HIV at the Al-Fateh Hospital in Benghazi in 1998.
The court has denied requests by defence lawyers to hear evidence from
international experts. Instead, five Libyan physicians testified in August
that they stand by the conclusions of their 2003 report, commissioned by the
court in an earlier trial, and on 29 August the prosecution called for the
medics to be given the death penalty. The trial is due to end on 31 October
(see 'Countdown to a verdict').
With a guilty verdict looking likely, Nature obtained an English translation
of the Libyan report, which has been key to the prosecution's case, and
asked leading international experts to assess it.
"I don't see any evidence in it," says Janine Jagger, an epidemiologist and
MacArthur fellow who heads the International Health Care Worker Safety
Center at the University of Virginia in Charlottesville. "It wouldn't meet
the lowest standards of epidemiological evidence for establishing any causal
relationship."
In 2003, the court also ordered a report from Luc Montagnier, who discovered
the AIDS virus and is president of the World Foundation for AIDS Research
and Prevention, and Vittorio Colizzi, an AIDS researcher at Rome's Tor
Vergata University. They concluded that the infections were caused by poor
hospital hygiene, and started before the medics arrived in Libya (see
"Montagnier and Colizzi's conclusions"). But the court threw out this
report, on the grounds that the Libyan panel had reached the opposite
conclusion. The panel had dismissed the external report as "hypothetical"
and "lacking precision".
'That's tosh'
"The [Libyan] report refutes the Montagnier and Colizzi report on the
grounds that there is no written record of the reuse of injecting equipment,
and a blank denial that indwelling catheters were ever used," says Robin
Weiss, an AIDS virologist at University College London. "It wrongly turns
lack of evidence into evidence of absence."
'A shocking lack of evidence'
T. PENOV/BTA/REUTERS
Bulgarian president Georgi Parvanov (left) visits HIV-positive children in
Benghazi, Libya, in 2005.
The report argues that HIV and hospital hygiene were not a problem in Libya
(the prosecution describes the Al-Fateh Hospital as a "model") and that the
outbreak is so large that deliberate, malicious infection of HIV cannot be
excluded. "I don't agree with that statement," says Weiss. "And even if I
did, it does not amount to sufficient evidence to incriminate the accused
medical staff."
The Libyan report also suggests that because the genetic sequence of the
Benghazi HIV strain is different from any lodged in public databases, there
are grounds for suspecting foul play. "That's tosh," says Weiss. Montagnier
agrees, pointing out that the virus was a new natural recombinant of a
highly infectious strain common in Central and West Africa, which has
replaced most other strains in the region over the past few years.
In contrast, Weiss describes Montagnier andColizzi's report as excellent.
"Colizzi has done a really superb job in difficult circumstances," he says.
After studying both reports, Weiss concludes: "There are no grounds for
suspicion of deliberate infection by any staff, and strong evidence of
hospital-acquired infection before the arrival, and after the departure, of
the Palestinian physician and the Bulgarian nurses."
There are no grounds for suspicion of deliberate infection, and strong
evidence of hospital-acquired infection.
'Completely inadequate'
Jagger, an expert in occupational exposures to blood-borne pathogens, says
she is astonished that the medics were even arrested, given the flimsiness
of the prosecution's scientific evidence. In this sort of case, she says the
minimum standard should be a thorough field study that tracks all medical
procedures carried out during the outbreak, and calculates attack rates,
epidemic curves and other standard epidemiology measures for inferring
cause. She describes the Libyan data as "completely inadequate".
To firmly establish any cause, a case-control study should also have been
done, Jagger adds, comparing risk factors and medical procedures used
between the HIV-infected patients and a similar uninfected group to try and
explain transmission. "Inexcusably, there has been no attempt by Libyan
officials to conduct an epidemiological study that could establish a causal
link between the infected patients and individual care givers."
Luc Perrin, a clinical virologist at Geneva University Hospital in
Switzerland, who has treated many of the infected children, describes the
Libyan report as "a lot of generalities that are not always correct". The
report also fails to provide any evidence for its assertion that HIV
infection has not been seen in children at other Libyan hospitals, he says.
Perrin is an expert on primary HIV infection. He has analysed samples from
148 of the infected children, collected in September 1998, and has obtained
further data on 37 of them and 46 of their parents, when they were treated
in Switzerland. Perrin says his genetic data support Colizzi's analysis, and
that many of the 1998 samples have protein profiles corresponding to
infections well over a year old: "I can tell for sure that the HIV infection
cases occurred before September 1997 and the first cases most likely before
1996." The accused medics first arrived in Libya in March 1998.
The Libyan report is also silent on the prevalence of hepatitis at Al-Fateh
Hospital and other Libyan hospitals, notes Perrin — who found that half of
the HIV-infected children were also infected with hepatitis B or C. He says
these high levels "clearly indicate" that the children were exposed to
infection via contaminated blood or other medical material. Moreover, many
of the children were infected with several subtypes of hepatitis, suggesting
they were exposed to hospital contamination on multiple occasions, possibly
when receiving vaccination injections. "If a single source of contaminated
blood had caused the HIV outbreak, all the children would be infected by the
same hepatitis C subtype," says Perrin. "What we observed can [instead] be
explained by the reuse of syringes or poor sterilization procedures."
Perrin believes the most likely scenario is that a child who was infected
with HIV in Al-Fateh in 1997 or earlier, returned to the hospital in 1998.
"The child now is highly infectious, so poor medical procedures or
sterilization procedures will rapidly translate into a number of new HIV
infections."
'Sinister legacy'
Perrin was commissioned to write reports for the Libyan government in 2000
and 2001, and for President Muammar Gaddafi in 2004, but says that they
received no response. "It is strange that I was asked by the World Health
Organization representative of Libya to investigate, and received a grant
for that, that I sent the reports accordingly and finally the report is not
considered," he says. Testimony he submitted to the court was also rejected,
he adds.
The purported 'smoking gun' in the Libyan report is the detection of HIV
antibodies in vials allegedly found at one of the nurses' homes during a
raid in 1999, but not tested until 2003. Both Montagnier and Colizzi have
seen the results of a western blot, a test to detect proteins: they are
"indeterminate", says Montagnier. "They say nothing," adds Colizzi. In 2002
Libya promised that they could test the samples independently, but neither
has ever been given access.
Even a positive test could detect only antibodies to HIV. It would not show
that the vials had contained the virus, points out Massimo Amicosante, a
biologist also at Tor Vergata. "This is one of the main weak and
controversial points of the Libyan report," he says. Finding the virus would
require testing for HIV RNA, which has not been done.
After reviewing the evidence, experts are in no doubt as to the consequences
of a guilty verdict. "If the accused are found guilty, it will be a travesty
of justice," says Weiss. "Moreover, it would be foolhardy for any expatriate
healthcare worker, whether from the Arab world or elsewhere, to work in
Libya."
Jagger's conclusions are similar: "There is a shocking lack of evidence in
this case," she says. "The Libyan government stands to carry out an act that
would not be forgotten by the international healthcare community. Such a
horrific humanitarian tragedy would stand for ever as a sinister legacy of
the Libyan government."
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