesanddata.Asthereisnorelevanttranslationinanyform,thetranslationofthesource1 textcanbeofsomehelpinthisaspect.AndthepointsofviewpresentedinthesourcetextbreakfreshgroundforthegeneralpublicinChina,especiallyChineseacademics.Thetranslationprojectisbothanepidemiologicalreferenceandamodernpopularsciencetextforawiderangeofreaders.Therefore,thebackgroundofthistranslationprojectcanbeconcludedfromthreeaspects.Itisarareopportunityforthetranslatortopracticeandimprovetranslationskillswiththisacademicpaper"TheAIDSPandemic:TheCollisionofEpidemiologywithPoliticalCorrectness"asthesourcetextforatranslationprojectreport.Fromtheperspectiveofsociology,theprojectbringsitsreadersamoreextensiveandmoreaccurateunderstandingofHIV/AIDSpandemics.Asfarastheacademicvalueisconcerned,itcanbeseenasamilestoneforpopularizingthecorrectconceptionsofHIV/AIDStotheChinesemedicalpractitionersaswellasthegeneralpublic.1.2SignificanceoftheTranslationReportThesignificanceofthistranslationprojectcanbesummarizedfromthreeaspects.Tobeginwith,thistranslationprojectwillexertpositiveeffectsonthedevelopmentofHIV/AIDSepidemiology.ItcanridprofessionalsofthemisconceptionsandprovidegroundbreakingnewconclusionsabouttheHIV/AIDSpandemicfacts.Ithelpsdevelopabetterunderstandingofoneofthetoughestproblemsfacingmankind,duringwhichtheprofessionalscanbeawareofthelatestdataandnewfoundingofhowHIVspreadsandwhoarethehighestriskgroup.Secondly,ThetranslationprojectcanalsobebeneficialtoMTIstudentsandthosewould-betranslators.Afterallthetheoreticallearningandtranslationpracticeduringthepost-graduatedays,itcanstillbehardfortheMTIstudentstotackleconcreteproblemsencounteredattheworkplace.Withregardtothis,translationskillsforaddressingthornyproblemsintheconcretetranslationprojectandpreparingtheMTIstudentsandthosewould-betranslatorsforfutureworkwillbeexploredinthistranslationreport.Furthermore,thewriterofthistranslationreporthasacquiredalotoftranslationtechniquesandmedicalknowledge,backloggingabundanttheoretical2 knowledgeandpracticalexperience.Finally,thetranslationprojectof"TheAIDSPandemic:TheCollisionofEpidemiologywithPoliticalCorrectness"willprovidethegeneralpublicwithpopularsciencereading,whichwillridthemoftheirmisunderstandingaboutHIV/AIDS.1.3StructureoftheTranslationReportThistranslationprojectfallsintofiveparts:PartOneintroducesthetranslationproject,containingitsbackground,significanceandstructure.AndtheintroductiontothesourcetextispresentedinPartTwo,whichincludesthebriefintroductiontotheauthorofthesourcetext,anditsmaincontentandlinguisticfeatures.PartThreepresentsthetranslationapproachandtextanalysis.ThetranslationdifficultiesandtranslationmethodsareillustratedinPartFour,inwhichtranslationmethodsincludeliteraltranslation,freetranslation,divisionandinversionandsoon.Thesourcetextconcernssomemedicaltheories,sotherearemanyprofessionalvocabulariesandpropernounsandlongandcomplexsentences.Therefore,inordertoconveytheauthor’sideasandbefaithfultotheoriginaltext,thetranslatorneedstoconsultlotsofprofessionalmaterialsandmakeacomprehensiveanalysis.Thelastpartpresentstheconclusion.3 Chapter2IntroductiontotheSourceText2.1BriefIntroductiontotheAuthorJames(Jim)Chinisapublichealthepidemiologist.Heservedasheadofthegeneralepidemiologyunit,BureauofCommunicableDiseaseControl,CaliforniaStateDepartmentofHealthServices,Berkeley,from1968to1971andwaschiefoftheinfectiousdiseasesectionfrom1971to1987.HehadstudiedtheAIDSpandemicfromtheearly1980sinCalifornia,wherehewasinchargeofsurveillanceandcontrolofcommunicablediseasestothelate1980s.HewaswiththeWorldHealthOrganizationinGeneva,Switzerland,wherehewasresponsiblefordevelopingthemethodsandguidelinesforglobalandregionalHIV/AIDSsurveillanceandheworkedaschiefofthesurveillance,forecastingandimpactassessmentunit(SFI)oftheGlobalProgrammeonAIDSfrom1987to1992.SincehisresignationfromGPA/WHOin1992,hehasworkedasanindependentconsultantfordifferentinternationalagenciestoevaluatethepatternsandprevalenceofHIVindevelopingcountries,primarilyinAfricaandAsia.Besides,heworkedasaclinicalprofessorofepidemiologyattheSchoolofPublicHealth,UniversityofCaliforniaatBerkeley,from1992until2009whenheretiredfromactiveteaching.2.2MainContentoftheSourceTextTheoriginaltext"TheAIDSPandemic:TheCollisionofEpidemiologywithPoliticalCorrectness"writtenbyJamesChinisapopularscienceworkpublishedbyCRCPresson6July,2016.Ittotals248pagesandthereisnoChinesetranslationyet.ThistranslationprojectselectsChapter9asthesourcetext,whichcontains5315words.AsAIDSisanillnessthatsoendangersthehumanhealthbutthereisnoeffectivecureavailable.Itiscrucialforthegeneralpublictohaveafullunderstandingofit.While,toavoidstigmatizingthealreadymarginalizedpopulation,themainstreamorganizationspopularizetherelevantconceptionswhicharepoliticallycorrectbutepidemiologicallywrong.Thisworkaimstodispelthese4 misunderstandingandmisconceptionstoprovidethereaderswithabetterandmoreaccurateviewofHIV/AIDS.Thesourcetextprimarilyfocusonthreeparts.Namely,majordeterminantsofepidemicHIVtransmission,gloriousmythsormisconceptionsofHIVtransmissiondynamics,andswimmingupstreamagainstmainstreamAIDSagencies.2.3LinguisticFeaturesoftheSourceTextPopularsciencetextswrittenasinformativetextsusuallycontainagoodnumberofaccuratewordsandtechnicaltermstoformthedetailed,precise,andobjectivewritingstyle.Theremarkablechoiceofwordsinthesourcetextshouldbenoted.Forinstance,thesourcetextisimbuedwithabbreviationsofinternationalorganizations,certainregions,specialpopulationgroupsandprofessionalmedicalterms,whichrevealthewriter’sexpertiseandabundantexperienceintheresearchofHIV/AIDSfield.Thetranslatorshouldpaymoreattentiontothesewordssoastobettertransmitthefullreferentialandconceptualcontentofthesourcetext.Besides,inordertomakethefactsandtheiropinionsbetterunderstood,popularscienceauthorsusuallyturntorhetoricdevices.Therefore,thetranslatorshouldtakecareoftherhetoricdevicestoconveytheoriginalmeaningtothefull.Moreover,popularsciencetextspresentdataanalysisandresearchresults.Torevealthewriter’sproficientlanguageskillsandprofessionalknowledgeandtocultivatetheformalsenseandauthorityofthedataanalysisandresearchresults,longandcomplexsentencesareoftenexploitedinthesourcetext.Whentranslatingtheselongandcomplexsentences,thetranslatorshouldmakeeffortstoretaintheoriginalmeaningoftheworkwhilemakingsureofthedifferencesbetweenEnglishandChinese.Translationskillsareneededsoastoenablethetargetreaderstogetthefeelasthesourcereadersdo.5 Chapter3TheoreticalBasisfortheTranslationProject3.1IntroductiontoNord’sTextAnalysisThesourcetextfortranslationisapopularsciencework.AccordingtoReiss’categoriesoftexttypes,itisaninformativetext,whichfeaturesinformation,knowledge,opinionsetc.Sincetheinformativetextmainlypresentsobjectivefacts,thetranslatorshouldexploitthecontent-focusedtranslationpolicytoaccuratelyandcomprehensivelyconveytheinformationofthesourcetext.Withthisregard,thetranslatorshouldfocusonthecoreinformationoftheworkduringthetranslationprocess.Inordertoanalyzethesourcetext,ChristianeNord,oneofthemostfamousfunctionalschoolscholarsfromGermany,hasputforwardherfunctionaltheoryoftranslation.ChristianeNordilluminatesamodelofsourcetextanalysiswhichcanbeappliedtoalltexttypesandtranslationsituations.Themodelisbasedonafunctionalconcept,enablingunderstandingofthefunctionoftheSTfeaturesandtheselectionoftranslationstrategiesappropriatefortheintendedpurposeofthetranslation.Shepresentsamoredetailedfunctionalmodelincorporatingelementsoftextanalysis,whichexaminestextorganizationatorabovesentencelevelinherworkTextAnalysisinTranslation(Nord,1988).AndNordisthefirstonetomakeadistinctionbetweentwobasictypesoftranslation,documentaryandinstrumental.Documentarytranslation“servesasadocumentofasourceculturecommunicationbetweentheauthorandtheSTrecipient”(Nord,2005,p.80)Forexample,inliterarytranslation,wheretheTTallowstheTTreceiversaccesstotheideasoftheSTbutwherethereaderiswellawarethatitisatranslation.OtherexamplesofdocumentarytranslationgivenbyNordareword-for-wordandliteraltranslationand“exoticizingtranslation”.(Nord,1997,p.59)SincetheprojectinvolvespopularscienceworkwhosefeaturesandtranslationdifficultiesareconsistentwithNord’stranslationtheory.ThetargettextofthisinformativetextshouldtransmitthefullreferentialandconceptualcontentoftheST,6 especiallytheepidemiology-relatedcontent,whichisnewtotheoriginalreadersaswellasthetargetreaders.Besides,Thetranslationshouldbein“plainprose”.Redundancyisnotallowedintranslationandexplicitationcanbeutilizedwhennecessary.Moreover,consideringthatthepopularsciencetranslationiskindofdocumentarytranslationserving“asadocumentofasourceculturecommunicationbetweentheauthorandtheSTrecipient”(Nord,2005,p.80).It’sproperforthetranslatortotakeNord’stranslationtheoryasthetheoreticalbasisforsuchatranslationproject.Themeaningofthisanalysisofthesourcetextandthetargettextshouldbevaluedandthedetailedanalysisofbothtextswouldbeelaboratedinthefollowingparts.Asaresult,bygivingattentiontothesourcetextinaccordancewiththemodeloftext-analysis,thetranslatorcanhopetoenhancehertranslationtechniquesandacquiremoreexperienceinthistranslationprojectfromthepre-translationworkoffunctionalistapproaches.3.2AnalysisoftheSourceTextTypeThesourcetextisapopularscienceworkinvolvingAIDSpandemic.Therefore,thetranslatorshouldbewellequippedwithrelatedtheoriesandbackgroundinformation.Moreover,apopularscienceworkisdifferentfromanyothertexttype.Foronething,itslanguagestyleisliteraryandeasyforthereaderstounderstand.Foranother,itssentencepatternsarerigorousandwell-organized.Andforthelargenumberofterminologiesinmedicalscienceandstatisticsmentionedinthesourcetext,thetranslationshouldbeboththeoreticalandsystematic.Withthisregard,thetranslatorshouldleavenostoneunturnedtoachievefaithfulnessandsmoothnessandkeepitsscientificnatureandpopularizationatthesametime.Pastexperienceshowsthatthetranslationofpopularscienceisfraughtwithtypicaldifficulties.Forexample,thetranslatorfailstounderstandthesourcetextthoroughlyandthetargettextfailstokeeptheoriginalscientificnatureandreadabilityforthetargetreaders.Speakingoftranslationapproachesofpopularsciencetranslation,therearethreepointstobeelaborated.Firstly,literaltranslationis7 advocatedbymanyscholarstokeeptheliteralrhetoricandstyleofthesourcetext.Secondly,thetranslatorshouldfollowthe“traditionalcustom”,whichmeansthetranslatorshouldadoptthewidely-acceptedversiontobeunderstandable.Thirdly,theprofessionaltermsshouldbestandardized.Popularsciencetranslationhasitspracticalsignificance.Sinceitsreformandopeningup30yearsago,morethan100thousandpopularsciencetranslationworkshavebeenpublishedinChina,whichplaysaimportantroleinpromotingscientificspiritandideologyandpopularizingscientificconceptions,methodsandknowledge.(Xinhua.com,2008)However,thedomestictranslationqualityinthisaspectpromiseslittleoptimism.Inaddition,eventranslatorsholdthepartialideathatpopularsciencetranslationjustexpressessimplefactsinconciselanguage.Sometranslatorsjumptothefinalversionsohastilythattheymisunderstandthesourcetext,orfailtokeeptheoriginalscientificnatureandsmoothness.(GuoJianzhong,2007)That’swhyweneedtotheoreticallyenhancethepracticeofpopularsciencetranslationandmasterthetranslationskills.3.3Translation-orientedTextAnalysisInaccordancewiththeconceptsraisedbyNord,thesourcetextchoseninthetranslationprojectcanbeclassifiedintodocumentarytextandthetargettextservesasamessagestransmitterfromtheoriginalculturetothetargetculture.Hence,thetargettextreceiverscanacquireinformationaboutthegloriousmythsormisconceptionsofHIVtransmissiondynamics,themajordeterminantsofepidemicHIVtransmission,andnewvoicesagainstthemainstreamAIDSagencies.Theintendedtextfunction:Thesourcetextpossessesthefunctionofinformation,aimedattransformingthesource-textauthor’snewfoundinganddifferentvoicesabouttheAIDSpandemic.ItelaboratesthemajordeterminantsofepidemicHIVtransmission,alsodispelstheexistingmisconceptionsofHIVtransmissiondynamics,whichprovidesthereaderswithathoroughunderstandingoftheAIDSpandemic.Thesourcetexttransmitsreferentialcontentsothatitisalsoacontent-focusedtext.Therefore,thetargettextshouldbe“plainprose,without8 redundancyandwiththeuseofexplicationwhererequired.”(Munday,2008,p.73)Theaddressees:theaddresseesofthesourcetextmaybeEnglishnativespeakerswhoarewell-educatedandhavesomeinterestinthelatestAIDSpandemicsstudyandfacts.Besides,theyarelikelytoreadthesourcetextonAmazonoronthebookpublishedbyCRCpress.TheymayevenbethestudentsoftheauthorwhowasonceaclinicalprofessorattheUniversityofCalifornia.ThetargettextaddresseesarethetargetlanguagereaderswhostudyinepidemiologyoraremedicalscholarsandwhoareinterestedinAIDSpandemics.Thetimeandplaceoftextreception:ThesourcetextwaspublishedinTheAIDSPandemic:TheCollisionofEpidemiologywithPoliticalCorrectnessreleasedbyCRCPressinJune,2016,whilethetargettextwillbepresentedinthetranslator’stranslationprojectreport.Themedium:thesourcetextisaprintedpopularsciencework,whichcanalsobereadonlineonpayment,whilethetargettextisthegraduatepaperofthetranslatorwiththesameformatstillinuseandthequotesinthesourcetextattached.Butthelanguageexploitedinthesourcetextwillbesubstitutedbythetargetlanguage.Themotive:TryingtodispelthemisconceptionsofAIDSpandemic,thesourcetextistorepresentthefactsandnewconclusionsofAIDSpandemicandrevealthemisleadingpublicityparadigmoutofpoliticalcorrectness.Andthetargettextisaimedtobefaithfultothesourcetextandsmoothandreadableforthetargetreaders,provingthemwithabetterunderstandingofAIDSpandemic.9 Chapter4TranslationDifficultiesandSolutions4.1TranslationDifficultiesDuringthetranslationofthesourcetext,thetranslatorhasencounteredseveraldifficulties,suchastheterminologies,abbreviations,metaphorandlonganddifficultsentences,thelastbeingwhatthetranslatorwillfocuson.Whentheauthorpresentsfactsandopinions,hetendstoexploitlonganddifficultsentencestomakehispointfullandtoformaformalwritingstyle.Sothesourcetextcontainsalotoflonganddifficultsentences,whicharehardtounderstand.Ifthetranslatortransmitsthemwordforwordwithoutanytranslationtechniquesinthetargetlanguage,itwillbeillogicalandhardforthereaderstocomprehend.Herecomesthequestion.Whyarelonganddifficultsentencessohardtounderstandforthetargetreaders?ItisagreedamongmanylinguisticsthatChineseandEnglishhavedifferentsentencepatterns.Forexample,manyattributiveclausescanbefoundintheoriginaltext.Besides,EnglishisfeaturedbyhypotaxiswhileChinesebyparataxis.Inotherwords,theformeremphasizestheformalcohesionthatrequiresthesentencestructurebeintegratedwithitsimpliedmeaning.Nevertheless,thelattertendstobeastyleofchronicleandattachesmoreimportancetothecoherentmeaningthesentencecarries.DifferentfromEnglish,Chineseislessrestrictedbythechangesandfeaturesofthelinguisticform.ToproperlytransmitthelonganddifficultsentencesfromEnglishtoChinese,thetranslatorshouldthoroughlyunderstandthemandanalyzetheirstructurescarefully.Translationtechniquesshouldbeused,suchassequentialtranslation,divisionandinversion.AndsomesentencesstructuresshouldberedonetoconformtotheChineselanguagestyle.Tosumup,thetranslatorshouldmasterthesourcelanguageandthetargetlanguageandthedifferencesbetweentheminordertoconveythefullinformationofthesourcetext.Andtranslationofthelonganddifficultsentencesplaysanimportantinthewholetranslationproject.10 4.2TechniquesEmployedintheProcessofTranslatingInviewofthetranslationtheorybasisandthedifficultiesandproblemsencounteredintranslation,thewriterofthetranslationprojectwillpresentssomeexamplestoilluminatehowtoconveyafullinformationofthesourcetexttothetargetreadersbymeansofthefollowingtranslationmethodsandstrategies.Inaccordancewiththetranslation-orientedtextanalysisinChapter3,thewriterwouldliketoexplorethesolutionstothetranslationdifficulties,especiallythoseoflonganddifficultsentencesbyfollowingNord’stheoryoffunction.4.2.1SequentialTranslationTheprerequisitesforproperlytranslatinglonganddifficultsentencesliesinthetranslator’saccurateunderstandingoftheoriginaltextandhis/herabilitytopresentthefullthoughtofthesourcetextinthetargetlanguage.Withthisregard,tofullycomprehendthesourcetextisthefirstandforemoststepforasuccessfultranslation.Besides,whentranslatingatext,thetranslatorshouldalsomakeabalancebetweenfaithfulnessandsmoothnessofthetargettext.Basedonthetextanalysisofthesourcetext,thefirsttranslationmethodissequentialtranslation.InanEnglish-Chinesetranslationproject,sequentialtranslationisappliedwhenthelongEnglishsentencehasthesamesentenceorderwiththeChineseconvention,whichmeansthelonganddifficultsentenceshouldbetranslatedbyitsoriginalsequencefromEnglishtoChinese.Example1：ThestudiesandobservationsdescribedinChapter5onHIVepidemiologyandtransmissiondynamicsandtheglobalHIV/AIDSpatternsandprevalencedescribedinChapter7haveledmetofardifferentconclusionsaboutthepotentialforepidemicHIVtransmissioninmostheterosexualpopulations.TT:通过第五章中描述的艾滋病毒病原学和传染病动力学的观察和研究，以及第七章描述的全球艾滋病毒/艾滋病模式和流行，我对艾滋病疫情在大部分异性人群中的潜在蔓延危机得出了完全不同的结论。Example2：ThereisnoquestionamonginfectiousdiseaseepidemiologiststhattheprimarydeterminantsofepidemicHIVtransmissionareriskbehaviorsthat11 includehavingunprotectedsexwithmultipleandconcurrentsexpartnersand/orroutinelysharingdruginjectingequipmentwithotherIDU.TT:传染病流行病学家普遍认为，高危行为是艾滋病毒传播流行的主要决定因素，包括同时与多个性伴侣进行的不安全性行为，以及/或是长期和静脉吸毒人员共用毒品注射工具的行为。Intheexamplesabove,thetranslatordividestheselongdifficultsentencesintoseveralsemanticunits,translatestheminorderandfinallyjoinsthemsmoothlybymeansofamplificationandomission.InExample1,“ledmeto”isomittedand“通过”isaddedtomakethesentencesmooth.InExample2,“一致认为”isaddedinordertomaketheinformationoftheoriginaltextknowntothetargetreaders.AccordingtoNord’stheoryofdocumentarytranslation,theTTallowstheTTreceivertheaccesstotheideasoftheSTbutthereadersiswellawarethatitisatranslation.Inthisregard,thesyntacticstructureandoriginalsequenceofthelonganddifficultsentencesistobemaintainedasconsistenttothesourcetextaspossible.Inthetargettext,thetranslatoremployssequentialtranslationasthesolutiontoagreatnumberoflonganddifficultsentencesinordertoreproducethevalueofthesourcetext.4.2.2DivisionDivisionmeanswhentranslating,thetranslatordividesalonganddifficultsentenceintoseveralshortpartsbytakingcertainelementsoutofthelongsentenceandtreatingthemseparately.Thistranslationskillcanbeadoptedwhencuttingandembeddingfailstoproperlydealwithalonganddifficultsentence.Forexample:Example3:UNAIDSandmostAIDSactivistsbelievethattheseconclusions,especiallymysecondconclusion,arenotsociallyandpoliticallycorrectandwillleadtocomplacencybythepublicandpolicymakersregardingthepotentialcourseandseverityoftheAIDSpandemic.TT:联合国艾滋病预防规划署和大部分艾滋病宣传人员都认为这些理论，特别是第二条，其社会意义和政治意义都不正确。它们会导致大众和决策者轻视艾滋疫情的严重性和潜在威胁。Example4:BelowarewhatIconsidertobethemajormythsor12 misconceptionsaboutHIVepidemiologyandtransmissiondynamicsthatcontinuetobeusedbyUNAIDSandmainstreamAIDSagenciestosupporttheprevailingsociallyandpoliticallycorrect,butepidemiologicallyincorrect,UNAIDSparadigm:intheabsenceofaggressivepreventionprogramsdirectedtothegeneralpopulation,especiallyyouth,itisonlyamatteroftimebeforeepidemicheterosexualHIVtransmissionwillbreakoutinpopulationswhereHIVprevalenceislow.TT:我认为艾滋病流行病学和传播动力学的主要误解（或误解）如下（联合国艾滋病预防规划署和主流艾滋病机构仍继续利用它们来支持普世的社会和政治正确性，但从流行病学出发，它们却是不正确的）。联合国艾滋病预防规划署的范式是：若不积极采取针对大众人群，特别是针对青少年的预防计划，那么在原本艾滋病毒感染率低的人群中，爆发异性艾滋病毒传播流行只是个时间问题。Translationisthemostobviouslyrecognizabletypeofrewriting…(Lefevere,1992,a:9)ChineseandEnglishhavesomedistinctdifferences.AndthesentencestructureisthemostimportantbetweenChineseandEnglish.TheformeroftenexploitsparataxiswithshortsemanticunitssothattherearemoresimplesentencesinChinese.However,thelatterfocusesonthehypotaxisfeaturingthestrictlogicalsentencestructuresandclausesinEnglish.Therefore,divisionwillbeemployedinthetranslationprocesstohandlelongandcomplexsentences,namely,todividethemintoseveralintegratedsentencesthatpreservethesemanticmeaningandlexicalstyleofthesourcetext.AtypicalexampleisshowninExample3.Thetranslatordividesthelongandcomplexsentenceintotwosmallerpartswithoutalteringanyofitsmeaning.Thetranslatorrecodesandtransmitsamessagereceivedfromanothersource.Thustranslationinvolvestwoequivalentmessagesintwodifferentcodes.(Jakobson1959/2004:139)Inthisregard,topreservethesemanticmeaningofthesourcetextisthefirstprioritywhenthetranslatorcan’tfindasolutiontopreservethesyntacticstructureatthesametime.InExample4,“BelowarewhatIconsidertobethemajormythsormisconceptionsaboutHIVepidemiologyandtransmissiondynamicsthatcontinuetobeusedbyUNAIDSandmainstreamAIDSagenciestosupporttheprevailingsociallyandpoliticallycorrect,butepidemiologicallyincorrect,UNAIDS13 paradigm:intheabsenceofaggressivepreventionprogramsdirectedtothegeneralpopulation,especiallyyouth,itisonlyamatteroftimebeforeepidemicheterosexualHIVtransmissionwillbreakoutinpopulationswhereHIVprevalenceislow”areconvertedintotwoparts,“我认为艾滋病流行病学和传播动力学的主要误解（或误解）如下(联合国艾滋病预防规划署和主流艾滋病机构仍继续利用它们来支持普世的社会和政治正确性，但从流行病学出发，它们却是不正确的）。”and“联合国艾滋病预防规划署的范式是：若不积极采取针对大众人群，特别是针对青少年的预防计划，那么在原本艾滋病毒感染率低的人群中，爆发异性艾滋病毒传播流行只是个时间问题。”Nordhasputforwardthatfunctionisthemostimportantcriterionforatranslation.Therefore,bydivision,thetranslatorgainsthefunctionalequivalencebetweenthesourceandtargetlanguages.4.2.3InversionInversionreferstoadjustingthesequenceofthegivensentencebeingtranslated,soastomakethetargettextconformtotheChineseconvention.Namely,thesentencestructurewillbereorganizedthroughchangeoforderinitselements.Thefrontpartofthesentencemaybeputattheendinthetargettextwhilethelatterhalfservesasthesentencebeginning.Example5:However,itdoesnotfollowlogicallythatthepotentialforextensiveHIVepidemicsinMSM,IDU,FSWandtheirclientsisequallypresentinallpopulationsandcountries.TT:然而，艾滋病毒在男男性行为者、静脉吸毒者、女性性工作者和他们的客户之中广泛流传的可能性在全世界所有人群和任何国家当中都是同样的，这并不符合以上逻辑。Example6:However,Idon'tknowofaclearandsimpleanswertothisquestion,sinceIconsideritmorelikelythatcultural,social,religious,andmanyotherfactors,includingeconomicfactors,allcollectivelyplaysomeroleasdeterminantsofsexualandIDUriskbehaviors.TT:但在我看来，文化、社会、宗教以及其他因素（例如经济因素）共同14 影响着高危性行为和静脉吸毒人员危险行为的决定因素。所以什么是艾滋病毒高危行为的决定因素？我给不出一个简单明确的答案。Thetwoexamplesabovespecificallyillustratewhatinversionmeans,whichistorearrangetheconstituteelementsofthesentenceinaconverseorder.Differentlanguageshavedifferentlogicalorders,semanticunitsandwordorders.Therefore,thelogicalorderinEnglishandChinesemaybequitetheopposite.Inotherwords,asoneofthetranslationskills,inversioncanbedefinedastheinevitablechangeofwordorderinalongsentenceinaccordancewiththesentencestructureofthetargetlanguage.(LiChangshuan,2004,pp.230-339).InExample5,thefrontpart“itdoesnotfollowlogicallythat”isplacedattheendofthesentence“这并不符合以上逻辑”,whilethelatterpart“thepotentialforextensiveHIVepidemicsinMSM,IDU,FSWandtheirclientsisequallypresentinallpopulationsandcountries”isplacedatthebeginningofthesentence“然而，艾滋病毒在男男性行为者、静脉吸毒者、女性性工作者和他们的客户之中广泛流传的可能性在全世界所有人群和任何国家当中都是同样的，”AndinExample6,theformerandthelatterpartsgettheirpositionschangedtosatisfytheChineselogicalorder.Asthesourcetextisapopularsciencework,whichcontainslotsoffacts,latestfindingsandconclusionsconcerningAIDSpandemic,theauthoremployslongandcomplexsentencestoformaauthoritativeandprecisewritingstyle.AsdescribedinChapter3,theintendedtextfunctioninthesourcetextistotransmittheinformationabouttheauthor’snewfindinganddifferentvoiceabouttheAIDSpandemic,whilethetargettextisaimedtobesmoothandreadableforthetargetreaders,providingthemwithabetterunderstandingofAIDSpandemic.Sothetranslatorexploitsinversiontoensurethetranslationconveysthefullinformationofthesourcetextanditsmeaningasclosetothetargetlanguageaspossible.15 Chapter5Conclusion5.1LessonsandEnlightenmentsGroundedonthefeaturesofthepopularsciencetext,thistranslationreportemploysNord’stranslationtheorytoanalyzethesourcetextsothatthetranslatorcouldselecttheoptimaltranslationwhichcouldbewellreceivedbythetargetreaders.Suchkindofsciencethesisasthesourcetextitis,thetranslatormustcarefullycopewiththeinvolvedandcomplicatedsentencesbysortsoftranslationtechniqueasismentioninthechapter4.Fromthedetailedelaborationoftheseexamples,itcanbegenerallyconcludedthatthelongdifficultsentencesarecrucialtothetranslation,eventhoughthetranslation-orientedtextareclearlyanalyzedinadvance.Thelessonsandenlightenmentintheprocessoftranslatingcanbesummarizedintwoaspects.Tobeginwith,thepreparationworkplaysavitalroleinatranslationproject.BeingaMITstudent,thetranslatorhasdevotedmostofhertimetotranslationtheoryandtranslationpractice,whichpreparesherabeginnerinthisprofessionaltranslationfield.Certainly,theoryknowledgeandtranslationpracticeincollegeisstillnotenoughforthetranslatortoaccomplishatranslationproject,oreventobecomeapractitionerinthetranslationindustry.Foranother,it’sstillalongwaytogoforthosewhohavedecidedtofollowtranslationastheirfuturecareer.Ancapabletranslatorshouldpossessexquisitelanguagecapabilityandhaveabroadrangeofgeneralknowledgeaswell.Duringthetranslation,thetranslatorhasenrichedhertheoreticalknowledgeandpracticecompetence.Moreover,shehaslearnedaboutthelatestfactsandconclusionsaboutAIDSpandemic,whichbroadenshervision.Havinghadamoreaccurateunderstandingofthesourcetext,thetranslatorhasdoneherbesttodeliveritsfullmessageandvaluetothetargetreaders.5.2ProblemstoBeSolvedUponthecompletionofthistranslationproject,thetranslatorhasgaineda16 profoundunderstandingofpracticaltranslationdifficultiesduringtranslationpractice.Althoughthetranslatorhasacquiredsometechniquestohandlethetranslationoflonganddifficultsentences,therearestillotherproblemsthatmeritsreflecting.Asapopularsciencework,thesourcetextisinterspersedwithabbreviations.Andthetranslatorcanbynomeansavoidtheminthetranslationprocess.Forinstance,“MSM,IDU,FSW,SSA”,theexactmeaningofwhichiscrucialforthereaderstounderstandthewholeconceptionofmajordeterminantsofhighHIVprevalence,sothetranslatorcannotsimplyleavethemuntouchedinthesourcetext.However,someabbreviationscanbeuseinmanysituation.Duringthetranslationprocess,translatorneedstochoosetherightmeaningwhichcanconveyitsoriginalwords.Forexample,FSWreferstoFederalSkilledWorkersandFemaleSexWorkers,andSSAreferstoSocialSecurityAdministration,SocietyofScottishArtists,andSub-SaharanAfrica.Asthesourcetextisapopularsciencework,metaphorisappliedtomakethecontentmorevividandeasiertounderstand.Forexample,“gloriousmyths”referstomisunderstandingandmisconceptionofAIDSpandemic.Is“广为流传的误解”appropriateinthetargettext?And“bridgestonowhere”meansthosewhohavealreadyinfectedHIV(bridges)can’tpassthediseasetoothers(tonowhere).Is“哪儿也不到的纽带”preciseorbriefenough?Thetranslatormusttakespecialcareofabbreviationsandmetaphorsinthesourcetext,domoretranslationpracticeandhopetohandlethemmoreproperlyinthenearfuture.17 ReferenceHeim,M.H.andTymowski,A.W.GuidelinesfortheTranslationofSocialScienceTexts.NewYork:AmericanCouncilofLearnedSocieties,2006.Jakobson,R.(1959/2004).OnLinguisticAspectsofTranslation.L.Venuti(ed).PP138-43.Lefevere,A.(1992a)Translation,RewritingandtheManipulationofLiteraryFame.LondonandNewYork:Routledge.Munday,J.(2008).IntroducingTranslationStudies:TheoriesandApplication,2ndversion.LondonandNewYork:Routledge.Nida,E.A.andTaber,C.R.TheTheoryandPracticeofTranslation.Shanghai：ShanghaiForeignLanguageEducationPress,2004.Nord,C.(2005).TextAnalysisinTranslation:Theory,MethodologyandDidacticApplicationofaModelforTranslation-orientedTextAnalysis.Amsterdam:Rodppi.Nord,C.(1997).TranslationasaPurposefulActivityaFunctionalistApproachesExplained.Manchester:StJerome.Reiss,K.(1977).EnglishTranslationasTextTypes,TranslationTypesandTranslationAssessment.Chesterman,112.Vermeer,H.J.(1987).WhatDoesItMeantoTranslate?.IndianJournalofAppliedLinguistics,13(2),29.Wilss,W.TheScienceofTranslation:ProblemsandMethods.Shanghai:Shanghai18 LanguageEducationPress,2001.林本椿.(2004).英汉互译教程.上海:上海百家出版社.李长栓.(2004).非文学翻译理论与实践.北京:中国对外翻译出版公司.冯庆华.(2002).实用翻译教程.上海：上海外国语教育出版社.刘宓庆.(2006).新编汉英对比翻译.北京：中国对外翻译出版社.马会娟.(2003).奈达翻译理论研究.北京：外语教学与研究出版社.19 AppendixISourcetextTheAIDSPandemic:TheCollisionofEpidemiologywithPoliticalCorrectness(Chapter9)AsdescribedinChapters3and4,mostofthefarout,"flat-earth"typetheoriesoftheoriginofAIDSandwhatAIDSisandisn't,weredismissedbymainstreamscienceandpublichealthbythemid-1980s.However,several"glorious"mythsand/ormisconceptionsaboutHIVepidemiologycontinuetobeacceptedandusedbyUNAIDSandothermainstreamAIDSagenciesandactivists.ThesemythsareneededtosupporttheUNAIDSparadigmthatwithoutaggressiveHIV/AIDSpreventionprograms-especiallydirectedtoyouth-itisjustamatteroftimebeforeheterosexualHIVepidemicseruptincurrentlowHIVprevalencepopulations.ThestudiesandobservationsdescribedinChapter5onHIVepidemiologyandtransmissiondynamicsandtheglobalHIV/AIDSpatternsandprevalencedescribedinChapter7haveledmetofardifferentconclusionsaboutthepotentialforepidemicHIVtransmissioninmostheterosexualpopulations.Myconclusionsare:1HIVprevalencecanriseonlytothoselevelspermittedbytheprevailingpatternsandprevalenceofHIVriskbehaviorsandtheprevalenceoffacilitatingandprotectivefactorsand2inmostheterosexualpopulations,thepatternsandfrequencyofsexpartnerexchangerarenotsufficienttosustainepidemicsexualHIVtransmission.UNAIDSandmostAIDSactivistsbelievethattheseconclusions,especiallymysecondconclusion,arenotsociallyandpoliticallycorrectandwillleadtocomplacencybythepublicandpolicymakersregardingthepotentialcourseandseverityoftheAIDSpandemic.UNAIDS,othermainstreamAIDSagencies,andmanysocialactivistsbelieve-withoutepidemiologicsupport-thatthemajordeterminantsofhighHIVinfectionratesarepoverty,discriminationandlackofaccesstohealthcare.Withoutaggressivepreventionprogramsdirectedtothegeneralpublic,especiallyyouth,theybelievethatitisonlyamatteroftimebeforeheterosexualHIVepidemicseruptinalmostalldevelopingcountrieswhereHIVinfectionrates20 arecurrentlylow.SomemainstreamAIDS"experts"assertthatthereareinsufficientdatatosupportmyconclusionsorparadigm.MyresponseisthattherearenodatatosupporttheirconcernthatHIVcanandwillspreadintogeneralpopulationsor"ordinary"peopleifaggressivepreventionprogramsdirectedtothegeneralpublic,especiallyyouth,arenotimplemented.Inthischapter,IwillprovidemyevaluationofthegloriousmythsandmisconceptionsaboutHIVepidemiologyandtransmissiondynamicsusedtosupportandperpetuatetheprevailingUNAIDSparadigm.IwillalsodescribewhenandwhyIbegantoswimupstreamagainsttheorthodoxbeliefsofmainstreamAIDSagencies,butfirstitwouldbehelpfultoreviewwhatIunderstandtobethemajordeterminantsofepidemicHIVtransmission.MajorDeterminantsofEpidemicHIVTransmissionIneedtostressthatmyunderstandingofHIVtransmissiondynamicsisnotverydifferentfrommostmainstreamepidemiologists’TheprobleminacceptingmyconclusionsandparadigmisthatmostAIDSactivistsdonotwanttoacknowledgethatepidemicHIVtransmissionrequiresthehighestriskpatternsandprevalenceofHIVriskbehaviors.Theseactivistsdonotwanttofurtherstigmatizepersonsorpopulationgroups(MSM,IDU,FSW,etc.)whohavesuchhighlevelsofHIVriskbehaviorsandwhoarealreadymarginalized.Firstandforemost,wehavetobeawarethat,asdescribedinChapter5,allpublishedsexpartnerstudiesshowtheriskofHIVtransmissionfromanysinglecoitalactisverylow-about1per1000orless.Bycontrast,apandemicinfluenzaviruswouldbecapableofgeneralizedspreadinanypopulationbecausevirtuallyallinfants,children,andadults,youngoroldwouldbeatmoderatetohighriskofinfectiontosuchanagent.However,HIVtransmissionrequirestheexchangeofasignificantamountofbloodorsexualfluids.Thus,onlyasmallpercentofmostgeneralpopulationsor"ordinary"personswouldbeatmoderatetohighriskofexposuretoandinfectionwithHIV.ThereisnoquestionamonginfectiousdiseaseepidemiologiststhattheprimarydeterminantsofepidemicHIVtransmissionareriskbehaviorsthatincludehavingunprotectedsexwithmultipleandconcurrentsexpartnersand/orroutinelysharingdruginjectingequipmentwithotherIDU.EpidemicHIVtransmissionhasbeendocumentedonlywherethehighestlevelsofsuchriskbehaviorsarepresent.Thus,itisonlylogicaltoconcludethatintheabsenceofhighHIVriskbehaviors,epidemictransmissionwillnotoccur.Whathasbeenessentiallyignoredisthemoreimportantandrelevantquestion:whatarethemajordeterminantsofHIVriskbehaviors?21 MostsocialactivistsdonothesitatetosaythatpovertyanddiscriminationaretherootcausesofHIVriskbehaviors.However,Idon'tknowofaclearandsimpleanswertothisquestion,sinceIconsideritmorelikelythatcultural,social,religious,andmanyotherfactors,includingeconomicfactors,allcollectivelyplaysomeroleasdeterminantsofsexualandIDUriskbehaviors.BecausethereisnoclearanswertowhatarethemajordeterminantsofHIVriskbehaviors,manyworthysocialagendashavebeenhitchedontotheAIDSprogramwagon.Thesesocialissues,suchaspoverty,discrimination,genderinequity,andlackofaccesstohealthcare,aremajorproblemsthatclearlyhindereffectiveHIVpreventionandtreatmentprograms,buttheyarenotthemajordeterminantsofepidemicHIVtransmission!GloriousMythsorMisconceptionsofHIVTransmissionDynamicsBelowarewhatIconsidertobethemajormythsormisconceptionsaboutHIVepidemiologyandtransmissiondynamicsthatcontinuetobeusedbyUNAIDSandmainstreamAIDSagenciestosupporttheprevailingsociallyandpoliticallycorrect,butepidemiologicallyincorrect,UNAIDSparadigm:intheabsenceofaggressivepreventionprogramsdirectedtothegeneralpopulation,especiallyyouth,itisonlyamatteroftimebeforeepidemicheterosexualHIVtransmissionwillbreakoutinpopulationswhereHIVprevalenceislow.•VirtuallyeveryoneisatalmostequalriskofinfectionwithHIVTheoriginofthisgloriousmythderivesfromtheinitialshortdoublingtimesforreportedAIDScasesintheearly1980sthatledtothefalseconclusionthatAIDSwascausedbyahighlyinfectiousagent.ObservationsthatHIVriskbehaviors(sexualpromiscuityinhomosexualandheterosexualpopulationsandroutinesharingofinjectingdrugequipment)arepresentinvirtuallyallcountriesthroughouttheworldalsoledtothebeliefthatHIVepidemicswouldeventuallyoccurinallpopulations.However,itdoesnotfollowlogicallythatthepotentialforextensiveHIVepidemicsinMSM,IDU,FSWandtheirclientsisequallypresentinallpopulationsandcountries.Further,itissimplynotpossibleforHIVtojumpintoany"general"populationfromthesehighriskgroupstospreadinepidemicfashionin"ordinary"people.TherearenocredibleSTDexpertswhoareconcernedthatsyphiliswhichiscausedbyabacterialagentthatishundredsoftimesmoreinfectiouspercoitalcontactthanHIV-hasthepotentialtosweepthroughgeneralpopulations"likeahotknifethroughcoldbutter!"ThemajorcharacteristicofHIVasaninfectiousdiseaseagentisthatitsriskoftransmission22 is,intheabsenceoffacilitatingfactors,verylowforanysinglesexencounter.ThischaracteristicofHIVisnotsomethingthatAIDSprogramsoragenciesusuallyincludeintheireducationalmessagesaboutHIVtransmission.BothJonMannandMikeMersonspecificallyinstructedmenottodistributeatableIhadpreparedontheriskofHIVtransmissionbytypeofexposuresincethistableindicatedthat,intheabsenceoffacilitatingfactors,theriskofHIVtransmissionpersinglecoitalactwasabout1per1000orlower.Theywerebothawarethatmytablewasaccurate,butbothbelievedthatdistributingthisinformationtothepublicwouldbesendingthepublicamixedmessageabouttheriskofHIVtransmissionviaunprotectedsexualintercourse.AsidefromthelowinfectivityofHIV,thepatternandprevalenceofHIVriskbehaviorsdiffermarkedlyfromcountrytocountry.AsdescribedindetailinChapter5,theWHOsurveysofsexualknowledge,attitudes,behaviors,andpractices(KABP)carriedoutinthelate1980sfoundthat:1thepatternofsexpartnerexchangeinSSApopulationsismainlyonaconcurrentbasiswhereasinmostdevelopedcountries,sexpartnerexchangeismainlyserial,notconcurrentand2arelativelylargepercent(upto40percent)offemalesinsomeSSAcountrieshavesexoutsideofmarriage,whereaslessthan1to2percentofAsianfemalesreportsuchbehavior.Thesefindings,aswellastheobservationthattheprevalenceofmultiplefacilitatingfactors,thatcangreatlyincreasetheriskofsexualHIVtransmission,aremorethan10timeshigherinSSApopulationscomparedwithmostotherpopulations,helpexplainwhyepidemicheterosexualHIVtransmissionhasoccurredinmostSSAcountriesbutnotinmostotherpopulations.InthefewAsiancountrieswhereepidemicheterosexualHIVtransmissionhasbeendocumentedinFSWandtheirclients,thiscanbeattributedtothelargecommercialsexnetworksthatwerepresent.UNAIDSandmostAIDSactivistshaveeitherintentionallyoroutofhonestignoranceignoredthefactthatHIVisverydifficulttotransmitsexually.ByrefusingtoacceptthefactthatHIVisverydifficulttotransmitsexuallywithoutthehighestlevelsofsexualriskbehaviors,AIDSprogramshaveavoidedlabelingsomepopulationsasbeingmorepromiscuousthanothers.ItisamuchmoresociallyandpoliticallycorrectpublichealthmessagetosaythatsexualpromiscuityexistsinallpopulationsandthustheriskofepidemicheterosexualHIVtransmissiontothe"general"public,orto"ordinary"peoplecanbepreventedonlybyaggressiveABCprograms23 directedatthegeneralpopulation,andespeciallytoyouth.AparallelpandemicofAIDS"experts,"mostwithoutanyepidemiologictraining,haveusedavarietyofepidemicmodelstoprojectlargeheterosexualepidemicsincountrieswhereHIVprevalenceratesinthegeneralpopulationarestillverylow.These"experts"soundalarmsthatthe"nextwaves"ofHIVepidemicsareimminent,orHIVis"onthebrink"ofjumpingintothegeneralpopulationfromexistingfociinMSMandIDUpopulations.The"nextwaves"ofHIVepidemicspredictedforthegeneralheterosexualpopulationsindevelopedcountriesduringthe1980shavenevermaterialized.MostoftheseAIDS"experts"havegivenupsoundingalarmsaboutheterosexualHIVepidemicsindevelopedcountriesandhaveturnedtheirattentiontolargepopulouscountriesinAsia.ForcountriessuchasIndiaandChinatheyprojectsevereheterosexualHIVepidemics,ifanysexoutsideofmaritalsexispermittedtooccur,andeducationofthegeneralpublic,especiallyyouth,onhowHIVistransmitted,arenotaggressivelyimplemented.•HIV"bridge"populationswillinvariablyigniteheterosexualHIVepidemicsAnothermajormisconceptionaboutHIVtransmissiondynamicsisthatinfectedbisexualmalesorinfectedIDU(maleorfemale)serveasthe"bridge"populationforHIVentryintothegeneralheterosexualpopulation.Whathasbeenvirtuallyignoredoverthepasttwodecadesisthatsuch"bridging"hasandcontinuestooccurfromwhatisdescribedinChapter5asnonepidemictransmissionbetweenHIV-discordantcouples,i.e.,HIVtransmissionfromaninfectedperson(regardlessofhowinfectionwasacquired)tohis/herregularsexpartnerorpartners.ThisiscurrentlythepredominantmodeofHIVtransmissionthroughouttheworld,buttheseareusually"bridgestonowhere."ThisisbecauseepidemicheterosexualHIVtransmissionhasnotandcannotoccurinanypopulationwithoutthepresenceofaveryhighriskpatternandfrequencyofsexpartnerexchange.Intheabsenceoftheselatterfactorstherewillnotbesignificantspreadwithinthegeneralpopulation.ThisisexactlywhathashappenedfollowingthehundredsofHIVepidemicsthathavebeendocumentedinMSMandIDUpopulationsthroughouttheworldsincetheearly1980s.ThisalsohappenedwiththemanyHIV-infectedpersonswhotraveledoutofAfricaduringthe1960sand1970s:therewereprobablyhundredsorthousandsofsuch"sparks"thatintroducedHIVintomanypopulationsbuttheydidnotstartsignificantepidemicspreaduntilsucha"spark"wasintroducedintoagaybathhouseoranIDU"shootinggallery."ItshouldbenotedthatinSSA,whereheterosexualHIVtransmissionhasbeensoextensive,24 themajorityof"general"populations,eveninSSAcountrieswiththehighestHIVprevalencerates,areatlowtonoriskofacquiringHIVviasexualintercoursebecausetheyaremonogamousorfaithfultotheirspouses.TheseaspectsofHIVtransmissiondynamicswerenotfullyunderstoodduringthelate1980sandearly1990s.IntheUSAandinmostdevelopedcountries,whereexplosiveHIVepidemicsinMSMandIDUpopulationsoccurredduringtheearly1980s,theanticipated"nextwave"ofHIVepidemicsdidnotmaterializeinany"general"heterosexualpopulation.MichaelFumentoaccuratelyandingreatdetaildocumentedthissituationinhisbookTheMythofHeterosexualAIDS.However,healsoseriouslyquestionedthelargeandwelldocumentedheterosexualHIVepidemicsinSSAandThailandduringthissametimeperiod.MainstreamscienceandpublichealthdidnotquestiontheselargeheterosexualHIVepidemicsbutduringthistimeperiodwereatalosstoexplainwhyepidemicheterosexualHIVtransmissionwassorampantinSSAandtoalesserextentinafewpopulationsintheCaribbeanandAsiaandalmostnonexistentindevelopedcountriesandmostdevelopingcountries.Someoftheinitialtheorieswerethat:analintercoursewasmoreprevalentinAfricanandAsianpopulationsthanwasthenbelievedand/orthatpovertywasamajordeterminantofhighHIVprevalence.ThesemythsormisconceptionsaboutheterosexualHIVtransmissioncontinuetohavestaunchsupporters.Therehasandcontinuestobesomesortoffixationaboutanalintercoursethatisalsonotwarranted.ThereisnothingexceptionalormysteriousaboutanalintercoursecomparedwithvaginalintercoursewithregardtotheriskofHIVtransmission.Analintercourseresultsinahigherrisksimplybecauseofthegreaterlikelihoodoftissuetraumaandthusmorelesionsinthefragilerectalepitheliumcomparedtovaginalepithelium.However,therearemultiplefacilitatingfactorsthatcanincreasetheamountofbloodorsexualfluidsthatmaybeexchangedduringvaginalintercourseandasdescribedinChapter5,thesefacilitatingfactorsarehighlyprevalentinSSApopulationscomparedtomostotherpopulations.•AllhighHIVriskbehaviorswillresultinHIVepidemicsUntilthemid-1990s,itwasnotfullyrealizedthattherearemajordifferencesinthepatternandsizeofcommercialsexnetworks.Itwasbelieved,almostasamatteroffaith,thatonceHIVwasintroducedintoanycommercialsexnetwork,epidemicHIVtransmissionwouldinevitablyensue.Idon'twanttominimizethepublichealthriskthatepidemicHIVtransmissioncanoccurin25 virtuallyallcommercialsexnetworks,butitshouldberealizedthatthisriskcanrangefromverylowtoveryhigh.Fortunately,theriskhasbeenverylowinthosenetworkswherepartnerexchangeratesarenotthehighest.AIDSdenialistssuchasDuesbergandhisfollowers,whobelievethatsexualtransmissionofHIVisamyth,pointtothemanystudiesoffemaleprostitutesindevelopedcountriesandinmanydevelopingcountriesthatshoweithernoHIVinfectionsoronlyafewtosupporttheirtheories.CalculationoftheannualprobabilityofaFSWacquiringanHIVinfectioninalowHIVprevalencecountryindicatesthatlargeannualincreasesinHIVincidenceandprevalencecannotbeexpected(seeAppendix1toChapter5).Accordingtothesecalculations,iftherewereseveralhundredthousandFSWinthePhilippines,lessthan100mightacquireanHIVinfectioneachyearbecauseofsexwork.TheseinfectedFSWcanbeexpectedtoinfectseveralmaleclientsduringanarbitraryworkspanof10yearsasaFSW.However,thesenumberswillbelargelyoffsetbythehundredsofAIDSdeathsthatcanbeexpectedannuallyfromthethousandsofprevalentinfectionsinthisverylowHIVprevalencecountry.Sincetheearly1990s,sentinelsurveillanceinthePhilippineshasconsistentlyfoundannualHIVprevalenceinregisteredFSWtobeabout1per1000.Thislowprevalencecanbeattributedtoseveralfactors:1averylowHIVprevalenceinmaleclientsofFSW-lessthan1per10002mostmalesinthePhilippinesarecircumcisedatabouttheageofpuberty3mostFSWaveragelessthanoneclientadayand4reportedcondomusewithFSWinthePhilippinesismorethan50percent.IncountrieswhereexplosiveHIVepidemicshaveoccurredinIDUpopulations,amajorpublichealthconcernisthatsomeHIV-infectedfemaleIDUwillbecomeaFSWinordertosupporttheirdruguse.SuchanincreaseinHIV-infectedFSWhasbeenfoundinalmostallHIVepidemicsinIDUpopulations.TheseFSWcantransmitinfectiontosomeoftheirclients,butasdescribedabovesuchincreasedtransmissioninlowHIVprevalencecountriesdoesnotleadtoverylargeincreasesinannualnationalHIVincidenceandprevalence.ThefactorsneededforsustainedepidemicheterosexualHIVtransmissioninclude:1largeopenoroverlappingsexnetworks2highnumbersofdailysexpartnerexchanges3alowpercentageofmalecircumcision26 4lowcondomusageratesand5ahighprevalenceofmultiplefacilitatingfactors.Thus,theprobabilityofepidemicheterosexualHIVtransmissioninalowHIVprevalencecountrylikethePhilippines,eveninthehighestriskpopulation(FSWandtheirclients),islow.ThehighestpublichealthpriorityinlowHIVprevalencepopulationsistoassurethatHIVprevalenceinpersonswiththehighestlevelsofheterosexualriskbehaviors(FSWandtheirmaleclients)remainaslowaspossible.ThiscanbeaccomplishedbycontinuouspreachingofAbstinenceandBefaithful,butmostlikely,forpersonswiththesesexualriskbehaviors,promotionofC(consistentcondomuse)forallcommercialsexwillbethemoreeffectivemeasureforkeepingHIVprevalencelowinsuchpopulations.AggressiveimplementationofallABCmeasuresinthegeneralpopulationwithafocusonyouthisepidemiologicallynotessentialandwillhavelittleimpactonpotentialHIVtransmissioninFSWandtheirmaleclients.Inanycountry,somepocketsofveryhighsexpartnerexchangeratesexistandtheyinclude:borderareaswithextensivepopulationmovement;extensivemigrationand/ortravelawayfromstablesocialenvironmentssuchasfromruraltourbanareasforemployment;seasonalworkers;migrantworkers;military,sailors/merchantseamen;longdistancetruckdrivers;largedevelopmentorconstructionprojects;etc.PrimaryHIVpreventionprogramsneedtobetargetedtothesevulnerablepopulationswherevertheymaybe,regardlessofwhetherthepotentialforepidemicheterosexualHIVtransmissionisconsideredloworhigh.•Poverty,discrimination,andlackofaccesstohealthcarearemajordeterminantsofhighHIVprevalenceThislitanyusedbyUNAIDSandmostAIDSprogramsincludesmostofthesociallyandpoliticallycorrectmythsaboutmajordeterminantsofHIVtransmission,butthereisnoepidemiologicsupportforthesemythsandmisconceptions.PovertyisasociallyandpoliticallyattractivehypothesistoaccountforhighHIVprevalence,butavailabledatasuggesttheopposite.AsdescribedinChapter5,personsinthetop20percentforincomeinKenyaandTanzaniahaveHIVinfectionrates2to3timeshighercomparedtopersonsinthelowest20percent-probablybecausethewealthiestpersons,bothmalesandfemales,haveagreaternumberofsexpartners.SomeoftherichestcountriesinSSAhavethehighestHIVprevalenceratesandmostofthepoorestcountriesintheworldhavethelowestrates.PovertyasamajordeterminantofHIV27 transmissionisagloriousmyththatisnoteasilydispelledeventhoughtherearenoepidemiologicdatatosupportthismyth.Ihavechallengedallstudentswhohavetakenmyclasssincethenewmillenniumtoprovidemewithdatatosupportthismythandtheyhaveyettocomeupwithany.In1987,JonMannappropriatelydeclaredthatthequestforeffectivetreatmentandapossiblecureforAIDSwasaninherentbasichumanrightofallpersonslivingwithHIV.However,hewentontosay:"...Beingexcludedfromthemainstreamofsociety,orbeingdiscriminatedagainstongroundsofrace/ethnicity,nationalorigin,religion,gender,orsexualpreference,led[leads]toanincreaseofHIVinfection."Frommyperspective,discriminationclearlyraisesbarrierstoHIV/AIDSpreventionandtreatmentprograms,butdiscriminationisnotadeterminantofHIVriskbehaviorsand,thus,notadeterminantofepidemicHIVtransmission.ThisgloriousmythwasquicklyanduncriticallyacceptedbyAIDSactivists,andisthecenterpieceofUNAIDS'litanythatpoverty,discrimination,andlackofaccesstohealthcarearemajordeterminantsofhighHIVprevalence.Personally,Iam100pluspercentagainstpoverty,discrimination,andlackofaccesstohealthcare,butIalsobelievethatevenif"we"wereabletoeliminatethesesocialandpublichealthproblems,wewouldnotmakemuchofanimpactonthehighHIVprevalenceratesthatarepresentinMSM,IDUandmanySSApopulations.•HIVprevalenceisincreasingtorecordhighs.In2005thereweremorethan40millionpersonslivingwithHIVandtherewere5millionnewHIVinfectionsTheseHIV/AIDSnumbersaremuchtoohigh:theycannotbesupportedbytheavailabledataorbyrecentHIVprevalencetrendsreportedbyUNAIDSformostglobalregions.AlsoasdescribedindetailinChapter7,IbelievethatvirtuallyalloftheUNAIDSestimatesin2001and2003wereoverestimated,especiallyforSSAandAsia.Inmid-2006,UNAIDSsignificantlyreducedmanyHIVprevalenceestimatesinSSAandtheCaribbeantomorerealisticlevels.However,IbelievethattheywillneedtoreducetheirloweredestimateforHaitievenmorewhenthepopulation-basedHIVserosurveys(DHS+)arecompletedinHaitisometimein2006.SimilarreductionswillalsoneedtobemadeforEasternEuropeandCentralAsia(RussiaandUkraine),SouthandSEAsia(India),andEastAsiaandthePacific(China).Ihaven'tseenanyregionalestimatethatIconsidertobeanunderestimateandI'mconvincedthatevenwiththereductionsmadeinthemid-2006report,UNAIDSwillbeforcedtorevisemostoftheirregionalestimatesfurtherdownwardsintheirnextglobalreportontheAIDSpandemic.Globalestimatesthatare28 moreconsistentwithcurrentdataandprevalencetrendsareabout30millionpersons(15-49)livingwithHIVandcloserto3millionannualnewadultHIVinfections.ContinualdenialbyUNAIDSoftherealityoflowerHIVprevalencenumbersandcontinualalarmsaboutHIVbeing"onthebrink"ofjumpingintogeneralpopulationswilleventuallyleadtoabacklashagainstAIDSprogramsforcontinuallycryingwolfwhenthereisnoepidemiologicbasisforsuchalarms.UNAIDSconsidersitselfprimarilyanadvocacyagency.Thus,itdoesnotapproachtheestimationofHIV/AIDSstatisticsasanobjectivetechnicalorscientificagency.IrecallanexchangeIhadwiththeMinisterofHealthinthePhilippinesintheearly1990swhenIcautionedhimabouttheveryhighestimatehemadebymultiplyingthe50reportedHIV/AIDScasesbyafactorofathousandtoarriveatanationalprevalenceestimateof50000.Hetoldme:"...accuracyisnotneededforadvocacy!"ThisunfortunatelyishowUNAIDScontinuestoapproachtheestimationofHIV/AIDSincidenceandprevalence.Withoutallthe"doomandgloom"HIVscenariosandwithoutthealarmingnewsreleasesthatwarnaboutconstantlyincreasingHIVinfections,AIDSactivistsfearthatthepublicandpolicymakerswillnotcontinuetogiveAIDSprogramsthehighprioritythatithasreceiveduptonow.AIDSactivistsareconcernedthatthepublicandpolicymakerswillbecomecomplacentaboutthepotentialriskofHIVtothegeneralpopulationandwillreducesupporttoAIDSprogramsifmostregionalHIVratesare"stable"ordecreasingandHIVremainsconcentratedinMSM,IDU,FSWandtheirclients,andinmostSSApopulations.Thisisarealisticconcern,butasdescribedattheendofChapter7:1globalandregionalHIVrateshaveremainedstableorhavebeendecreasingduringthepastdecade2HIVhasindeedcontinuedtobeconcentratedinpopulationswiththehighestlevelsofHIVriskbehaviorsand3HIVisincapableofepidemicspreadinthevastmajorityofheterosexualpopulations.DenialoftheserealitieswillleadtofurthererosionofwhatevercredibilityUNAIDSandothermainstreamAIDSagenciesmaystillhave.SwimmingUpstreamAgainstMainstreamAIDSAgenciesAssomeonewhowasinthevanguardofmainstreammedicalscienceandpublichealthunderstandingabouttheHIV/AIDSpandemicuntilmyresignationfromGPA/WHOinearly1992,29 IfullyunderstandandamsympathetictothebeliefsandpositionsthatAIDSactivistshavetakenandcontinuetodefend.Isharethesameobjectivesasmymainstreamcolleagues;effectivepreventionandcontrolofHIV/AIDS;andtheprovisionofeffectiveARTforallHIV-infectedpersons.However,overthepastdecade,IhavecometobelievethatAIDSprograms,especiallythosedevelopedandsupportedbyinternationalagenciesandfaith-basedorganizationshavebeenpoliticallycorrectandmorallymotivatedbutepidemiologicallyincorrect.WhenAIDSwasfirstrecognizedinCaliforniain1981,Ihadalreadyworkedasapublichealthepidemiologistingeneralcommunicablediseasecontrolforclosetotwodecades.IwasrapidlytotallyimmersedinthestudyofAIDS.InadditiontomyevaluationofallstudiesandreportsofHIV/AIDSinCaliforniaastheStateEpidemiologistresponsibleforinfectiousdiseasecontrol,IservedonaNationalAcademyofScience/InstituteofMedicine(NAS/IOM)committeein1986thatpreparedanationalreportonAIDS.Duringthe6-monthworkperiodofthiscommittee,Iwasabletohelpreviewandevaluateallofthenationalandinternationalepidemiologic,clinical,andlaboratorystudiesonHIV/AIDSthatweremadeavailabletothiscommittee.Thus,whenItookearlyretirementfromtheCaliforniaHealthDepartmentin1987tojoinJonMannatWHOinGeneva,IhadbeeninvolvedalmostfulltimeinthestudyofHIVepidemiologyforabout6years.Inretrospect,alloftheinitialHIVprevalenceestimatesthatIwaspersonallyinvolvedwithweregrossoverestimates.IwasamemberofasmallgroupofepidemiologistswhomadethefirstnationalHIVprevalenceestimatefortheUSAduringthe1986CoolfontConferenceinWestVirginia.Basedonthelimiteddataavailabletoourgroupweestimatedthattherewerefrom1to1.5millionHIVinfectedpersonsintheUSA.ThefirstHIVestimationmeetingthatIorganizedafterJonanointedmetoheadtheSurveillance,Forecasting,andImpactAssessment(SFI)unitatGPAwasheldinStrbskePleso,Slovakiainearly1988.InreviewingtheHIVprevalenceestimatesmadeduringthismeeting,Inowrealizethatmostoftheseestimateswerealsogrossoverestimates:theUKestimatewas40000andthisestimatewaslaterreducedbyalmosthalf;theinitialworkingestimateforFrancewas200000andthisestimatewasalsoreducedbymorethanhalfaftermoredatabecameavailable.In1986,JonMannestimatedthattherewerefrom5to10millionHIV-infectedpersonsworldwide;thiswasthe"official"globalestimateIinheritedwhenIwasappointedChiefofSFL30 DuringtheFourthInternationalAIDSConferenceinStockholminmid-1988,BobBiggers,aCDC(Atlanta)epidemiologistwhowasworkinginAfrica,confrontedmeinahallwayandchallengedtheWHOglobalestimateof5-10million.IhadbeencollectingandreviewingallavailableHIVdatafromWHOmembercountriesandhadtoagreewithBobthattheestimateof5-10millionwastoohigh.IbroughtthissituationtoJon'sattentionandrecommendedthatWHOrevisetheglobalestimatetoabout5millionsincemyestimatebasedonthedataIhadreviewedcouldreasonablyonlysupportanestimatethatwaslessthan5million.Ievendraftedastatementforhisconsiderationforrelease:WHOin1986,basedonthelimitedHIVdataavailable,estimatedglobalHIVprevalencetobe5to10million.However,asofmid-1988,withadditionalHIVdata,thebestestimateofglobalHIVprevalenceisclosertothelowerrangeofabout5million.JondecidednottoissuethisstatementbecausehefeltsurethatattheapparentrateofincreaseinHIVprevalenceinSSAnotedinthemostrecentHIVdatasets,thatwithinayearortwoatmost,globalHIVprevalencewouldbewellwithinthe5-10millionrange.Jonprovedtoberightonthemarkandbytheearly1990s,globalHIVprevalenceincreasedtowellwithinthe5-10millionrange.AsIgraduallyrecognizedthattheHIVestimatesdescribedaboveweregrossoverestimates,IresolvedthatanyestimateIwouldberesponsibleforwouldbeconservative,andfurther,IwouldnotreleaseanestimatethatIcouldnotdefendwiththeavailabledata.AftermyresignationfromWHOinearly1992,ImaintainedcontactwithmyformerstaffatSFIandwaspleasedthatHIVprevalenceestimatespreparedbySFIuptothemid-1990scontinuedtobeconservativeanddefendable.Iwas,however,concernedabouttheurban/ruralHIVdifferentialinSSA.Thus,IurgedWHOandsubsequentlyUNAIDSstafftodevotemoreefforttomeasurethisdifferentialsincethemajorityofpopulationsinSSAlivedinruralareas.Thisfactorhasturnedouttobethemajorreasonforthe50percentormoreoverestimateofHIVprevalenceinmostSSAandCaribbeancountries.MostAIDSactivistsweregreatlydisturbedbyanydownwardrevisionofofficialHIVprevalenceestimates:theyperceivedsuchrevisionsasadeliberateploybypublichealthprogramstominimizetheseverityofHIV/AIDSepidemics.TherewasandcontinuestobegreatdistrustofofficialHIVprevalenceestimatesbymostAIDSactivists.Duringthelate1980sandearly1990s,highandconstantlyincreasingHIV/AIDSestimateswereaccepteduncriticallyandassumedtobe31 theunchangingtrendofallHIV/AIDSepidemicsbyAIDSprogramadvocatesandactivists.AnyloweringofanestimateoranyprojectionthatHIVorAIDSmightbepeakingordecreasingwasconsideredtobedangeroustoHIV/AIDSprograms.Itwasthoughtsuchprojectionswouldleadtocomplacencyinimplementingpreventionandcontrolmeasures.Thus,whenIpredictedin1991that"...indevelopedcountriesannualAIDScaseswereprojectedtoreachapeakbeforethemiddleofthedecade...,"IincurredthedispleasureofSirDonaldAcheson,theChiefMedicalOfficerintheUK.Heapparentlywasintheaudienceformylectureandheimmediatelydispatchedoneofhisbestandbrightestmedicalofficers,Dr.AnneJohnson,averyastutemedicalepidemiologist,todetermineifmyprojectionofAIDScasespeakingindevelopedcountriesbefore1995couldberefuted.AnneJohnsonandIhadaverycordialandcollegialdiscussionregardingmyprediction.AsanexperiencedSTD/HIVepidemiologist,shewasawarethatHIVincidenceratespeakedintheUSAandtheUKbeforethemid-1980s.AnyonewhoknewthemedianprogressionintervalfromHIVinfectiontothedevelopmentofAIDSwasestimatedtobefrom8to10yearsdidnotrequireanycomplexmathematicalmodeltopredictthatAIDScaseswouldpeakinthesecountriesbeforethemid1990s.Apparently,AnneJohnsonwasabletoadequatelyexplaintheepidemiologicbasisofmypredictiontoSirDonaldsinceIdidnothearanymoreaboutthis.IhadthoughtmyprojectionregardingthenaturaldeclineinAIDScasesthatcouldbeexpectedbasedonthenaturalhistoryofHIVinfectionsandonHIVincidenceandprevalencetrendswouldbewelcomedas"good"news,ratherthan"bad"news.32 AppendixⅡ中文译文《艾滋病的蔓延：流行病学碰撞政治正确性性》（第九章）正如前面第三、四章所描述的那样，上世纪八十年代中期，关于艾滋病起源和定义的“地平说”理论不切实际、脱离现实，被主流媒体和公共卫生摒弃。然而，联合国艾滋病预防规划署和其他主流艾滋病机构、宣传人员却一如既往接受和采用一些艾滋流行病学广为流传的误解和错误观念。联合国艾滋病预防计划署的宣传范式是：要是不采取积极的艾滋病预防计划，尤其是针对青少年的预防，那么在原本艾滋病感染率低的异性恋人群中，疫情的爆发只是时间问题。而广为流传的误解恰恰支持了这一说法。通过第五章中描述的艾滋病毒病原学和传染病动力学的观察和研究，以及第七章描述的全球艾滋病毒/艾滋病模式和流行，我对艾滋病疫情在大部分异性人群中的潜在蔓延危机得出了完全不同的结论。我的结论如下：1.艾滋病毒能流行到什么程度，全由流行途径、高危感染行为的普遍与否、促进疫情蔓延的因素和阻止疫情蔓延的因素决定。2.在大部分异性人群中，性伴侣交换者的模式、频率都不足以维持艾滋病毒通过性传播。联合国艾滋病预防规划署和大部分艾滋病宣传人员都认为这些理论，特别是第二条，在社会层面和政治层面都不正确。它们会导致大众和决策者轻视艾滋疫情的严重性和其潜在威胁。联合国艾滋病预防规划署，其他主流艾滋病机构，和众多社会活动者都认为，艾滋病毒高感染率的主要决定因素是贫困、歧视、和医疗卫生的欠缺。而这一看法并得不到流行病学的理论支持。他们还认为，虽然现在大多数发展中国家的艾滋病毒感染率还很低，但如果不对大众、特别是青年人采取积极的预防计划，那么艾滋病毒在这些国家的爆发只是个时间问题。一些主流艾滋病“专家”声称，没有足够的数据能够支持我的结论。对此，我的回应是，他们担忧如果不针对大众、特别是青年人实施积极的预防计划，艾滋病毒能够，也将会在一般人群或“普通人”当中蔓延。而这种担忧才是没有任何数据支持的。这些关于艾滋病流行规律和传染病动力学的误解和错误观念曾导致和支持了联合国艾滋病预防规划署广为流传的宣传范式，在本章中，我将谈谈我对这些误解和错误观念的看法。在本章中，我还将33 解释我何时开始，以及为何要逆主流机构的“正统观念”而上。首先，回顾一下我认为导致艾滋病传播的主要决定性因素，以助于对本文的理解。艾滋病传播流行的主要因素我必须先强调，就艾滋病传播动力学而言，我的理解和大多数主流流行病学家的理解差异甚微。但大部分艾滋病活动者不愿意承认最高风险的行为模式和高危感染行为的普遍流行才能导致艾滋病毒的传播流行，因而不愿意接受我的结论和模式。一些人群、族群（男男性行为者、静脉吸毒人员、女性性工作者等）虽然确有高程度的危险行为，但他们已经被社会边缘化，所以艾滋病活动者们不愿意再给他们贴上“艾滋病”的标签。首先，也是最重要的一点，如第五章所描述的那样，所有已发表的性伴侣研究都表明，单一性行为感染艾滋病毒的风险非常低，小于或等于1/1000。但相比之下，流行性流感病毒却在任何人群中都有广泛传播的危险。这是因为几乎所有婴幼儿、成年人，不论老幼，对于此类病毒都有中度至高度的感染风险。但艾滋病毒的传播需要大量血液或性液体的交换，因此仅有一小部分普通民众或“普通”人群有中度至高度的风险会接触或感染艾滋病毒。传染病流行病学家普遍认为，高危行为是艾滋病毒传播流行的主要决定因素，包括同时与多个性伴侣进行的不安全性行为，以及/或是长期和静脉吸毒人员共用毒品注射工具的行为。据统计，仅在此类最危险行为流行之处存在记录在册的艾滋病毒传染案例。因此，在没有出现艾滋病毒高危行为的地区，就没有艾滋病的传播流行，这是唯一符合逻辑的结论。然而我们从本质上忽略了一个更重要的相关问题：感染艾滋病毒高危行为的主要决定因素是什么？大部分社会活动家会毫不犹豫地回答：贫穷和歧视是这些高危行为的根源。但在我看来，文化、社会、宗教以及其他因素（例如经济因素）共同影响着高危性行为和静脉吸毒人员危险行为的决定因素。所以什么是艾滋病毒高危行为的决定因素？我给不出一个简单明确的答案。正因为目前未得出一个明确的答案，很多有价值的社会活动一直寄希望于艾滋病项目。这些社会问题，例如贫困、歧视、不平等的两性关系、医疗保健的缺失，显然阻碍了有效的艾滋病预防和治疗，但它们决不是艾滋病毒传播流行的主要决定因素！艾滋病毒传播动力学的辉煌误解（或误解）我认为艾滋病流行病学和传播动力学的主要误解（或误解）如下（联合国艾滋病预防规划署和主流艾滋病机构仍继续利用它们来支持普世的社会和政治正确性，但从流行病学出发，它们却是不正确的）。联合国艾滋病预防规划署的范式是：若不积极采取针对大众人群，特别是针对青少年的预防计划，那么在原本艾滋病毒感染率低的人群中，爆发异性艾滋病毒传播流行只是个时间问题。34 人人几乎都有感染艾滋病毒的同等风险这个“辉煌”误解产生于上世纪八十年代。最初艾滋病通报病例人数经历了一个短暂的人口倍时，这使人们错误地认为艾滋病由高度感染性的病原体所导致。而据观察，感染艾滋病毒的高危行为（同性恋和异性恋人群的性乱交行为、长期共用毒品注射器行为）几乎存在于全世界任何国家。所以人们得出艾滋病毒最终会在全人类全面流行的结论。然而，艾滋病毒在男男性行为者、静脉吸毒者、女性性工作者和他们的客户之中广泛流传的可能性在全世界所有人群和任何国家当中都是同样的，这并不符合以上逻辑。进一步说，艾滋病毒根本不可能从高危人群扑向“一般”民众，在“普通人”之中大肆流行。虽然导致梅毒的细菌在一次性接触中的传染性比艾滋病毒高出数百倍，也并没有权威的性传播疾病专家担忧梅毒会像“滚烫的餐刀切入冰冷的黄油中”那样席卷普通大众。作为传染病原，艾滋病毒的主要特征是，若没有其他促进因素，其在单次性接触中的传播风险非常之低。而艾滋病计划、相关机构在普及艾滋病传播知识时，并未提及这个特征。按照接触病毒的不同途径，我准备了一份分别显示其传播风险的图表。因为图表中显示，若没有其他促进因素，单次性行为传播艾滋病毒的几率小于或等于1/1000。所以乔恩·曼和迈克·默森皆特别告诫我不要发表此图表。他俩都清楚我的图表是准确的，但他们担心的是这类信息一经公之于众，无异于向公众传播一个跟“不安全性行为有传播艾滋病毒的风险”相悖的信息。除了艾滋病毒的低感染性，感染艾滋病毒高危行为的模式和流行程度在不同国家中也大相径庭。如第五章所详述，上世纪八十年代，世界卫生组织对性知识、态度、行为、实践（信念及行为）的调查表明：1.在撒哈拉以南非洲国家人群中的性伴侣交换模式主要是并发的，而在大部分发达国家中，性伴侣交换往往是连续的。2.在某些撒哈拉以南非洲国家中，女性婚外性行为的比率相当高（高达40%）。相比下，亚洲女性的这一比率低于1%到2%。这些现象，以及能大大增加艾滋病毒通过性传播风险的促进因素，在撒哈拉以南非洲国家人群中存在的比率比在其他大部分人群存在的比率要高出10倍以上。这也就解释了为什么异性艾滋病毒的传播会在大多数撒哈拉以南的非洲国家中流行，而不在其他大多数人群中传播。记录表明，少数亚洲国家中，异性艾滋病毒传播流行于女性性工作者及其客户之间，这归因于曾经存在的巨大性交易网。联合国艾滋病预防规划署和大多数艾滋病活动家故意或确实由于无知地忽略了一个事35 实，那就是艾滋病毒很难通过性传播。艾滋病毒很难通过性传播，除非存在高风险性行为。而艾滋病项目拒绝接受这一事实，以此避免给某类人群贴上更加滥交的标签。更加社会正确、政治正确性的公共卫生信息是：性滥交存在于各种人群，仅通过针对大众，尤其针对青少年的简单积极的预防计划便可预防异性艾滋病毒的流行传播爆发于“普通”民众或“一般”人群之中。艾滋“专家”和艾滋病毒同样“流行”，而他们当中的大多数并未接受过任何流行病学专业培训的。他们用各种流行病模式去预测艾滋疫情在某些国家异性人群中将大肆流行。而这些国家目前大众感染率仍旧很低。这些“专家”危言耸听，表示艾滋病毒传播流行的下一波浪潮就要来临，或是艾滋病毒正处于从仅感染男男性行为者和静脉吸毒人群到扑向普通大众的边缘。上世纪九十年曾被预测会见证“下一波”艾滋病毒传播流行的浪潮，但这个浪潮从未真正出现。所以大多数艾滋“专家”放弃对艾滋病毒在发达国家异性人群中的流行耸人听闻，而把注意力转移到亚洲的人口大国上。他们预测，在印度和中国这样的国家，如果允许婚外性行为出现，以及不积极面向普通大众，特别是针对青少年，普及艾滋病毒传播途径的话，艾滋病毒将在异性人群中大面积爆发。传播艾滋病毒的“纽带”人群始终会引发异性恋艾滋病毒流行另一个关于艾滋病毒传播动力学的错误观念是：已经感染的双性恋男性，或已经感染的静脉吸毒人员（不论男女）是艾滋病毒传播给普通异性人群的“纽带”。但过去二十年内几乎被忽略的是，这样的“纽带”传播曾经是、未来也会是一方携带艾滋病毒的夫妇之间的传播，例如艾滋病毒从一个感染者（不论何种感染途径）传染给他/她的稳定性伴侣或性伴侣们。在第五章中这样的传播被称为非疫传播，而非疫传播在全世界范围内都是艾滋病毒流行的主要途径，所谓“纽带”，通常都是“哪儿也不到的纽带”。这是因为只要没有非常高危且频繁的性伴侣交换，异性艾滋病毒从未也无法在任何人群中传播流行，艾滋疫情也不会在普通大众中大肆爆发。自从上世纪八十年代出现男男性行为者和静脉吸毒人群中艾滋病毒感染者记录以来，数百年内事实都是如此。上世纪六十至七十年代，很多离开非洲的艾滋病毒感染者情况也是如此：大概有数以百计甚至数以千计的“火花”（艾滋病毒感染者）将艾滋病毒的烈火带到众多人群的面前，而只有当这些“火花”烧到男同志桑拿室和静脉吸毒人员的“聚众注射室”时，才会出现严重的疫情爆发。值得注意的是，就算是异性艾滋病毒广泛传播的撒哈拉以南的非洲国家，甚至此间感染率最高的国家，多数“普通”人群通过性行为感染艾滋病毒的风险仍旧很低或者为零，因为他们遵从一夫一妻制，或是忠诚于自己的伴侣。36 而在上世纪八十年代末九十年代初，艾滋病毒传播动力学的这些事实并不为大众所透彻理解。上世纪八十年代早期的美国和大多数发达国家，艾滋病毒在男男性行为者和静脉吸毒人员之间爆发性流行，但所谓的艾滋病毒流行的“下一波浪潮”却并未在“普通”异性人群中变成现实。米歇尔·福门托在其《异性艾滋病误解》一书中精准而无比详细地记录了这一情况。同时，他对撒哈拉以南方非洲国家和泰国同期记录在案的大量异性之间的艾滋病毒传播案例表示严肃质疑。主流科学和公共健康却并没有质疑这些异性恋艾滋病毒的大量感染，但与此同时，为什么异性恋艾滋病毒传播流行在撒哈拉以南非洲国家如此猖獗，而在加勒比地区和亚洲只在少数人群中传播流行，甚至在某些发达国家和大多数发展中国家并没有疫情存在？他们对于这些问题也是一头雾水。一些最初的理论表示：肛交在非洲和亚洲国家中比当时想象中更为普遍，或者贫困是艾滋病毒高感染率的主要决定因素。关于异性恋艾滋病毒传播的这些误解和错误观念仍有坚实的拥护者。尽管肛交也不被推崇，但某种程度上的固定思维仍将存在。就感染艾滋病毒的风险而言，肛交相比于性交并无特殊和神秘。肛交有更高的感染风险仅仅是因为其更容易导致软组织创伤，因为同阴道上皮相比，脆弱的直肠上皮更容易受到损伤。然而，在性交中，多层促进因素会导致过程中交换更大量的血液或性液体。如第五章所诉，相比其他人群，这些促进因素在撒哈拉以南非洲国家人群中相当流行。所有高危行为都将导致艾滋病毒流行直到上世纪九十年代中期，人们才意识到不同的性交易网从模式到规模都有着很大的不同。人们怀着信仰般的坚信，一旦性交易网沾染上艾滋病毒，那么艾滋病会不可避免地紧接着传播流行。艾滋病毒可能在几乎所有性交易网传播流行，公共卫生是存在这样的风险，我不是妄图轻视这个风险，但人们应该认识到，这样的风险可高可低。幸运地是，在伴侣交换率不是最高的性交易网中，这个风险非常低。艾滋病否认主义者，例如迪斯贝格和他的同事们认为，艾滋病毒通过性传播是一个误解，为支持其理论，他们指出很多针对发达国家和众多发展中国家女性性工作者的调查显示，并无艾滋病毒感染者或仅有少数病例。在艾滋病毒传播率低的国家，对于女性性工作者感染艾滋病毒年几率的统计，反应出艾滋病毒感染率和流行性大幅度年增长的可能很小（见第五章附录一）。根据统计显示，若菲律宾存在数十万女性性工作者，其中每年因性工作感染艾滋病毒的人数少于100名。这些被感染的女性性工作者，在任意十年的工作年限中，可能会传染数名男性客户。然而，在这个艾滋病毒感染率很低的国家，成千上万感染者之中，每年预计有成百上千名感染者死于艾滋病，被传染的男性客户数量和这个数字比起来可以忽略不计。从上世纪九十年代初至今，37 菲律宾进行的哨点监测表明，记录在册的女性性工作者中，艾滋病毒年感染率始终在1/1000左右。导致低感染率的因素是：1．女性性工作者的男性客户感染率极低（小于或等于1/1000）；2．菲律宾大部分男性在青少年期接受过割包皮手术；3．大部分女性性工作者每天平均接客少于一人；4．据报道菲律宾女性性工作者中避孕套使用率超过50%。在很多国家，艾滋病毒在静脉吸毒人群中爆发流行，人们对于公共卫生存在的最大的担忧是：某个已感染艾滋病毒的女性静脉吸毒人员，从事性服务以赚的毒资。几乎所有爆发艾滋病毒流行的静脉吸毒人群中，感染艾滋病毒的女性性工作者的数量都有所上升。这些女性性工作者有可能会把毒传染给自己的一些客户。但如上诉，在感染率低的国家中，这样的传播并不会导致全国艾滋病毒感染率和流行程度的上升。异性恋艾滋病毒持续传播的必要条件是：1.大规模的开放或交叉的性网络；2.大量的每日性伴侣交换；3.男性割包皮手术的普及率低；4.避孕套的使用率低；5.多重促进因素的流行。因此，在菲律宾这样原本艾滋病毒感染率低的国家中，即使是高危人群（女性性工作者和其客户）里，异性恋艾滋病毒传播的几率很低。公共卫生的最高要务是确保在低感染率人群中，艾滋病毒在有最高危异性恋行为者（女性性工作者和其男性客户）中的感染率越低越好。此任务可通过对节欲和忠诚的持续宣传来完成。但对于这些危险性行为者来说，在所有性交易中推广C计划（持续使用避孕套）才是保持艾滋病毒低传染率的更有效途径。在任何国家，极高的性伴侣交换率都藏污纳垢于某些区域，它们包括：人口流动量大的边界区域，大量移民或来自稳定社会环境的外来务工人员（例如从农村进城的务工者）、季节工、外来工、军队、士兵/商船船员、长途货车司机、大型开发或建设项目等。不论异性恋艾滋病毒传播的潜在危险是大是小，不论这些人口分布何处，针对这些易感染人群的基本预防工作都需要开展。贫困、歧视、缺乏医疗条件是艾滋病毒流行的主要决定因素联合国艾滋病预防规划署和大多数艾滋病计划，包括大多数社会正确、政治正确性的误解都长篇累牍地强调这些艾滋病毒流行的主要决定因素，然后流行病学理论并不支持这样38 的误解和错误观念。从社会正确、政治正确性出发，把高艾滋病毒流行程度归咎于贫穷似乎很合情理，但数据表明，一切正好相反。如第五章所诉，肯尼亚和坦桑尼亚收入前20%人群中，艾滋病毒流行率比收入后20%人群高出了2-3倍。这大概是因为最富有的人群，不论男女，都拥有更多的性伴侣。在撒哈拉以南那些最富有的国家艾滋病毒流行率是最高的，而这个几率在全世界最贫穷的国家里却是最低的。贫困是艾滋病毒传播的主要决定因素，这一辉煌误解，即使没有流行病学数据支持，也深入人心，难以更正。自从千禧年后听过我课的学生，纷纷接受了我这一挑战，看能不能找出一些数据支持这个误解，但目前为止，并无人成功。1987年，乔恩·曼恰当地指出，对艾滋病有效疗法和治愈之道的探求是所有艾滋病毒感染者的固有基本人权。然而，他继续表示：“……然而被排除在主流社会之外，或因为种族、国籍、宗教、性别、或性取向被歧视，都会导致艾滋病毒感染率的上升。”在我看来，歧视的确是艾滋病毒/艾滋病预防、治疗计划实施道路上的障碍，但歧视决不是艾滋病毒高危行为的决定因素，所以它决不是艾滋病毒传播流行的决定因素。艾滋病活动者轻易而不加批判地接受了这个辉煌误解。联合国艾滋病预防规划署的连篇累牍表示：贫困、歧视、医疗条件的缺乏是艾滋病毒高流行率的主要决定因素，而其中歧视占据了中心位置。从个人角度来说，我百分之百反对贫困、歧视、稀缺的医疗条件，我相信就算“我们”有能力解决这些公共社会问题，但这些问题的解决对于男-男性行为者、静脉吸毒者、和很多撒哈拉以南非洲国家人群中高艾滋病毒感染率的影响，可谓微乎其微。艾滋病毒感染率再创新高。2005年，有4000万艾滋病毒携带者，其中500万是新增病毒感染者。这样的艾滋病毒/艾滋病感染数量相比现实高出了太多：可查的数据和联合国艾滋病预防规划署针对全球大部分地区的艾滋病毒流行趋势的调查，是绝得不出如此高感染率结论的。如第七章所详述，所有联合国艾滋病预防规划署所预计的2001年和2003年感染数量，我都认为实在是有所高估，尤其是针对撒哈拉以南非洲国家和亚洲的数据。在2006年中期，联合国艾滋病预防规划署大大减低了撒哈拉以南非洲国家和加勒比地区的艾滋病毒预计感染人数，将这一数据降至一个更现实的层面。但是我认为，因为2006年海地完成了基于人群的血清学调查（DHS+），联合国艾滋病预防规划署应该针对海地将这个评估再次降低。同样的，东欧、中东（俄罗斯、乌克兰）、南亚、东南亚（印度）、东亚和太平洋地区（中国）等地的数据也应当降低。所有的区域评估我都认为是有所高估，就算2006年中期的数据已经进行了降低调整，但联合国艾滋病预防规划署在下一份全球艾滋病流行报告中，仍需要降低调整其大部分区域评估的数据。比较符合目前数据和艾滋病毒流行趋势的全球评估是大约有300039 万（15-49）病毒携带者，每年新增将近300万成年感染者。事实是艾滋病毒感染人数比评估的数据要低，而联合国规划署一再否认这个事实，并警告说艾滋病病毒处于扑向大众人群的边缘。这一行为最终会引起大众对艾滋病计划的强烈反对，反对它们一直“谎报敌情”，警告“狼来了”，而这种警报缺乏流行病学理论支持。联合国艾滋病预防规划署主要将自己视为一个宣传机构。所有在处理艾滋病毒/艾滋病评估数据时，它不能像技术机构或科学机构一样客观。我想起90年代初期同菲律宾卫生部长的一次交流，对他做出的过高感染率估计我表示需要慎重，他将50例艾滋病毒/艾滋病感染率乘以1000，得出全国感染5万例的估计。他告诉我：“……宣传不必精确！”很遗憾，这也是联合国艾滋病预防规划署一如既往处理艾滋病毒/艾滋病发病率和感染率的态度。如果不再将艾滋病营造成一副凄惨景象，不再通过新闻警示不断上涨的感染病例，艾滋病活动者们担忧公众和决策者不会再给予他们一直以来所受到的优待和重视。如果大部分区域艾滋病毒感染率保持稳定或下降趋势，如果艾滋病毒仍旧仅集中于男-男性行为者、静脉吸毒人员、女性性工作和她们的客户、大部分撒哈拉以南非洲国家人群当中，艾滋病活动家们担忧工作和决策者会自满而轻视艾滋病毒对普通大众的威胁，会减少对艾滋病计划的支持。这是出于现实的担忧，但诚如第七章末所描述的那样：1.全球和各区域的艾滋病毒感染率在过去十年内保持稳定，甚至有所下降；2.艾滋病毒的确集中在拥有艾滋病毒最高危感染行为的人群当中；3.在绝大多数异性恋人群中，艾滋病毒不会广泛传播。如果否认以上事实，联合国艾滋病预防规划署和其他主流艾滋病机构的可信度会进一步降低。逆艾滋病机构主流而上直到1992年早期从世界卫生组织辞职，我在主流医学科学和公共卫生对艾滋病毒/艾滋病流行的理解方面都扮演着先锋派角色。所以对于艾滋病活动者所持的观念和所处的位置，我完全能够理解，并且有些同情。我和主流的同事们持有相同的目的：有效地预防和控制艾滋病毒/艾滋病，以及为艾滋病毒感染者提供有效的抗逆转录病毒疗法（ART）。然后，过去十年里，我渐渐认识到，艾滋病项目，特别是那些由国际机构和宗教组织发展和支持的项目，一直坚持走政治正确性和道德驱动的路线，但就流行病学角度而言，确是不正确的。1981年，我已是工作将近20年的公共卫生流行病学家，致力于一般传染病的防控。当时加利福利亚确诊了第一例艾滋病，而我立刻全心投入到艾滋病的研究当中。1986年，作为负责传染病防控的国家流行病学家，除了评价加利福利亚所有艾滋病毒/艾滋病的研究和报40 告之外，我也是国家科学院（NAS），美国医学研究所（IOM）委员会的一员，而后者致力于艾滋病的全国性报告。在委员会工作的六个月中，我协助检查和评价过我们能接触到的全国和国际上流行病学、临床、实验室关于艾滋病/艾滋病毒的所有研究报告。因此，1987年我从加州健康部门提前退休，与日内瓦世界卫生组织的乔恩·曼做搭档之时，我在艾滋病毒流行病学领域已全职研究了六年。回顾从前，我亲自参与的所有最初关于艾滋病毒感染率的估计都存在严重高估的现象。1986年，西弗吉尼亚召开冷锋会议期间，少部分流行病学家第一次对全美艾滋病毒感染率做出过评估。而我是其中一员。基于我们能参考的有限数据，我们估计，全美大约有100万到150万艾滋病毒感染者。1988年初，在乔恩指定我负责监测预报和影响评估（SFI）工作之后，我组织了第一次艾滋病毒感染率会议。会议在斯洛伐克的什特尔布斯凯普莱索召开。回顾此次会议对艾滋病毒感染率的估计，我现在意识到这些估计也是严重的高估：英国估计的人数为4万人，而这个数据随后减少了大半；法国最初的评估为20万人，但当越来越多数据可参考后，这个数据同样也减少了大半。1986年，乔恩·曼预估全球艾滋病毒感染人数为500万到1000万。1988年中期，第四届全球艾滋病会议在斯德哥尔摩召开，其间我被任命为监测预报和影响评估首席官员，而500万到1000万这一估计，也是我当时得到的官方数据。疾病防治中心（亚特兰大）的鲍勃·比格斯当时正在非洲工作。与会期间我俩在走廊相遇，对于世界卫生组织全球估计的这一数据（500万-1000万）他表示质疑。当时我一直在收集和评审世界卫生组织成员国所上报的可用数据，所以对于他的质疑我表示赞同。500万到1000万这个数据确实过高。我随即向乔恩通报了这一情况，并建议世界卫生组织修改全球预估人数，将此人数降至500万。因为从我接触到的数据看来，这以人数低于500万才是合理的。我甚至起草了一份公告，发布鲍勃的观点：1986年世界卫生组织基于有限的艾滋病毒相关数据，预估全球艾滋病毒感染人数在500万到1000万之间。但直到1988年中期，相关的可用数据有所增加，对于全球艾滋病毒感染人数的合理估计降至500万人左右。但乔恩确信，从大多数数据资料看来，以艾滋病毒感染率目前在撒哈拉以南非洲国家的上涨速度，一年，或最多两年内，全球艾滋病毒感染人数就会上涨到500万到1000万这个区间。所有乔恩决定不发布我的公告。90年代初期，乔恩的推断得到证明，全球艾滋病毒感染人数的确上涨到500万-1000万。我渐渐发现上述所有对于艾滋病毒感染者人数的估计都被严重夸大，于是决定自己将负责的任何评估都应持保守态度，并且我不会发布任何缺乏有效数据支持的评估结果。1992年初从世界卫生组织卸任后，我仍同从前在监测预报和影响评估机构的同事保持着联络。我41 非常高兴地看到，一直到90年代中期，监测预报和影响评估机构对于艾滋病毒感染人数的估计都是保守且有数据支持的。但我担心的是，撒哈拉以南非洲国家中城市和农村艾滋病毒感染状况的差别。这些国家里大部分人口居住在农村地区，所以我敦促世界卫生组织及联合国艾滋病预防规划署的工作人员投入更多的工作以量化这一差别。经验证，这种差别是导致大部分撒哈拉以南国家和加勒比地区国家中艾滋病毒感染率被夸大了50%及以上的主要原因。官方对艾滋病毒感染率估计数据的降低，使大多数艾滋病活动家心怀不满。他们认为这是公共卫生部门的诡计，旨在将艾滋病毒/艾滋病流行传播的严重性最小化。大多数艾滋病活动家目前不信任官方对于艾滋病毒感染率的估计，将来也一样会保持怀疑态度。上世纪80年代末90年代初，艾滋病毒/艾滋病感染率估计数据居高不下，并不断向上调整，艾滋病计划的拥护者和活动者们对此不加怀疑地接受了，并相信这是艾滋病流行的不变趋势。然而任何对估计数据的下调、任何关于艾滋病毒或艾滋病将猛增或下降的预测，都被视为不利于艾滋病毒/艾滋病计划。人们认为这样的预测会引起对防控措施的自满。因此，当我1991年时预测“……发达国家年艾滋病病例将在95年之前达到峰值……”时，招致了英国首席医疗官唐纳德·艾奇逊先生的不满。当时他是我演讲的听众之一，一听此言论，他立刻吩咐手下最权威、最聪慧的医疗官员安妮·约翰逊博士判断一下我的这一预测有没有反驳的余地。安妮博士是一位非常精明的流行病学专家，我们对这一问题展开了激烈的学术讨论。作为一位经验丰富的监测预报和影响评估/艾滋病流行病学家，她很清楚在美国和英国，艾滋病发病率在80年代中期达到峰值。从感染艾滋病毒到发展为艾滋病患者的平均潜伏期是8-10年，任何了解这一事实的人，不需要借助任何复杂数学模型就能推测出，在90年代中期之前，这些国家的艾滋病病例数量会达到峰值。安妮·约翰逊很显然将支持我预测的流行病学理论详述给了唐纳德博士，于是此后我再未听闻此类非议。艾滋病病例将自然递减这一推测，是基于艾滋病毒感染的自然史，基于艾滋病毒患病和感染趋势的。我曾认为自己的这一推测会是一个受到欢迎的“好消息”，而非“坏消息”。42