I admit that I am one of those people who reads everything I can about HIV/AIDS. I buy used textbooks to chart the course of changes in educational presentations about HIV. I have Google Alerts for HIV issues and I am on over a dozen HIV related list serves.

So it really should be no surprise that when a friend brought over their microbiology text for Biology 203 at Lansing Community College, I eagerly sought out the HIV references. There in this book, Microbiology:Principles and Explorations, 7th edition, prepared for Lansing Community College by Wiley Custom Learning Solutions, were 5 pages dedicated to HIV. Certainly not extensive, in reference to the amount we know about HIV, but certainly no slack of information either.

In those 5 pages, I identified 7 factual errors. You can imagine how angry this got me. The information created implications which were indeed dangerous in relation to HIV prevention, and counter to the facts known about the disease.

On Jan. 13, I e-mailed Lansing Community College, as well as called Wiley and Sons, Inc. I also e-mailed the author, as well as forwarded that e-mail to Kaye Pace, vice president and executive publisher at Wiley and Sons, Inc.

After several e-mail updates from Pace (she kept me informed every step of the way which was incredibly helpful), today I received the following e-mail from her:

Dear Mr. Heywood,

We appreciate your contacting us with your concerns regarding the HIV/AIDS coverage in Black-Microbiology: Principles and Applications 7e.  At Wiley, we take pride in our long history of scientific publishing and the quality of our content, and of course, it is important to us that our coverage is accurate.

To that end, we asked two experts to review your concerns. We asked these experts to advise us on the accuracy of the information in the textbook and offer suggestions for correction and clarification as necessary. The reviewers agreed with your comments related to Kaposi’s sarcoma. As a result, we will correct this error in the next re-print or in the next edition, as well as provide the correction now on our book companion website to which all readers of the book have access—this should be posted later today.

Our experts felt that your remaining comments should be considered in the next edition to strengthen the coverage in this section of the book.  They did not agree that these examples were errors but rather differences around wording and have in some cases recommended clarifications or the use of different terminology. See the attached for more explanation.

Thank you, again, for your assistance in this matter.  We have also shared our findings with faculty and administration at Lansing Community College.  We wish you continued success in reaching the public with HIV/AIDS awareness and education.

Sincerely,

Kaye Pace

Vice President, Executive Publisher

So, you might be asking yourself, what WERE the errors?

Pace’s document she sent attached to the e-mail:

Quote from Black: “Although these early battles [following infection] result in a draw, the virus eventually wins the war.”

Heywood comments: You fail to note that with the advent of anti-retroviral medications, many people are able to continue win the battle with the virus, making HIV a manageable, rather than terminal, condition. You also fail to note that a small percentage of human beings who are infected with the virus see no impact on the immune system at all. These folks, many of them gay men infected in the early 1980s, continue to have very low or undetectable viral loads and normal CD4 cell levels. In short, while infected with the virus, they remain happy, healthy and fully functional– with some for well over 25 years. I am labeled as a nonprogressor because my viral load has never been detectable.

Note of Clarification: On page 558, the author uses the word “untreated.”

Expert Findings: The author’s statement is generally, but not always, true. Perhaps the author could add that in the absence of treatment, the virus eventually wins. And, as Heywood notes, there are some people who are long-term non-progressors. In the absence of treatment, for the vast majority of people, the statement as written is accurate. Further, in the next section, anti-retroviral medications are discussed.

Suggested Clarification/Action: Change the wording in the next edition to read, “Untreated, the vast majority of people will succumb to the virus. Some people called long-term progressors (1-5% of HIV positive cases) move very slowly, or not at all, along the progression of disease. Several genes, including multiple mutations within these genes, appear to hamper entry of the virus into cells.”

Heywood comments:  (Black) Says that all people with HIV will eventually get AIDS. AIDS is a very precise clinical diagnosis. Many people continue to die from HIV ravished immune systems, but they do not qualify for a clinical– thus legal– diagnosis of AIDS. It is for this reason many in the public health field prefer the use of the term HIV disease, using immune markers are the definition boundaries, rather than the arbitrary and shifting sands of co-infections.

Note of Clarification: The author does not actually make the statement that “all people with HIV will eventually get AIDS.” On page 556 the author writes, “The virus gradually but relentlessly destroys the immune system. The lack of a functional immune system leaves the body open to a variety of malignancies and opportunistic infections, most of which are rarely seen among people who are not suffering from advanced HIV disease or AIDS. These complications—either alone or in combination—can prove fatal.” Also, See figure 18.24 on page 557: CDC Classification of HIV Disease.

Expert Findings: Heywood seems to be concerned with the clinical definition of AIDS. According to the CDC, AIDS is defined as HIV(+), CD4 count below 200 per uL of blood, and an AIDS-defining infection. For people in developing countries, a CD4 count may not be available and as a result, technically, they do not match the CDC definition.. Heywood is correct, though, that most people in the field now refer to HIV disease, rather than AIDS. It is a more inclusive term.

Suggested Clarification/Action: Change all appropriate references to HIV disease rather than AIDS.

Quote from Black: “However, there have been no reported cases of deaths among AIDS patients from Kaposi’s Sarcoma.”

Heywood comments: Quote from recent research that provides evidence of Kaposi ’s sarcoma being a cause of death in “around 11% of affected AIDS patients.”

Note of clarification: Author refers Heywood to a 2009 citation “only one died.”—see attachment below.

Expert Findings Findings: On this point, I would agree with Heywood. Most people with HIV-associated KS probably have other HIV-related

illnesses and attributing death to a specific opportunistic infection is difficult. I would agree with Heywood, though, that deaths have been attributed to KS, and not infrequently.

Suggested Clarification/Action: We will update this, and post it on our book companion website immediately, and add the following in the re-print or in the next edition: “Most people with HIV-associated Kaposi’s sarcoma probably have other HIV-related illnesses. Attributing cause of death to a specific opportunistic infection is always difficult, however, it should be noted that death has in some cases been attributed to Kaposi’s sarcoma.”

Heywood’s comments:  “The book creates the false presentation that HAART and the

cocktails are two different regimes. HAART and “the cocktails” are exactly the same– with the preferred terminology now being ART, or anti-retroviral treatment. The treatment regiment varies based on viral sensitivity to various specific medications available, allergies of the patient, and lifestyle of the patient.”

Expert Findings: Perhaps the writing could be re-worded, but there are no factual errors. The cocktail is more of a slang term. HAART has a more specific meaning. Antiretroviral therapy (ART) is more commonly used today as a catch-all phrase. I suppose these terms each could be explained more fully, but the author does not state anything incorrectly.

Suggested Clarification /Action: Define the terms HAART and (ART) more comprehensively in next edition.

Quote from Black: “HAART has increased the life-expectancy of HIV-infected patients dramatically! However, it does not cure the disease. Furthermore, if discontinued because of side effects or lack of funds, death usually follows swiftly–sometimes within a month.”

Heywood comments: “Quite often HIV-positive people take medication vacations, varying from a month to a year. This is considered standard treatment protocol now. “

Expert Findings: On this point, I would disagree strongly with Heywood. Drug holidays remain very controversial. They certainly are not standard treatment protocol. Many studies have shown that short breaks result in rapid increases in a person’s viral load.

Suggested Clarification /Action: None.

Quote from Black: “All available evidence suggests that it is virtually impossible to become infected with HIV through casual contact.”

Note of Clarification: The very next sentence in Black reads, “Rather, a person becomes infected with the AIDS virus only through intimate contact with the body fluids of an infected individual and by transmission from infected mother to fetus.”

Heywood comments: The Centers for Disease Control and Prevention in Atlanta, as well as the World Health Organization have documented no cases of transmission of HIV through casual contact. Thus it is not “virtually” impossible, rather after nearly 30 years, it is clearly impossible.

Expert Findings: Virtually impossible to become infected with HIV through casual contact. The CDC has reported one case of probable transmission through French kissing involving a man with gum disease. Presumably, transmission occurred via blood in his mouth and not saliva. So I guess it depends on what you consider casual contact. Also, as a scientist, I dislike absolutes. I am much more comfortable stating that something is virtually impossible, rather than impossible. Scientifically, it is problematic to state that an event is impossible. Further, the next sentence makes it quite clear that infection does not occur through casul contact.

Suggested Clarification/Action: None

Quote from Black: “Condoms can reduce but not eliminate transmission because they have a significant failure rate (17 to 54% in various studies) usually the result of improper use, and not all types of condoms are equally effective in blocking HIV. Natural skin condoms allow passage of the virus; latex (and polyurethane) condoms are much safer.”

Heywood comments: You fail to cite the actual studies which you reference here, but from my considerable background and experience in HIV prevention and education, at least one study to which you are referring– I can deduce by the 54% failure rate you cite– has been discredited as wishful thinking science by a right wing think tank which opposes premarital sex, abortion, homosexuality, and birth control. The study was discredited as junk science several years ago, when it was being used by a right to life front group which was selling “sex education” programming to public schools. This study was debunked along with much of the junk science the Bush administration used in justifying the abstinence only model of HIV prevention.

Expert Findings: Condoms. I agree with Heywood that the studies on condom failure are suspect. When used correctly and consistently, latex and polyurethane condoms are highly effective. HIV can pass through lamb skin condoms. Various studies have stated various failure rates.

Suggested Clarification/Action. Delete information on failure rates or research more data on failure rates, and cite any studies that are referenced. Add “and polyurethane” as indicated above.

The effect of HAART in 254 consecutive patients with AIDS-related Kaposi’s sarcoma.

Bower M, Weir J, Francis N, Newsom-Davis T, Powles S, Crook T, Boffito M, Gazzard B, Nelson M.

Department of Oncology, Chelsea and Westminster Hospital, London, UK. m.bower@imperial.ac.uk

OBJECTIVE: A prospective cohort study was performed to evaluate the clinical outcomes of patients with histologically confirmed AIDS-related Kaposi’s sarcoma diagnosed since the introduction of HAART. METHODS: Two hundred and fifty-four consecutive patients (96% men) diagnosed with Kaposi’s sarcoma between 1996 and 2008 are included. Clinicopathological and treatment details were prospectively collected. The median follow-up is over 4 years and maximum 12 years. RESULTS: The mean age at Kaposi’s sarcoma diagnosis was 39 years and average duration of known HIV seropositivity was 4 years. At Kaposi’s sarcoma diagnosis, only 19% patients were on HAART and only 7% patients had an undetectable plasma HIV viral load. Seventy-nine (31%) patients had AIDS clinical Trial Group stage T1 disease at Kaposi’s sarcoma diagnosis and 122 (48%) had AIDS clinical Trial Group stage I1 disease (CD4 cell count < 150 cells/microl). Nodular grade Kaposi’s sarcoma represented 28% of the tumours and was significantly associated with black African ethnicity and AIDS clinical Trial Group T1 stage disease. The overall 5-year survival is 89% (95% confidence interval 84-93). One hundred and sixty-three patients were treated with HAART alone for T0 stage Kaposi’s sarcoma; only one died of Kaposi’s sarcoma and only 37 (22%) required chemotherapy, giving a systemic treatment-free survival at 5 years of 74% (95% confidence interval 67-82) and the overall survival at 5 years is 91% (95% confidence interval 87-95). CONCLUSION: The high success rate of HAART in a large cohort of AIDS-Kaposi’s sarcoma patients over a prolonged period of follow-up will reassure patients and clinicians that this is a well tolerated and effective approach to stage T0 Kaposi’s sarcoma.

OK so they admit to errors, and need for clarifications, but will only issue one errata on this? Seriously? Do they really expect some one to rush to their website to review the additional information? And what about the students who spent $100 on the book, ought they not get their money returned?