Fundamentals of HIV Medicine 2019 1st

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 FACULT Y

L E A D E D I TO R Benjamin Alfred, NP-​C

Family Health Center of Worcester
W. David Hardy, MD, AAHIVS Jonathan Appelbaum, MD, FACP, AAHIVS
Senior Director, Evidence-​Based Practices Florida State University College of Medicine
Whitman-​Walker Health
Lisa Armitige, MD, PhD
Adjunct Professor of Medicine
Heartland National TB Center
Johns Hopkins University School of Medicine
Washington, DC Renata Arrington-​Sanders, MD, MPH, ScM
Johns Hopkins School of Medicine
Jason V. Baker, MD, MS
C O -​E D I TO R S
University of Minnesota
Ben J. Barnett, MD
Jonathan S. Appelbaum, MD, FACP, AAHIVS
McGovern Medical School at University of Texas at Houston
Florida State University College of Medicine
Tamara Bininashvili, MD
Roberto C. Arduino, MD
University of California, San Francisco
Professor of Medicine
Department of Internal Medicine Jatandra Birney, PharmD
Division of Infectious Diseases Ascension Via Christi Hospital
McGovern Medical School, University of Texas Health
Emily Blumberg, MD
Sciences Center at Houston
Hospital of the University of Pennsylvania
Laurie L. Dozier Jr., MD
Philip Bolduc, MD, AAHIVS
Education Director and Professor of Internal Medicine
Family Health Center of Worcester
Interim Chair, Department of Clinical Sciences
Florida State University College of Medicine Christopher M. Bositis, MD, AAHIVS
Greater Lawrence Family Health Center
Jeffrey T. Kirchner, DO, FAAFP, AAHIVS
Medical Director, Penn Medicine/​LGHP Christian Brander, PhD
Comprehensive Care IrsiCalxa AIDS Research Institute
Lancaster General Hospital University of Vic-​Central Catalonia
Lancaster, PA Hospital Universitari Germans Trias i Pujol
William R. Short, MD, MPH Christopher Brendemuhl, DMD
Associate Professor of Medicine Maricopa Integrated Health System
Division of Infectious Diseases McDowell Dental Clinic
Perelman School of Medicine
John P. Casas, MD
University of Pennsylvania
Albany Stratton VA Medical Center
Elizabeth Chiao, MD, MPH
C O N T R I B U TO R S Michael E. DeBakey VA Medical Center
Carolyn Chu, MD, MSc, FAAFP, AAHIVS
Saira Ajmal, MD
University of California at San Francisco
Advocate Healthcare Illinois
Joseph A. Church, MD
Kevin Alby, MD
Children’s Hospital Los Angeles
University of North Carolina Hospitals
Keck School of Medicine of University of Southern
California

vii
Eva Clark, MD, PhD, DTM&H Margaret Hoffman-​Terry, MD, FACP, AAHIVS
Baylor College of Medicine Milton S. Hershey Medical Center
Pennsylvania State University College of Medicine
Jennifer Cocohoba, PharmD, BCPS, AAHIVP
Lehigh Valley Hospital
University of California, San Francisco, School of Pharmacy
University of California, San Francisco, Women’s HIV Jennifer Husson, MD, MPH
Program University of Maryland School of Medicine
Dagan Coppock, MD Nikyati Jakharia, MD
Drexel University College of Medicine University of Maryland
Vishal Dahya, MD Boris D. Juelg, MD, PhD
Florida State University College of Medicine Massachusetts General Hospital
Elizabeth David, MD Joseph S. Kass, MD, JD, FAAN
Baylor College of Medicine Baylor College of Medicine
Trew Deckard, PA-​C, MHS, AAHIVS Jeffrey T. Kirchner, DO, FAAFP, AAHIVS
Medical Practice of Dr. Steven M. Pounders Penn Medicine/​LGHP Comprehensive Care
Lancaster General Hospital
Alejandro Delgado, MD
Einstein Medical Center Philadelphia David E. Koren, PharmD
Temple University School of Pharmacy
Paul W. DenOuden, MD, AAHIVS
Temple University Hospital
Multnomah County Health Department
Carolyn Kramer, MD, MHS
Madeline B. Deutsch, MD, MPH
Sidney Kimmel Medical College at Thomas Jefferson
University of California, San Francisco
University
Quentin Doperalski, MD
Doris Kung, DO
University of California, San Francisco
Baylor College of Medicine
Richard Dunham, PhD
Eurides Lopes, MD
GlaxoSmithKline
Loma Linda University Healthcare
HIV Cure Center, University of North Carolina at
Chapel Hill Adrian Majid, MD
Weill Cornell Medicine
James P. Dunn, MD
New York-​Presbyterian Hospital
Wills Eye Hospital
Sidney Kimmel Medical College at Thomas Jefferson Poonam Mathur, DO, MPH
University University of Maryland Medical Center
Derek M. Fine, MD Jessica A. Meisner, MD, MS
Johns Hopkins Hospital University of Pennsylvania Health System
Anna Forbes, MSS Steven Menez, MD
American Academy of HIV Medicine Johns Hopkins School of Medicine
Rajesh Gandhi, MD Ana Monczor, MD
Massachusetts General Hospital McGovern Medical School at University of Texas at Houston
Harvard Medical School
Kudakwashe Mutyambizi, MD
Taylor K. Gill, PharmD, BCPS, AAHIVP MD Anderson Cancer Center
Ascension Via Christi Hospital The University of Texas Medical School at Houston
Michelle K. Haas, MD Puja H. Nambiar, MD
Denver Public Health Assistant Professor, Department of Medicine/​Infectious
University of Colorado, Anschutz Medical Campus Diseases
Louisiana State University Health
Dennis J. Hartigan-​O’Connor, MD, PhD
University of California, Davis Naiel Nassar, MD, FACP
University of California, San Francisco
Rodrigo Hasbun, MD, MPH
McGovern Medical School at University of Texas at Houston Karin Nielsen-​Saines, MD, MPH
David Geffen School of Medicine
Emily L. Heil, PharmD, BCIDP, BCPS, AAHIVP University of California, Los Angeles
University of Maryland School of Pharmacy

viii • FAC U LT Y
Karen Nunez-​Wallace, MD Baylor College of Medicine
Baylor College of Medicine
Kalpana D. Shere-​Wolfe, MD
Babafemi Onabanjo, MD, AAHIVS University of Maryland Medical System
Family Health Center of Worcester
Elizabeth M. Sherman, PharmD, AAHIVP
Edgar T. Overton, MD Nova Southeastern University
University of Alabama School of Medicine
William R. Short, MD, MPH, AAHIVS
Bruce J. Packett II University of Pennsylvania
American Academy of HIV Medicine
Daniel J. Skiest, MD, FACP, FIDSA
Neha Sheth Pandit, PharmD, AAHIVP, BCPS Baystate Health Professor of Medicine
University of Maryland School of Pharmacy University of Massachusetts Medical School-Baystate
Rachel A. Prosser, PhD, APRN, CNP, FAANP, AAHIVS Anthony C. Speights, MD, FACOG, AAHIVS
Hennepin County Medical Center Florida State University College of Medicine
University of Minnesota School of Nursing
Sally Spencer Long, ANP C
Metropolitan University School of Nursing
Bay State Medical Center
Centurion
RAAN Gary F. Spinner, PA, MPH, AAHIVS
Positive Healthcare LLC Southwest Community Health Center
Christian B. Ramers, MD, MPH, AAHIVS Rohit Talwani, MD
Family Health Centers of San Diego University of Maryland Medical Center
University of San Diego School of Medicine
San Diego State University School of Public Health Zelalem Temesgen, MD, FIDSA
Mayo Clinic
Brandon H. Samson, PharmD, MPW
Vaniam Group LLC Karen J. Vigil, MD
McGovern Medical School at University of Texas at Houston
Aroonsiri Sangarlangkarn, MD, MPH
HIV Netherlands Australia Thailand Research Sana Waheed, MD
Collaboration Clinic University of Wisconsin Hospitals and Clinics
Thai Red Cross Rakel Beall Wilkins, MD
Jason J. Schafer, PharmD, MPH, BCPS Magellan Health
AQ-​ID, BCIDP, AAHIVP Amanda L. Willig, PhD, RD
Jefferson College of Pharmacy The University of Alabama at Birmingham
Thomas Jefferson University
Daniel Wlodarczyk, MD
Hans P. Schlecht, MD, MMSc University of California, San Francisco
Baystate Health San Francisco General Hospital
Jeffrey T. Schouten, MD San Francisco Department of Public Health
Fred Hutchinson Cancer Research Center David A. Wohl, MD
James D. Scott, PharmD, Med, APh, University of North Carolina at Chapel Hill
FCCP, FASHP, AAHIVP NC AIDS Training and Education Center
Western University of Health Sciences College of Pharmacy Hojoon You, MD
Rajagopal V. Sekhar, MD Einstein Medical Center Philadelphia
Baylor College of Medicine Barry Zevin, MD
Lydia J. Sharp, MD San Francisco Department of Public Health

FAC U LT Y • ix
JOINT ACCREDITATION STATEMENT

In support of improving patient care, this activity has been planned and implemented by the
Postgraduate Institute for Medicine and American Academy of HIV Medicine. The Postgraduate
Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical
Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the
American Nurses Credentialing Center (ANCC) to provide continuing education for the healthcare
team.

x
 PHYSICIAN CONTINUING MEDICAL EDUCATION

The Postgraduate Institute for Medicine designates these en- 1 Credit(s)™. Physicians should claim only the credit com-
during materials for a maximum of 43.75 AMA PRA Category mensurate with the extent of their participation in the activity.

xi
 CONTINUING PHAR MACY EDUCATION

The Postgraduate Institute for Medicine designates these con- Pharmacists should check their NABP account to ensure
tinuing education activities for 43.75 contact hour(s) (4.375 credit has been submitted; it must be submitted within
CEUs) of the Accreditation Council for Pharmacy Education. 60 days of completion of activity.

xii
 CONTINUING NUR SING EDUCATION

The maximum number of hours awarded for these Continuing for a total of 10 contact hours of pharmacotherapy credit for
Nursing Education activities is 40.7 contact hours; designated Advanced Practice Registered Nurses.

xiii
 CONTENTS

Disclosure of Conflicts of Interes xix Pharmacists –​0.75 contact hours (0.075 CEUs)
Method of Participation and Request for Credit xxii ACPE UAN: JA4008162-​9999-​19-​656-​H02-​P;
Knowledge
Disclosure of Unlabeled Use  xxiii
7. HIV Testing and Counseling 67
1. Epidemiology and the Spread of HIV 1 Physicians –​maximum of 0.75 AMA PRA Category 1
Physicians –​maximum of 0.1.0 AMA PRA Category 1 Credits™
Credits™ Nurses –​0.6 contact hours
Nurses –​1.0 contact hours Pharmacists –​0.75 contact hours (0.075 CEUs)
Pharmacists –​1.0 contact hours (0.10 CEUs) ACPE UAN: JA4008162-​9999-​19-​657-​H02-​P;
ACPE UAN: JA4008162-​9999-​651-​H02-P; Knowledge
Knowledge 8. Laboratory Testing Strategies Detection and Diagnosis 73
2. The Origin, Evolution, and Epidemiology of HIV-​1 Physicians –​maximum of 0.75 AMA PRA Category 1
and HIV-​2 15 Credits™
Physicians –​maximum of 0.75 AMA PRA Category 1 Nurses –​0.6 contact hours
Credits™ Pharmacists –​0.75 contact hours (0.075 CEUs)
Nurses –​0.6 contact hours ACPE UAN: JA4008162-​9999-​19-​658-​H02-​P;
Pharmacists –​0.75 contact hours (0.075 CEUs) Knowledge
ACPE UAN: JA4008162-​9999-​652-​H02-P; 9. The Medical History and Physical Examination of the
Knowledge Patient with HIV 83
3. Mechanisms of HIV Transmission 21 Physicians –​maximum of 0.5 AMA PRA Category 1
Physicians –​maximum of 0.75 AMA PRA Category 1 Credits™
Credits™ Nurses –​0.5 contact hours
Nurses –​0.6 contact hours Pharmacists –​0.5 contact hours (0.05 CEUs)
Pharmacists –​0.75 contact hours (0.075 CEUs) ACPE UAN: JA4008162-​9999-​19-​659-​H02-​P;
ACPE UAN: JA4008162-​9999-​653-​H02-P; Knowledge
Knowledge 10. Initial Laboratory Evaluation and Risk Stratification of
4. HIV Transmission Prevention 25 the Patient with HIV 87
Physicians –​maximum of 1.0 AMA PRA Category 1 Physicians –​maximum of 0.25 AMA PRA Category 1
Credits™ Credits™
Nurses –​1.0 contact hours, 0.1 pharmacotherapy for APRN Nurses –​0.2 contact hours
Pharmacists –​1.0 contact hours (0.10 CEUs) Pharmacists –​0.25 contact hours (0.025 CEUs)
ACPE UAN: JA4008162-​9999-​19-​654-​H02-​P; ACPE UAN: JA4008162-​9999-​19-​660-​H02-​P;
Knowledge Knowledge
5. Immunology 49 11. Recognition of Acute and Advanced HIV Infection 91
Physicians –​maximum of 0.75 AMA PRA Category 1 Physicians –​maximum of 0.75 AMA PRA Category 1
Credits™ Credits™
Nurses –​0.7 contact hours, 0.2 pharmacotherapy for APRN Nurses –​0.7 contact hours, 0.3 pharmacotherapy
Pharmacists –​0.75 contact hours (0.075 CEUs) for APRN
ACPE UAN: JA4008162-​9999-​19-​655-​H02-​P; Pharmacists –​0.75 contact hours (0.075 CEUs)
Knowledge ACPE UAN: JA4008162-​9999-​19-​661-​H02-​P; Knowledge
6. HIV Cure Strategies 59 12. Health Maintenance 97
Physicians –​maximum of 0.75 AMA PRA Category 1 Physicians –​maximum of 1.25 AMA PRA Category 1
Credits™ Credits™
Nurses –​0.7 contact hours, 0.5 pharmacotherapy for Nurses –​1.2 contact hours, 0.1 pharmacotherapy
APRN for APRN

xv
 Pharmacists –​1.25 contact hours (0.125 CEUs)
ACPE UAN: JA4008162-​9999-​19-​662-​H02-​P;
Knowledge
13. Issues in Specific Patient Populations 115
Physicians –​maximum of 2.25 AMA PRA
Category 1 Credits™
Nurses –​2.1 contact hours, 0.4 pharmacotherapy for APRN
Pharmacists –​2.25 contact hours (0.225 CEUs)
ACPE UAN: JA4008162-​9999-​19-​663-​H02-​P;
Knowledge
14. Complementary and Alternative Medicine/​Integrative
Medicine Approaches
Physicians –​maximum of 1.0 AMA PRA Category 1
Credits™
Nurses –​1.0 contact hours, 0.6 pharmacotherapy
for APRN
Pharmacists –​1.0 contact hours (0.10 CEUs)
ACPE UAN: JA4008162-​9999-​19-​664-​H02-​P;
Knowledge
15. HIV Care Coordination
Physicians –​maximum of 0.75 AMA PRA Category 1
Credits™
Nurses –​0.7 contact hours
Pharmacists –​0.75 contact hours (0.075 CEUs)
ACPE UAN: JA4008162-​9999-​19-​665-​H02-​P;
Knowledge
16. The Pharmacist’s Role in Caring for HIV-​Positive
Individuals
Physicians –​maximum of 0.75 AMA PRA Category 1
Credits™
Nurses –​0.7 contact hours
Pharmacists –​0.75 contact hours (0.075 CEUs)
ACPE UAN: JA4008162-​9999-​19-​666-​H02-​P;
Knowledge
17. The Role of the Physician Assistant and the Nurse
Practitioner in Caring for Persons Living with HIV
Physicians –​maximum of 1.0 AMA PRA Category 1
Credits™
Nurses –​1.0 contact hours
Pharmacists –​1.0 contact hours (0.10 CEUs)
ACPE UAN: JA4008162-​9999-​19-​667-​H02-​P;
Knowledge
18. Hospice and Palliative Care in Advanced HIV Disease
Physicians –​maximum of 0.75 AMA PRA Category 1
Credits™
Nurses –​0.7 contact hours, 0.2 pharmacotherapy
for APRN
Pharmacists –​0.75 contact hours (0.075 CEUs)
ACPE UAN: JA4008162-​9999-​19-​668-​H02-​P;
Knowledge
19. HIV Virology
Physicians –​maximum of 1.0 AMA PRA Category 1
Credits™
Nurses –​1.0 contact hours, 0.4 pharmacotherapy
for APRN
xvi
Pharmacists –​1.0 contact hours (0.10 CEUs)
ACPE UAN: JA4008162-​9999-​19-​669-​H02-​P;
Knowledge
20. Principles of Applied Clinical Pharmacokinetics
and Pharmacodynamics in Antiretroviral Therapy 219
Physicians –​maximum of 0.75 AMA PRA
Category 1 Credits™
Nurses –​0.7 contact hours, 0.3 pharmacotherapy
for APRN
Pharmacists –​0.75 contact hours (0.075 CEUs)
ACPE UAN: JA4008162-​9999-​19-​670-​H02-​P;
157 Knowledge
21. Classes of Antiretrovirals 225
Physicians –​maximum of 0.75 AMA PRA Category 1
Credits™
Nurses –​0.6 contact hours, 0.6pharmacotherapy
for APRN
Pharmacists –​0.75 contact hours (0.075 CEUs)
ACPE UAN: JA4008162-​9999-​19-​671-​H02-​P;
175 Knowledge
22. Initiation of Antiretroviral Therapy: What to Start With 239
Physicians –​maximum of 0.5 AMA PRA Category 1
Credits™
Nurses –​0.5 contact hours, 0.1 pharmacotherapy
for APRN
Pharmacists –​0.5 contact hours (0.05 CEUs)
ACPE UAN: JA4008162-​9999-​19-​672-​H02-​P;
183 Knowledge
23. HIV-​1 Resistance to Antiretroviral Drugs 245
Physicians –​maximum of 0.5 AMA PRA Category 1
Credits™
Nurses –​0.5 contact hours
Pharmacists –​0.5 contact hours (0.05 CEUs)
ACPE UAN: JA4008162-​9999-​19-​673-​H02-​P;
Knowledge
189 24. Managing the Patient with Multidrug-​Resistant HIV 257
Physicians –​maximum of 0.5 AMA PRA Category 1
Credits™
Nurses –​0.5 contact hours, 0.4 pharmacotherapy
for APRN
Pharmacists –​0.5 contact hours (0.05 CEUs)
ACPE UAN: JA4008162-​9999-​19-​674-​H02-​P;
199 Knowledge
25. Future Antiretrovirals, Immune-​Based Strategies, and
Therapeutic Vaccines 261
Physicians –​maximum of 0.5 AMA PRA Category 1
Credits™
Nurses –​0.5 contact hours, 0.2 pharmacotherapy
for APRN
Pharmacists –​0.5 contact hours (0.05 CEUs)
205 ACPE UAN: JA4008162-​9999-​19-​675-​H02-​P;
Knowledge
26. Solid Organ Transplantation in Persons Living with HIV 275
Physicians –​maximum of 0.75 AMA PRA Category 1
Credits™
• C ontents
 Nurses –​0.6 contact hours
Pharmacists –​0.75 contact hours (0.075 CEUs)
ACPE UAN: JA4008162-​9999-​19-​676-​H02-​P; Knowledge
27. Antiretroviral Therapy in Pregnant Women 281
Physicians –​maximum of 0.5 AMA PRA
Category 1 Credits™
Nurses –​0.5 contact hours, 0.1 pharmacotherapy
for APRN
Pharmacists –​0.5 contact hours (0.05 CEUs)
ACPE UAN: JA4008162-​9999-​19-​677-​H02-​P;
Knowledge
28. Antiretroviral Therapy for Children and Newborns 287
Physicians –​maximum of 0.75 AMA PRA Category 1
Credits™
Nurses –​0.7 contact hours
Pharmacists –​0.75 contact hours (0.075 CEUs)
ACPE UAN: JA4008162-​9999-​19-​678-​H02-​P;
Knowledge
29. Immunosuppressants and Antiretroviral Therapy
in HIV-​Positive Transplant Patients 297
Physicians –​maximum of 0.75 AMA PRA Category 1
Credits™
Nurses –​0.6 contact hours, 0.3 pharmacotherapy
for APRN
Pharmacists –​0.75 contact hours (0.075 CEUs)
ACPE UAN: JA4008162-​9999-​19-​679-​H02-​P;
Knowledge
30. Understanding and Managing Antineoplastic and
Antiretroviral Therapy 301
Physicians –​maximum of 0.5 AMA PRA Category 1
Credits™
Nurses –​0.5 contact hours
Pharmacists –​0.5 contact hours (0.05 CEUs)
ACPE UAN: JA4008162-​9999-​19-​680-​H02-​P;
Knowledge
31. Substance Abuse in HIV Populations 309
Physicians –​maximum of 1.0 AMA PRA Category 1
Credits™
Nurses –​1.0 contact hours, 0.6 pharmacotherapy
for APRN
Pharmacists –​1.0 contact hours (0.10 CEUs)
ACPE UAN: JA4008162-​9999-​19-​681-​H02-​P;
Knowledge
32. Understanding the Use of Antiretrovirals in the Aging
Patient 317
Physicians –​maximum of 0.75 AMA PRA Category 1
Credits™
Nurses –​0.7 contact hours, 0.6 pharmacotherapy
for APRN
Pharmacists –​0.75 contact hours (0.075 CEUs)
ACPE UAN: JA4008162-​9999-​19-​682-​H02-​P;
Knowledge
33. Opportunistic Infections 323
Physicians –​maximum of 1.0 AMA PRA Category 1
Credits™
C ontents  •
Nurses –​1.0 contact hours, 0.3 pharmacotherapy for APRN
Pharmacists –​1.0 contact hours (0.10 CEUs)
ACPE UAN: JA4008162-​9999-​19-​683-​H02-​P;
Knowledge
34. Malignancies in HIV 337
Physicians –​maximum of 1.5 AMA PRA Category 1
Credits™
Nurses –​1.5 contact hours, 0.3 pharmacotherapy
for APRN
Pharmacists –​1.5 contact hours (0.15 CEUs)
ACPE UAN: JA4008162-​9999-​19-​684-​H02-​P;
Knowledge
35. Dermatologic Complications 379
Physicians –​maximum of 1.0 AMA PRA Category 1
Credits™
Nurses –​1.0 contact hours, 0.4 pharmacotherapy
for APRN
Pharmacists –​1.0 contact hours (0.10 CEUs)
ACPE UAN: JA4008162-​9999-​19-​685-​H02-​P;
Knowledge
36. Endocrine and Metabolic Disorders 391
Physicians –​maximum of 0.75 AMA PRA Category 1
Credits™
Nurses –​0.7 contact hours, 0.1 pharmacotherapy
for APRN
Pharmacists –​0.75 contact hours (0.075 CEUs)
ACPE UAN: JA4008162-​9999-​19-​686-​H02-​P;
Knowledge
37. Nonopportunistic Infections: Respiratory
Complications 399
Physicians –​maximum of 0.75 AMA PRA Category 1
Credits™
Nurses –​0.7 contact hours, 0.1 pharmacotherapy
for APRN
Pharmacists –​0.75 contact hours (0.075 CEUs)
ACPE UAN: JA4008162-​9999-​19-​687-​H02-​P;
Knowledge
38. Psychiatric Illness and Treatment in HIV Populations 403
Physicians –​maximum of 1.0 AMA PRA Category 1
Credits™
Nurses –​1.0 contact hours, 0.3 pharmacotherapy
for APRN
Pharmacists –​1.0 contact hours (0.10 CEUs)
ACPE UAN: JA4008162-​9999-​19-​688-​H02-​P;
Knowledge
39. Neurological Effects of HIV Infection 413
Physicians –​maximum of 1.25 AMA PRA Category 1
Credits™
Nurses –​1.2 contact hours, 0.3 pharmacotherapy
for APRN
Pharmacists –​1.25 contact hours (0.125 CEUs)
ACPE UAN: JA4008162-​9999-​19-​689-​H02-​P;
Knowledge
xvii
40. HIV and Hepatitis Coinfection 433 Pharmacists –​1.0 contact hours (0.10 CEUs)
Physicians –​maximum of 1.25 AMA PRA Category 1 ACPE UAN: JA4008162-​9999-​19-​696-​H02-​P;
Credits™ Application
Nurses –​1.2 contact hours, 0.6 pharmacotherapy for APRN 47. HIV-​Associated Lipodystrophy and Lipoatrophy 505
Pharmacists –​1.25 contact hours (0.125 CEUs) Physicians –​maximum of 0.75 AMA PRA
ACPE UAN: JA4008162-​9999-​19-​690-​H02-​P; Knowledge Category 1 Credits™
41. Ocular Complications 447 Nurses –​0.6 contact hours
Physicians –​maximum of 0.75 AMA PRA Pharmacists –​0.75 contact hours (0.075 CEUs)
Category 1 Credits™ ACPE UAN: JA4008162-​9999-​19-​697-​H02-​P;
Nurses –​0.7 contact hours, 0.1 pharmacotherapy Knowledge
for APRN 48. Immune Reconstitution Inflammatory Syndrome (IRIS) 513
Pharmacists –​0.75 contact hours (0.075 CEUs) Physicians –​maximum of 0.75 AMA PRA
ACPE UAN: JA4008162-​9999-​19-​691-​H02-​P; Category 1 Credits™
Knowledge Nurses –​0.6 contact hours
42. Cardiovascular Disease 453 Pharmacists –​0.75 contact hours (0.075 CEUs)
Physicians –​maximum of 1.0 AMA PRA Category 1 ACPE UAN: JA4008162-​9999-​19-​698-​H02-​P;
Credits™ Knowledge
Nurses –​1.0 contact hours, 0.4 pharmacotherapy 49. US Healthcare Systems, HIV Programs, and Coverage
for APRN Policy Issues 519
Pharmacists –​1.0 contact hours (0.10 CEUs) Physicians –​maximum of 0.75 AMA PRA Category 1
ACPE UAN: JA4008162-​9999-​19-​692-​H02-​P; Credits™
Knowledge Nurses –​0.6 contact hours
43. Renal Complications 469 Pharmacists –​0.75 contact hours (0.075 CEUs)
Physicians –​maximum of 1.0 AMA PRA Category 1 ACPE UAN: JA4008162-​9999-​19-​699-​H02-​P;
Credits™ Knowledge
Nurses –​1.0 contact hours, 0.5 pharmacotherapy 50. Legal Issues 525
for APRN Physicians –​maximum of 1.0 AMA PRA Category 1
Pharmacists –​1.0 contact hours (0.10 CEUs) Credits™
ACPE UAN: JA4008162-​9999-​19-​693-​H02-​P; Nurses –​0.8 contact hours
Knowledge Pharmacists –​1.0 contact hours (0.10 CEUs)
44. Body Composition Changes, Frailty, and ACPE UAN: JA4008162-​9999-​19-​700-​H02-​P;
Musculoskeletal Complications of HIV 481 Knowledge
Physicians –​maximum of 0.75 AMA PRA Category 1 51. Research Design and Analysis 541
Credits™ Physicians –​maximum of 0.75 AMA PRA
Nurses –​0.7 contact hours, 0.1 pharmacotherapy Category 1 Credits™
for APRN Nurses –​0.6 contact hours
Pharmacists –​0.75 contact hours (0.075 CEUs) Pharmacists –​0.75 contact hours (0.075 CEUs)
ACPE UAN: JA4008162-​9999-​19-​694-​H02-​P; ACPE UAN: JA4008162-​9999-​19-​701-​H02-​P;
Knowledge Knowledge
45. Sexually Transmitted Diseases 487 52. Ethical Conduct of Clinical Trials, Institutional
Physicians –​maximum of 0.75 AMA PRA Category 1 Review Boards, Informed Consent, and Financial
Credits™ Conflicts of Interest 545
Nurses –​0.7 contact hours, 0.1 pharmacotherapy Physicians –​maximum of 0.75 AMA PRA Category 1
for APRN Credits™
Pharmacists –​0.75 contact hours (0.075 CEUs) Nurses –​0.6 contact hours
ACPE UAN: JA4008162-​9999-​19-​695-​H02-​P; Pharmacists –​0.75 contact hours (0.075 CEUs)
Knowledge ACPE UAN: JA4008162-​9999-​19-​702-​H02-​P;
46. HIV and Bone Health 493 Knowledge
Physicians –​maximum of 1.0 AMA PRA Category 1
Credits™ Index 549
Nurses –​1.0 contact hours, 0.2 pharmacotherapy
for APRN

xviii • C ontents
 DISCLOSURE OF CONFLICTS OF INTEREST

The Postgraduate Institute for Medicine (PIM) requires
instructors, planners, managers, and other individuals who are
in a position to control the content of this activity to disclose
any real or apparent conflict of interest (COI) they may have
as related to the content of this activity. All identified COIs are
thoroughly vetted and resolved according to PIM policy. PIM
is committed to providing its learners with high-​quality CME
activities and related materials that promote improvements or
quality in healthcare and not a specific proprietary business
interest of a commercial interest.
The faculty reported the following financial relationships
or relationships to products or devices they or their spouses/​
life partners have with commercial interests related to the con-
tent of this CME activity:

Name of Faculty or Presenter Reported Financial Relationship

Saira Ajmal Nothing to disclose

Kevin Alby Nothing to disclose
Benjamin Alfred Nothing to disclose
Jonathan Appelbaum Consulting fees: Merck, ViiV Healthcare
Lisa Armitage Nothing to disclose
Roberto C. Arduino Contracted Research Viiv Healthcare, Inc.
Renata Arrington-Sanders Nothing to disclose
Jason Baker Nothing to disclose
Ben J. Barnett, MD Consulting fees: Gilead, BMS
Fees for non-CME/CE services: Gilead, Merck
Rakel Beall Wilkins Nothing to disclose
Tamara Bininashvili Nothing to disclose
Jatandra Birney Nothing to disclose
Saira Ajmal Nothing to disclose
Emily Blumberg Nothing to disclose
Philip Bolduc Nothing to disclose
Christopher Bositis Nothing to disclose
Christian Brander Salary: Aelix Therapeutics
Consulting fees: Gritstone Inc, GLG
Contracted research: Aelix Therapeutics
Ownership interest: Aelix Therapeutics
Christopher Brendemuhl Nothing to disclose
John Casas Nothing to disclose
Elizabeth Chiao Nothing to disclose
Carolyn Chu Nothing to disclose
Joseph Church Nothing to disclose
Eva Clark Nothing to disclose
Jennifer Cocohoba Nothing to disclose
Dagan Coppock Nothing to disclose
Vishal Dahya Nothing to disclose
Elizabeth David Nothing to disclose

xix
Trew Deckard Fees for non-CME/CE services received directly from a commercial interest
or their agents (e.g., speakers bureau): Gilead Sciences, Janssen
Alejandro Delgado Nothing to disclose
Paul DenOuden Nothing to disclose
Madeline Deutsch Contracted research: Gilead
Quentin Doperalski Nothing to disclose
Richard Dunham Nothing to disclose
James Dunn Fees for non-CME/CE services received directly from a commercial interest
or their agents (e.g., speakers bureau): AbbVie
Derek Fine Nothing to disclose
Anna Forbes Nothing to disclose
Rajesh Gandhi Consulting fees: Merck, Gilead
Research support: Gilead, Theratechnologies, ViiV, Janssen
Taylor Gill Nothing to disclose
Michelle Haas Nothing to disclose
Dennis Hartigan-O’Connor Nothing to disclose
W. David Hardy Consulting fees: Gilead, Merck, ViiV/GSK
Contracted research: Amgen, Gilead, Janssen, Merck, ViiV/GSK
Rodrigo Hasbun Consulting fees: Gilead
Fees for non-CME/CE services received directly from a commercial interest
or their agents (e.g., speakers bureau): Biofire
Contracted research: Biofire
Emily Heil Nothing to disclose
Margaret Hoffman-Terry Consulting fees: Gilead, ViiV
Fees for non-CME/CE services received directly from a commercial interest
or their agents (e.g., speakers bureau): Gilead
Contracted research: ViiV
Jennifer Husson Contracted research: Merck, Sharpe, Dome Inc., Intercept Pharmaceuticals
Niyati Jakharia Nothing to disclose
Boris Juelg Research support: Gilead Sciences
Joseph Kass Contracted research: Alzheimer’s Disease Clinical Trial supported by
Biogen, Takeda, Roche/Genentech, Novartis
Jeff Kirchner Nothing to disclose
David Koren Consulting fees: Gilead Sciences, ViiV Healthcare
Contracted research: Gilead Sciences
Carolyn Kramer** Nothing to disclose
Doris Kung Nothing to disclose
Eurides Lopes Nothing to disclose
Adrian Majid Nothing to disclose
Poonam Mathur Nothing to disclose
Jessica Meisner Nothing to disclose
Steven Menez Nothing to disclose
Ana Monczor Nothing to disclose
Kudakwashe Mutyambizi Maloney Nothing to disclose
Puja Nambiar Nothing to disclose
Naiel Nassar Nothing to disclose
Karin Nielsen-Saines Nothing to disclose
Karen Nunez-Wallace Nothing to disclose
Babafemi Onabanjo Nothing to disclose
Edgar Overton Consulting fees: ViiV Healthcare, Merck, Thera Technologies
Bruce Packett Nothing to disclose
Rachel Prosser Consulting fees: Gilead
Contracted research: Gilead, ViiV, GSK

xx • D isclosure of C onflicts of I nterest

 Christian Ramers Consulting fees: Gilead Sciences, AbbVie
Commercial interest or their agents (e.g., speakers bureau): Gilead Sciences,
AbbVie, ViiV, Merck
Contracted research: Gilead Sciences
Brandon Samson Nothing to disclose
Aroonsiri Sangarlangkarn Nothing to disclose
Jason Schafer Consulting fees: Theratechnologies Inc.
Contracted research: Merck Sharp and Dohme, Gilead Sciences
Hans Schlecht Nothing to disclose
Jeffrey Schouten Nothing to disclose
James Scott Nothing to disclose
Rajagopal Sekhar Nothing to disclose
Lydia Sharp Nothing to disclose
Kalphana Shere-Wolfe Nothing to disclose
Elizabeth Sherman Nothing to disclose
Neha Sheth Pandit Nothing to disclose
William Short Consulting fees: ViiV, Gilead Sciences
Fees for non-CME/CE services received directly from a commercial interest
or their agents (e.g., speakers bureau): Janssen
Daniel Skiest Nothing to disclose
Anthony Speights Nothing to disclose
Sally Spencer Long Nothing to disclose
Gary Spinner Consulting fees: Gilead Sciences
Ownership interest: Gilead Sciences
Rohit Talwani Nothing to disclose
Zelalem Temesgen Consulting fees: ViiV Healthcare
Karen Vigil Consulting fees: Viiv, Gilead, Napo Pharmaceuticals Consulting
research: Merck
Sana Waheed Nothing to disclose
Amanda Willig Nothing to disclose
Daniel Wlodarczyk Nothing to disclose
David Wohl Consulting fees: Gilead, ViiV, Janssen, Merck
Contracted research: Gilead, Merck, ViiV
Hojoon You Nothing to disclose
Barry Zevin Nothing to disclose

The planners and managers reported the following finan- The PIM planners and managers have nothing to disclose.
cial relationships or relationships to products or devices they
The AAHIVM planners and managers have nothing to
or their spouses/​life partners have with commercial interests
disclose.
related to the content of this CME activity:

D isclosure of C onflicts of I nterest  • xxi

 METHOD OF PARTICIPATION AND REQUEST
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xxiii
DISCLAIMER
Participants have an implied responsibility to use the newly
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 1.
EPIDEMIOLOGY AND THE SPREAD OF HIV
Philip Bolduc, Benjamin Alfred, and Babafemi Onabanjo
CHAPTER GOALS
Upon completion of this chapter, the reader should
be able to
• Provide an overview of the global AIDS pandemic
and the US epidemic
• Demonstrate and apply knowledge about the
evolving epidemiology of HIV to both individual
and population-​wide aspects of clinical practice
• Educate clinicians and patients about factors
driving HIV transmission so that they will
understand who is at greatest risk of infection
O VE RVI EW O F WO R L DW I D E PA N D E M I C
L E A R N I N G O B J E C T I VE
Discuss the global prevalence and geographic distribution of
HIV-​1 and HIV-​2 infections.
WH AT ’S N EW ?
The World Health Organization/​ Joint United Nations
Programme on HIV and AIDS (WHO/​UNAIDS) estimates
that, in 2017, nearly 40 million people worldwide were infected
with HIV (UNAIDS, 2018). Although the numbers of new
HIV infections and AIDS-​related deaths continue to decline
in many regions of the world, including sub-​Saharan Africa,
there are still certain regions where the incidence of HIV is
rising, most notably in the eastern European and eastern
Mediterranean areas. In his foreword to the UNAIDS Global
AIDS Update 2018, executive director Michel Sidibe writes
“The global AIDS response is at a precarious point—​partial
success in saving lives and stopping new HIV infections is
giving way to complacency. At the halfway point to the 2020
targets, the pace of progress is not matching the global ambi-
tion” (Sidibe, 2018).
K EY P O I N TS
• UNAIDS identified several demographic subgroups at
high risk for HIV infection and in danger of being left
1
behind by the global AIDS response, including adolescent
girls and young women, men who have sex with men
(MSM), transgender people, people who inject drugs,
prisoners, and sex workers.
• HIV occurs as types 1 and 2, with several groups and
subtypes comprising HIV-​1. Subtype B predominates
in the Western Hemisphere and Western Europe,
whereas other subtypes and recombinant forms are more
prevalent elsewhere. Introduction of other subtypes
and recombinant strains is occurring in the Western
Hemisphere and Western Europe.
O VE RVI EW O F G L O B A L PA N D E M I C
Data from the WHO and UNAIDS show global estimates
of HIV as a continuing pandemic, with increasing overall
prevalence (36.9 million) but fewer new infections each year
(1.8 million), more people on antiretroviral therapy (ART;
21.7 million), and fewer annual deaths (0.9 million) (Figures
1.1 and 1.2) (UNAIDS, 2018).
Africa remains the continent most heavily affected by
HIV/​AIDS, accounting for 70% of persons living with HIV
in 2017 (Figure 1.3). However, due to several global initiatives,
there has been a dramatic decline in the annual number of
new HIV infections (−24%) and deaths (−35%) in 2017
compared to 2000 (UNAIDS, 2018). Annual infections and
deaths have also declined over this period in the Americas
(−5% and −20%, respectively) and Southeast Asia (−27%
and −40%), but trends in Europe (+20% and −5%) and the
Western Pacific areas (+7% and −45%) are mixed, and the
Eastern Mediterranean area saw increases in both infections
and deaths (+27% and +59%) (UNAIDS, 2018).
Across all countries, several key demographic subgroups
continue to be most impacted by the HIV/​AIDS epidemic.
UNAIDS has identified six populations at higher risk of HIV
infection that are in danger of being left behind by the global
AIDS response: adolescent girls and young women, MSM,
transgender people, people who inject drugs, prisoners, and
sex workers. The risk of acquiring HIV is 27 times higher
among MSM; 23 times higher among people who inject
drugs; 13 times higher for female sex workers; and 12 times
 2017
Globally
36.9 million
People living with HIV
+14%
Relative to 2010
Figure 1.1 Global HIV epidemic since 2010—​prevalence, incidence and mortality trends.
higher for transgender women compared to other adults in
the general population (UNAIDS, 2018).
The importance of each of these populations varies by re-
gion and within countries. For example, in southern Africa,
age-​
disparate intergenerational sexual relationships and
transactional sex place adolescent girls and young women at
extremely high risk for HIV; in Eastern Europe and Central
Asia, most new HIV infections are associated with people
who inject drugs; and in the Latin American and Caribbean
regions, the largest proportion of new HIV infections is
among MSM. These six key populations and their sexual part-
ners account for 47% of new HIV infections globally, but with
wide geographic differences: just 16% in eastern and southern
Africa but an incredible 95% in Eastern Europe, central Asia,
the Middle East, and North Africa (UNAIDS, 2018).
As of 2017, 21.7 million people living with HIV were
accessing ART, an increase of 2.3 million since 2016 and
13.7 million from 2010. Additionally, in 2017, 80% of pregnant
women living with HIV had access to antiretrovirals to prevent
mother-​to-​child transmission (UNAIDS, 2018). With better
access to testing, 75% of all people living with HIV knew
35 000 000
30 000 000
25 000 000
20 000 000
15 000 000
10 000 000
5 000 000
0
2010 2011 2012
Figure 1.2 Increase in people receiving ART over time.
August 13, 2018.
2 •
1.8 million
–18%
New diagnoses annually
relative to 2010
0.9 million
–34%
Deaths annually
relative to 2010
SOURCE: UNAIDS/​WHO estimates, 2017.
their HIV status in 2017 compared with ~50% of those living
with HIV in 2014. Despite these significant achievements in
the global HIV response, there is still much work to be done.
The 2017 global HIV testing and care continuum (Figure 1.4)
demonstrates that more than half of the world’s people living
with HIV are still not on antiretroviral treatment and that
significant gaps remain to reach the UNAIDS 90-​90-​90 goal
by 2020 (90% of infected persons will be diagnosed, 90% of
those will be on treatment, and 90% of those will be virally
suppressed).
HIV DIVER SIT Y
There are two major types of HIV, designated HIV-​1 and
HIV-​2. Each has a similar but distinct genome with a ge-
netic difference of approximately 60%. The vast majority of
clinical cases are caused by HIV-​1, with HIV-​2 comprising
only 1–​2 million of the 36.9 million HIV cases living in 2016
(Campbell-​Yesufu, 2011). HIV-​2 is found almost exclusively
in persons from or living in West Africa and is transmitted at
lower rates than HIV-​1. It appears to have a longer incubation
2013 2014 2015 2016 2017 2018 2019 2020
Upper range Total number of people receiving ART
Lower range 2020 target
SOURCE: UNAIDS/​WHO estimates, 2017. WHO HIV Update 2018. Available at http://​www.who.int/​hiv/​data/​en/​. Accessed
F u ndamen tal s of H I V M edicine
Figure 1.3 People living with HIV by WHO region (2017). SOURCE: UNAIDS/​WHO estimates, 2017.

period, produce lower plasma viral load, and lead to AIDS in
fewer patients (Apetrei, 2004). HIV-​1 is classified into three
genetically related subtypes based on the coding sequence of
the envelope gene. Group M (Main) is the most common, and
groups O (Outlier) and N (Not-​M, Not-​O or New) remain
rare (Apetrei, 2004). Group M has at least 11 subtypes, or
clades, designated A–​K .
HIV subtype (i.e., group) variability may eventually in-
fluence how ART is used, although studies to date suggest
40
90%
30
75%
Millions
that most antiretroviral agents appear to be equally effective
regardless of the viral subtype. Certain subtypes may be less
sensitive to or have a greater propensity to develop resistance
to antiretroviral drugs or classes of these drugs (Spira, 2003;
Gomes, 2002; Wainberg, 2004). A study from Thailand
found that discordant viral load results were obtained in per-
sons with non-​B subtypes (Hackett, 2004).
There is limited clinical trial information on the effect of
ART for HIV-​2 infection. An in vitro study found that al-
though the HIV-​2 isolates tested were susceptible to the an-
tiviral activities of nucleoside reverse transcriptase inhibitors
and most protease inhibitors, they were highly resistant to
non-​ nucleoside reverse transcriptase inhibitors (NNRTIs)
90%
(Witvrouw, 2004). Older studies of patients infected with
90%
HIV-​2 receiving ART found mutations in HIV-​2 reverse tran-
scriptase and protease genes associated with HIV-​1 drug resist-

20 ance for each major drug class, including enfuvirtide, although

59% HIV-​2 also appears to have reverse transcriptase mutations
47% that are not found in HIV-​1 (Witvrouw, 2004; Colson, 2005;
10 Damond, 2005; Rodes, 2000).
A 2013 in vitro study found that HIV-​2 showed sus-
ceptibility to several newer antiretroviral agents, including
tenofovir, emtricitabine, and the integrase inhibitor
People living Aware of On treatment Viral load
with HIV HIV status suppression elvitegravir (Andreatta, 2013). A small study of five patients
with HIV-​2 found effective virologic responses and CD4+
Figure 1.4 HIV testing and care continuum (2017). SOURCE: UNAIDS/​WHO cell increases when raltegravir was part of their ART regimen
estimates, 2017. WHO HIV Update 2018. Available at http://​www.who.int/​hiv/​data/​en/​. Accessed August
13, 2018.
(Peterson, 2012). The net clinical implication of these findings

E pidemiology and t he Spread of H I V • 3

is that persons with HIV-​2 should not be treated with any of
the currently available NNRTI medications or enfurvitide,
whereas other classes are likely to be effective (US Department
of Health and Human Services [USDHHS], 2018).
RECOMMENDED READING
UNAIDS. Global HIV & AIDS statistics—​2018 fact sheet. Available at
http://​www.unaids.org/​en/​resources/​fact-​sheet. Accessed September
28, 2018.
World Health Organization. HIV/​AIDS data and statistics. Available at
http://​www.who.int/​hiv/​data/​en/​ Accessed September 28, 2018.
O VE RVI EW O F US E P I D E M I C
L E A R N I N G O B J E C T I VE
Describe current demographic trends in HIV disease in the
United States, especially regarding gender, sexuality, race/​eth-
nicity, age, injection-​drug use, socioeconomic status, and re-
cent initiatives.
WH AT ’S N EW ?
HIV, originally concentrated in the urban areas of the
Northeast and California, continues its shift into the south-
eastern United States.
K EY P O I N TS
• HIV incidence among young black and Latino MSM
continues to increase.
• The leading mode of HIV transmission continues to be
male same-​sex sexual contact.
• Nearly flat overall incidence rates and declining death
rates continue to drive up HIV prevalence and workforce
demands.
O V E R A L L US H I V P R EVA L E N C E , I N C I D E N C E ,
A N D D E AT H S
(NB: at the time of this writing, the majority of available
US HIV epidemiologic data from the US Centers for Disease
Control and Prevention [CDC] was published in 2016, covering
through 2015.)
According to the CDC, which reports on the prevalence
and incidence of HIV and AIDS in the 50 US states and six ter-
ritories, in 2015, an estimated 1.1 million persons aged 13 years
or older were living with HIV, including 15% who were una-
ware of their diagnosis (CDC HIV/AIDS Resource Library
Slideset, 2016). The year 2016 saw 39,782 new diagnoses, up
from 38,500 in 2015. From 2011 through 2015, the annual
number of new HIV diagnoses decreased in people who in-
ject drugs (−16%), heterosexuals (−15%), and white gay and
4 • F u ndamen tal s of H I V M edicine
bisexual men (−10%). However, within this same time period,
new cases increased among African American (+4%) and
Hispanic/​Latino (+14%) gay and bisexual men, accounting
for the overall increase in new infections (HIV.gov, 2016).
Death rates continue in a low, slow decline following
the sharp drop-​off with the advent of effective antiretroviral
treatments in 1996. With new infections outpacing deaths
by approximately 25,000 cases each year, HIV prevalence
continues to rise. Two important implications of this are that
more clinicians will be needed to care for the burgeoning HIV
population, and more must be done to prevent HIV transmis-
sion by targeting high-​risk populations with interventions of
proven efficacy, such as preexposure prophylaxis (PrEP) and
treatment-​as-​prevention.
H I V D E M O G R A P H I C S AC RO S S T H E S TAT E S
To take a regional look at these statistics, Figure 1.5 shows
the rates of people living with HIV by state in 2015, showing
clear weighting toward the West Coast, Northeast, and South.
The South is disproportionally affected, comprising half of
the new HIV infections in 2015, 46% of HIV prevalence,
and 53% of deaths among HIV patients, despite having only
38% of the US population. Despite this unequal impact,
Figure 1.5 also demonstrates that HIV is now also widely dis-
tributed throughout the United States. Consequently, HIV
clinicians will be needed in new geographic locations to reach
underserved areas. In addition, HIV prevention and educa-
tion must expand beyond historically high-​prevalence areas
to virtually every state and county in the United States to re-
duce new infections in a way that we have not been able to do
thus far.
A I D S R E M A I NS C O M MO N
Despite CDC and US Preventive Task Force recommendations
for routine, opt-​out, non–​risk factor-​based HIV screening
since 2006, AIDS remains disappointingly common, with
18,160 persons receiving a new AIDS diagnosis in 2016,
comprising 46% of the number of new HIV infections in 2016.
New AIDS diagnoses follow a geographic trend similar to
HIV diagnoses, with the heaviest impact in the South (53%),
followed by the West (17%), Northeast (17%), and Midwest
(13%). The high rate of AIDS despite widespread availability
of effective, tolerable antiretroviral treatment highlights the
need for improved HIV screening as well as care linkage, re-
tention, and treatment for those already diagnosed with HIV
(HIV.gov, 2016).
T H E US H I V C A R E C O N T I NU U M
The US rates of HIV diagnosis among persons estimated to
be HIV-​infected, care linkage and retention, and viral sup-
pression are represented in the CDC’s HIV care continuum
(Figure 1.6). Since the National HIV/​AIDS Strategy re-
lease in 2010, the HIV treatment community has focused on
the care continuum as the leading quality indicator in our
healthcare system’s response to HIV. As ART has become
 WA
208.3 ME
MT ND VT 123.7 128.5
66.1 53.4
OR
ID MN
193.7 171.3 WI NY NH 107.6
SD
79.2 122.0 768.8
73.3 MI MA 338.4
WY
174.6 RI 259.5
59.7 IA
NE PA 314.4 CT 338.7
NV 93.5 NJ 473.7
UT 131.6 OH
IL IN MD 657.8
371.0 116.4 212.5
CO 330.1 195.7 WV DE 404.9
CA MO
253.6 KS 113.3 307.7 DC 2,590.2
234.0 179.6
376.4 118.6 VA
KY
American Samoa 4.7
NC 354.9
Guam 59.3 AZ OK TN 297.4
270.0 NM AR SC
Northern Mariana Islands 14.9 179.9
186.5 214.8 394.6
Puerto Rico 564.0 AL
MS GA
Republic of Palau 39.6 302.4 588.0
TX LA 374.0
U.S. Virgin Islands 635.5
368.9
504.7 Rates per 100,000 population
FL 4.7–119.9
615.2 120.0–214.9
215.0–369.9
AK 109.3 HI 233.1
370.0–2,590.2
Data classified using quartiles

Figure 1.5 Rates of adults and adolescents living with diagnosed HIV infections, year-​end 2015 (United States and 6 Dependent Areas). N = 988,955, Total Rate = 364.3. CDC HIV/​AIDS Resource Library Slide Sets.
Available at http://​www.cdc.gov/​hiv/​library/​slidesets/​index.html. Accessed August 14, 2018.
 100
90 86
80
70 63

Percentage (%)
60 51
49
50
40
30
20
10
0
Diagnosed Receipt of care Retained in care Viral suppression

Figure 1.6 Persons living with diagnosed or undiagnosed HIV infection HIV care continuum outcomes, 2015 (United States). CDC HIV/​AIDS Resource Library
Slide Sets. Available at http://​www.cdc.gov/​hiv/​library/​slidesets/​index.html Accessed August 14, 2018.

increasingly potent, less toxic, and easier to take, the greatest T R A NS M I S S I O N BY MO D E A N D AG E

challenges in suppressing “community viral load” now exist Efforts at HIV screening and prevention must target those
primarily in the first two steps of the continuum, which in at greatest risk for HIV infection by understanding how
2015 were the percentage of undiagnosed patients (14%) and HIV transmissions are occurring and among what age
the additional percentage of diagnosed patients who were groups. MSM continue to make up the majority of new HIV
not receiving medical care (23%). Only minor progress was infections (68%), easily outpacing all other transmission
made from 2009 to 2012 in these measures, and in 2012 fewer modes combined (Figure 1.7). Another distinct trend is that
than one-​third of persons with HIV in the United States the decreasing incidence in all age groups older than 34 years
were virally suppressed. However, by 2016, 76% of persons re- is now outweighed by increases in HIV incidence among 13-​
ceiving an HIV diagnosis were linked to care within 1 month, to 24-​year-​old and 25-​to 34-​year-​old individuals (Figure 1.8).
improving the overall viral suppression rate to 51%. Providing Of the 39,782 new HIV diagnosis in the United States in 2016,
HIV care across a variety of settings, particularly community 41% were 13–​29 years old; however, 17% of new infections
health centers and other medical homes that serve affected were in the 50+ age group, reminding clinicians to screen for
populations with cultural competence, is critical to fur- HIV well outside the peak demographic (HIV.gov, 2016).
ther improving the HIV care continuum. This supports the
National HIV/​AIDS Strategy goals, which include reducing
new HIV infections, increasing access to care and improving
health outcomes for people living with HIV infection, and RECOMMENDED READING
reducing HIV-​ related health disparities (National HIV/​
AIDS Strategy, 2015 Accessed August 13, 2018). Centers for Disease Control and Prevention. HIV Surveillance
Report, 2016. Available at http://​www.cdc.gov/​hiv/​library/​reports/​
surveillance.

3,400 (9%) among

people who inject drugs*
S P R E A D O F H I V A M O N G WO M E N,
C H I L D R E N, A N D A D O L E S C E N TS

WH AT ’S N EW ?
Nineteen percent of HIV diagnoses in 2015 in the United
8,800 (23%) States were among women, which represents a decrease from
among 2013 (24%). With widespread utilization of ART, transmis-
heterosexuals
sion of HIV from mother to child has decreased to less than
1% in the United States.
26,200 (68%)
among gay and
bisexual men K EY P O I N TS
• High-​risk heterosexual contact remains the most common
risk factor for HIV acquisition among adult women.
• The CDC recommends opt-​out testing for all pregnant
women in the first trimester and repeat testing in the third
Estimated New HIV Infections in the United States by
Figure 1.7
trimester for women at risk for infection. Adolescent HIV
Transmission Category, 2015. SOURCE: CDC, 2017. transmission mirrors adult patterns, with large majorities

6 • F u ndamen tal s of H I V M edicine

 35

30 25–34 years

(per 100,000 population)

35–44 yea
25 rs

Diagnoses, Rate
20 45–54 years
15 13–24 years

10
≥55 years
5

0
2010 2011 2012 2013 2014 2015
Year of diagnosis

Figure 1.8 Rates of Diagnoses of HIV Infection among Adults and Adolescents by Age at Diagnosis, 2010–​2015 (United States). SOURCE: CDC, 2017. CDC
HIV In the United States At A Glance. Available at https://​www.cdc.gov/​hiv/​statistics/​overview/​ataglance.html. Accessed August 15, 2018. CDC HIV/​AIDS Resource Library Slide Sets. Available at http://​www.cdc.gov/​
hiv/​library/​slidesets/​index.html Accessed August 14, 2018.

of males infected via same-​sex contact and females via Factors that increase a woman’s risk of acquiring HIV in-
heterosexual contact. clude not knowing her partner’s risk factors for HIV infec-
tion, having a lack of HIV knowledge, and having a decreased
awareness of risk (CDC, 2011). Women’s relationships with
their partners play a pivotal role as well: in relationships in
WO M E N
which women are physically abused, vulnerability to HIV is
Worldwide in 2016, women continue to account for more increased because they may not insist on condom use due to
than half (51%) of all HIV-​infected persons and 43% of fear of being harmed. Women with a history of sexual abuse
new infections largely through heterosexual transmis- are more likely to engage in high-​risk sexual activity and use
sion (American Foundation for AIDS Research [amfAR], drugs compared to women without such behaviors. This
2017). In sub-​Saharan Africa, three of four new infections includes exchanging sexual activities for drugs and money as
are among girls aged 15–​19 years, and young women aged well as having difficulty refusing unwanted sex.
15–​24 years are twice as likely as men to be living with HIV The most common mode of transmission for women
(UNAIDS, 2018). However, in the United States, women is high-​ risk heterosexual contact (84–​ 88% across various
represented only 19% of HIV diagnoses in 2015, down groups), followed by injection drug use. These rates, current
from 24% in 2013, comprising an estimated 7,529 newly through 2016, may change with the deepening national opioid
diagnosed infections. This disparity is due to the preponder- crisis and outbreaks of HIV transmission among needle-​
ance of male-​to-​male HIV transmission in the United States. sharing networks (CDC, 2016).
Of these new diagnoses, approximately 4,271 were stage 3 Sexual HIV transmission occurs through unprotected vag-
(AIDS) classifications, a number that has been declining inal or anal sex, with receptive anal sex posing the highest risk
since 1996, but remains stubbornly fixed around one-​quarter and insertive vaginal sex the lowest. Oral sex is a theoretical
of all HIV diagnoses among women, highlighting the need to risk if there are breaks in the oral and genital mucosa through
improve testing to find patients before progression to AIDS. which blood or genital secretions may pass. Similarly, sexu-
HIV incidence among US women continues to be highest in ally transmitted infections that disrupt genital mucosa and
the South, followed by the industrial states of the Northeast. stimulate a local immune response increase the likelihood
Louisiana, with a rate of 15.3 infections per 100,000 popula- of acquiring or transmitting HIV. Because gonorrhea and
tion, is hardest hit, with a rate nearly three times the national syphilis in particular have a higher rate in women of color
average. compared to white women, this likely plays a role in their
From 2007 through 2015, black/​ African American heightened risk of HIV acquisition. Socioeconomic status
women accounted for the majority of new HIV diagnoses in also plays a role in HIV risk. In states with higher rates of pov-
US females (59% vs. 17% white). The seropositivity rate of erty and limited access to healthcare, women are more likely
these women (26.2 per 100,000 persons) was 15 times higher to use drugs and exchange sex for drugs or money. These risk
than that of white females (1.7/​100k) and 5 times higher than factors have been shown to increase risk of HIV, directly or
that of Hispanic females (5.3/​100k). Although black/​African indirectly (CDC, 2017).
American women comprised only 13% of the female popula-
tion, they accounted for 61% of diagnoses of HIV infection CHILDREN
among women. Hispanic/​Latino women made up 16% of
the female population and accounted for 16% of diagnoses. The reduction of mother-​to-​child HIV transmission in the
White women encompassed 63% of the US female popu- United States is a major success of the antiretroviral era. Although
lation and yet accounted for only 19% of HIV diagnoses in the CDC does not publish a similar graph showing perinatal
women overall (CDC, 2016). HIV transmission rates over time, Figure 1.9 shows the dramatic

E pidemiology and t he Spread of H I V • 7

 1000
Aged <13 years
900
800
700
Classification, No

600
500
400
300
200
100 Aged ≥13 years
0
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
Year of classification

Figure 1.9 Stage 3 (AIDS) classifications among persons with perinatally acquired HIV infection, 1985—​2015 (United States and 6 Dependent
Areas). SOURCE: CDC, 2017.

decline in perinatal AIDS diagnoses. In 1992, an estimated 952 children’s mothers were tested for HIV during their preg-
pediatric HIV transmissions were reported in the United States. nancy (Figure 1.11). Vertical transmission cannot be prevented
By 2004, the number declined to 177. In 2011, there were only if the mother’s HIV status is not known, thus highlighting the
53 reported perinatal infections, but this has since stabilized to importance of screening all pregnant women for HIV at least
around 100 infections per year through 2016 (CDC, 2017). The once during pregnancy.
overall rate of perinatal HIV infections reported by the CDC for HIV disproportionately affects black/​African American
2015 was 1.5 per 100,000 live births, surpassing the CDC’s goal children. While accounting for 64% of diagnoses, they
of 5.1 by the end of 2015 (CDC, 2017). comprised only 14% of the population of US children in
The recent persistence of the number of transmissions 2016, whereas Hispanic (26% of population, 13% of HIV
in the face of declining rates is due to an increasing number diagnoses) and white (50% of population, 13% of HIV
of pregnancies among HIV-​ positive women as the pow- diagnoses) children are infected far less often than their popu-
erful role of ART in preventing both horizontal and vertical lation percentages (CDC, 2016).
transmission has been promoted among persons living with
HIV. However, it bears noting that of all HIV diagnoses in
A D O L E S C E N TS
children younger than age 13 years during 2010–​2015, only
30% tested positive during their first year of life (Figure 1.10), Adolescents aged 13–​24, along with 25-​to 34-​year-​old
which is closely linked to data showing that only 20% of these young adults, account for the only two age groups in which

350

300

250
Diagnoses, No.

200

150

100

50

0
0–5 6–11 12–1718–23 2 3 4 5 6 7 8 9 10 11 12
Age in months Age in years

Figure 1.10 Diagnoses of HIV infection among children aged <13 Years, by age at diagnosis, 2010—​2015 (United States and 6 Dependent
Areas). N = 1,179. CDC, 2017.

8 • F u ndamen tal s of H I V M edicine

 Infected Infants Exposed but not infected
N = 440 N = 12,335

Before pregnancy 36% 77%

During pregnancy 20% 21%

At birth 5% 1%

After birth 17% <1%

Unknown 22% 1%

0 20 40 60 80 0 20 40 60 80
Diagnosis, % Diagnosis, %

Time of maternal HIV testing among children with diagnosed perinatally acquired HIV infection and children exposed to HIV, birth year
Figure 1.11
2010-​2014 (United States and Puerto Rico). SOURCE: CDC, 2016. SOURCE: CDC HIV/​AIDS Resource Library Slide Sets. Available at https://​www.cdc.gov/​hiv/​pdf/​library/​slidesets/​cdc-​hiv-​
surveillance-​women-​2016.pdf. Accessed August 02, 2018.

HIV incidence is rising in the United States, being driven
in particular by infections among black and Latino MSM
youth. Of all adolescents and young adults aged 13–​24 years
diagnosed with HIV infection, the CDC reported in 2015
that 54% were black/​African Americans, again far outpacing
their percentage of the general population. Another striking
disparity for black/​African American children is that their
percentage of all children with AIDS increases dramati-
cally with decreasing age, as seen moving right to left in
Figure 1.12.
Transmission rates through male same-​ sex contact
increased from 72% to 92.7% of all transmission from 2009 to
2016 in the adolescent and young adult population, whereas
heterosexual infections decreased from 20% to 3%. Infections
from injection drug use decreased among adolescents over this
period from 4% to 1% (CDC, 2016).
In 2016, females comprised 16% of the HIV diagnoses
in adolescents (13–​19 years) and 11% in young adults (20–​
24 years) compared to 21% of adults older than 24 years. The
mode of HIV transmission varies between sexes in this age
group, as it does in adults: whereas 84% of adolescent and
young adult females are infected through heterosexual con-
tact, more than 90% of males contract HIV through male-​to-​
male sexual contact (CDC, 2016).
RECOMMENDED READING
Centers for Disease Control and Prevention. HIV surveillance re-
port: Diagnoses of HIV infection and AIDS in the United States
and dependent areas. 2016. Vol. 28. Available at https://​www.
cdc.gov/​hiv/​pdf/​library/​reports/​surveillance/​cdc-​hiv-​surveillance-​
report-​2016-​vol-​28.pdf.

13–19 years 20–24 years ≥25 years

N = 224 N = 1,266 N = 16,880
American Indian/
<1% 1% 1%
Alaska Native

Asiana 1% 2% 2%

Black/African American 69% 58% 45%

Hispanic/Latinob 19% 25% 24%

Native Hawaiian/
other Pacific Islander <1% <1% <1%

White 7% 11% 25%

Multiple races 4% 4% 4%

0 20 40 60 80 0 20 40 60 80 0 20 40 60 80
Classifications, % Classifications, % Classifications, %

Stage 3 (AIDS) Classifications among persons aged 13 years and older with diagnosed HIV infection, by race/​ethnicity and age group,
Figure 1.12
2016 (United States and 6 Dependent Areas). SOURCE: CDC, 2017. SOURCE: CDC HIV/​AIDS Resource Library Slide Sets. Available at https://​www.cdc.gov/​hiv/​pdf/​library/​slidesets/​cdc-​hiv-​
surveillance-​women-​2016.pdf. Accessed August 02, 2018

E pidemiology and t he Spread of H I V • 9

Centers for Disease Control and Prevention. Adolescents and young U N EQ UA L BU R D E NS
adult surveillance. Available at https://​www.cdc.gov/​hiv/​pdf/​li-
brary/​slidesets/​cdc-​hiv-​surveillance-​adolescents-​young-​adults-​2016. Another important perspective of US HIV epidemiologic data
pdf. is to recognize the ethnic and racial groups hardest hit by HIV
Center of Disease and Prevention. Pediatric surveillance. Available at infection and deaths, particularly blacks/​African Americans.
https://​www.cdc.gov/​hiv/​pdf/​library/​slidesets/​cdc-​hiv-​surveillance-​
Figure 1.13 shows how this group steadily increased its per-
pediatric.pdf.
centage among AIDS diagnoses early in the epidemic while
cases among Caucasians steadily declined, overtaking them in
1995 before leveling off in 2000, continuing to far exceed all
SPREAD OF HIV AMONG MEN
other racial groups. Blacks/​African Americans continue to be
A N D WO M E N I N C O M MU N I T I E S
vastly overrepresented among persons living with HIV than in
OF COLOR
the general population in 2016 (44% vs. 12%). This is also true,
but to a lesser extent, for Hispanics (25% vs. 18%). These num-
WH AT ’S N EW ? bers for whites, by comparison, are 61% and 26%, respectively.
Results from CDC’s Young Men’s Survey (1994–​2000)
Young black/​African American MSM have the highest risk
found that many young black, African American, and Latino
for HIV infection of any demographic group in the United
MSM outwardly identify as heterosexual, with female spouses or
States.
partners, but also engage in same-​sex encounters with other men,
and that this high-​risk group represents a bridge for transmitting
K EY P O I N TS HIV to women (Fitzpatrick, 2004; Millett, 2004; Valleroy,
2004). In addition, many poor and/​or minority women lack
• Black/​African Americans are HIV-​infected at nearly
the agency—​whether economic, cultural, or otherwise—​to use
four times higher rates than their percentage of the US
condoms with or separate from abusive or unfaithful men who
population, with rates highest in the southeastern United
engage in high-​risk sex with other partners or commercial sex
States.
workers. HIV prevention efforts must account for such factors
• AIDS and AIDS-​related deaths among black/​African to make inroads against HIV transmission in these groups.
Americans and Hispanics are higher than population The current highest risk demographic in the United States is
norms, indicating poorer outcomes with HIV young black MSM who live in the South, driving the epidemic
infection. in this population overall in the United States, such that the

5
Multiple races
4
Classification, %

100
3

90 2

80 1 Asian
American Indian/Alaska Native
70 0 Native Hawaiian/other Pacific Islander
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
Classification, %

60
Year of classification
50 Black/African American
40
White
30
Hispanic/Latinoa
20

10

0
85
86
87
88
89
90
91
92
93
94
95
96
97
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99
00
01
02
03
04
05
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08
09
10
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12
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19
19
19
19
19
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20

Year of classification

Figure 1.13Percentages of stage 3 (AIDS) classifications among adults and adolescents with diagnosed HIV infection, by race/​ethnicity and year of
classification, 1985-​2015 (United States and 6 Dependent Areas). SOURCE: CDC, 2017. CDC HIV/​AIDS Resource Library Slide Sets. Available https://​www.cdc.gov/​hiv/​pdf/​library/​
slidesets/​cdc-​hiv-​surveillance-​race-​ethnicity-​2016.pdf. Accessed August 3, 2018.

10 • F u ndamen tal s of H I V M edicine

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 DANCE ON STILTS AT THE GIRLS’ UNYAGO, NIUCHI

Newala, too, suffers from the distance of its water-supply—at least

the Newala of to-day does; there was once another Newala in a lovely
valley at the foot of the plateau. I visited it and found scarcely a trace
of houses, only a Christian cemetery, with the graves of several
missionaries and their converts, remaining as a monument of its
former glories. But the surroundings are wonderfully beautiful. A
thick grove of splendid mango-trees closes in the weather-worn
crosses and headstones; behind them, combining the useful and the
agreeable, is a whole plantation of lemon-trees covered with ripe
fruit; not the small African kind, but a much larger and also juicier
imported variety, which drops into the hands of the passing traveller,
without calling for any exertion on his part. Old Newala is now under
the jurisdiction of the native pastor, Daudi, at Chingulungulu, who,
as I am on very friendly terms with him, allows me, as a matter of
course, the use of this lemon-grove during my stay at Newala.
 FEET MUTILATED BY THE RAVAGES OF THE “JIGGER”
(Sarcopsylla penetrans)

The water-supply of New Newala is in the bottom of the valley,

some 1,600 feet lower down. The way is not only long and fatiguing,
but the water, when we get it, is thoroughly bad. We are suffering not
only from this, but from the fact that the arrangements at Newala are
nothing short of luxurious. We have a separate kitchen—a hut built
against the boma palisade on the right of the baraza, the interior of
which is not visible from our usual position. Our two cooks were not
long in finding this out, and they consequently do—or rather neglect
to do—what they please. In any case they do not seem to be very
particular about the boiling of our drinking-water—at least I can
attribute to no other cause certain attacks of a dysenteric nature,
from which both Knudsen and I have suffered for some time. If a
man like Omari has to be left unwatched for a moment, he is capable
of anything. Besides this complaint, we are inconvenienced by the
state of our nails, which have become as hard as glass, and crack on
the slightest provocation, and I have the additional infliction of
pimples all over me. As if all this were not enough, we have also, for
the last week been waging war against the jigger, who has found his
Eldorado in the hot sand of the Makonde plateau. Our men are seen
all day long—whenever their chronic colds and the dysentery likewise
raging among them permit—occupied in removing this scourge of
Africa from their feet and trying to prevent the disastrous
consequences of its presence. It is quite common to see natives of
this place with one or two toes missing; many have lost all their toes,
or even the whole front part of the foot, so that a well-formed leg
ends in a shapeless stump. These ravages are caused by the female of
Sarcopsylla penetrans, which bores its way under the skin and there
develops an egg-sac the size of a pea. In all books on the subject, it is
stated that one’s attention is called to the presence of this parasite by
an intolerable itching. This agrees very well with my experience, so
far as the softer parts of the sole, the spaces between and under the
toes, and the side of the foot are concerned, but if the creature
penetrates through the harder parts of the heel or ball of the foot, it
may escape even the most careful search till it has reached maturity.
Then there is no time to be lost, if the horrible ulceration, of which
we see cases by the dozen every day, is to be prevented. It is much
easier, by the way, to discover the insect on the white skin of a
European than on that of a native, on which the dark speck scarcely
shows. The four or five jiggers which, in spite of the fact that I
constantly wore high laced boots, chose my feet to settle in, were
taken out for me by the all-accomplished Knudsen, after which I
thought it advisable to wash out the cavities with corrosive
sublimate. The natives have a different sort of disinfectant—they fill
the hole with scraped roots. In a tiny Makua village on the slope of
the plateau south of Newala, we saw an old woman who had filled all
the spaces under her toe-nails with powdered roots by way of
prophylactic treatment. What will be the result, if any, who can say?
The rest of the many trifling ills which trouble our existence are
really more comic than serious. In the absence of anything else to
smoke, Knudsen and I at last opened a box of cigars procured from
the Indian store-keeper at Lindi, and tried them, with the most
distressing results. Whether they contain opium or some other
narcotic, neither of us can say, but after the tenth puff we were both
“off,” three-quarters stupefied and unspeakably wretched. Slowly we
recovered—and what happened next? Half-an-hour later we were
once more smoking these poisonous concoctions—so insatiable is the
craving for tobacco in the tropics.
Even my present attacks of fever scarcely deserve to be taken
seriously. I have had no less than three here at Newala, all of which
have run their course in an incredibly short time. In the early
afternoon, I am busy with my old natives, asking questions and
making notes. The strong midday coffee has stimulated my spirits to
an extraordinary degree, the brain is active and vigorous, and work
progresses rapidly, while a pleasant warmth pervades the whole
body. Suddenly this gives place to a violent chill, forcing me to put on
my overcoat, though it is only half-past three and the afternoon sun
is at its hottest. Now the brain no longer works with such acuteness
and logical precision; more especially does it fail me in trying to
establish the syntax of the difficult Makua language on which I have
ventured, as if I had not enough to do without it. Under the
circumstances it seems advisable to take my temperature, and I do
so, to save trouble, without leaving my seat, and while going on with
my work. On examination, I find it to be 101·48°. My tutors are
abruptly dismissed and my bed set up in the baraza; a few minutes
later I am in it and treating myself internally with hot water and
lemon-juice.
Three hours later, the thermometer marks nearly 104°, and I make
them carry me back into the tent, bed and all, as I am now perspiring
heavily, and exposure to the cold wind just beginning to blow might
mean a fatal chill. I lie still for a little while, and then find, to my
great relief, that the temperature is not rising, but rather falling. This
is about 7.30 p.m. At 8 p.m. I find, to my unbounded astonishment,
that it has fallen below 98·6°, and I feel perfectly well. I read for an
hour or two, and could very well enjoy a smoke, if I had the
wherewithal—Indian cigars being out of the question.
Having no medical training, I am at a loss to account for this state
of things. It is impossible that these transitory attacks of high fever
should be malarial; it seems more probable that they are due to a
kind of sunstroke. On consulting my note-book, I become more and
more inclined to think this is the case, for these attacks regularly
follow extreme fatigue and long exposure to strong sunshine. They at
least have the advantage of being only short interruptions to my
work, as on the following morning I am always quite fresh and fit.
My treasure of a cook is suffering from an enormous hydrocele which
makes it difficult for him to get up, and Moritz is obliged to keep in
the dark on account of his inflamed eyes. Knudsen’s cook, a raw boy
from somewhere in the bush, knows still less of cooking than Omari;
consequently Nils Knudsen himself has been promoted to the vacant
post. Finding that we had come to the end of our supplies, he began
by sending to Chingulungulu for the four sucking-pigs which we had
bought from Matola and temporarily left in his charge; and when
they came up, neatly packed in a large crate, he callously slaughtered
the biggest of them. The first joint we were thoughtless enough to
entrust for roasting to Knudsen’s mshenzi cook, and it was
consequently uneatable; but we made the rest of the animal into a
jelly which we ate with great relish after weeks of underfeeding,
consuming incredible helpings of it at both midday and evening
meals. The only drawback is a certain want of variety in the tinned
vegetables. Dr. Jäger, to whom the Geographical Commission
entrusted the provisioning of the expeditions—mine as well as his
own—because he had more time on his hands than the rest of us,
seems to have laid in a huge stock of Teltow turnips,[46] an article of
food which is all very well for occasional use, but which quickly palls
when set before one every day; and we seem to have no other tins
left. There is no help for it—we must put up with the turnips; but I
am certain that, once I am home again, I shall not touch them for ten
years to come.
Amid all these minor evils, which, after all, go to make up the
genuine flavour of Africa, there is at least one cheering touch:
Knudsen has, with the dexterity of a skilled mechanic, repaired my 9
× 12 cm. camera, at least so far that I can use it with a little care.
How, in the absence of finger-nails, he was able to accomplish such a
ticklish piece of work, having no tool but a clumsy screw-driver for
taking to pieces and putting together again the complicated
mechanism of the instantaneous shutter, is still a mystery to me; but
he did it successfully. The loss of his finger-nails shows him in a light
contrasting curiously enough with the intelligence evinced by the
above operation; though, after all, it is scarcely surprising after his
ten years’ residence in the bush. One day, at Lindi, he had occasion
to wash a dog, which must have been in need of very thorough
cleansing, for the bottle handed to our friend for the purpose had an
extremely strong smell. Having performed his task in the most
conscientious manner, he perceived with some surprise that the dog
did not appear much the better for it, and was further surprised by
finding his own nails ulcerating away in the course of the next few
days. “How was I to know that carbolic acid has to be diluted?” he
mutters indignantly, from time to time, with a troubled gaze at his
mutilated finger-tips.
 Since we came to Newala we have been making excursions in all
directions through the surrounding country, in accordance with old
habit, and also because the akida Sefu did not get together the tribal
elders from whom I wanted information so speedily as he had
promised. There is, however, no harm done, as, even if seen only
from the outside, the country and people are interesting enough.
The Makonde plateau is like a large rectangular table rounded off
at the corners. Measured from the Indian Ocean to Newala, it is
about seventy-five miles long, and between the Rovuma and the
Lukuledi it averages fifty miles in breadth, so that its superficial area
is about two-thirds of that of the kingdom of Saxony. The surface,
however, is not level, but uniformly inclined from its south-western
edge to the ocean. From the upper edge, on which Newala lies, the
eye ranges for many miles east and north-east, without encountering
any obstacle, over the Makonde bush. It is a green sea, from which
here and there thick clouds of smoke rise, to show that it, too, is
inhabited by men who carry on their tillage like so many other
primitive peoples, by cutting down and burning the bush, and
manuring with the ashes. Even in the radiant light of a tropical day
such a fire is a grand sight.
Much less effective is the impression produced just now by the
great western plain as seen from the edge of the plateau. As often as
time permits, I stroll along this edge, sometimes in one direction,
sometimes in another, in the hope of finding the air clear enough to
let me enjoy the view; but I have always been disappointed.
Wherever one looks, clouds of smoke rise from the burning bush,
and the air is full of smoke and vapour. It is a pity, for under more
favourable circumstances the panorama of the whole country up to
the distant Majeje hills must be truly magnificent. It is of little use
taking photographs now, and an outline sketch gives a very poor idea
of the scenery. In one of these excursions I went out of my way to
make a personal attempt on the Makonde bush. The present edge of
the plateau is the result of a far-reaching process of destruction
through erosion and denudation. The Makonde strata are
everywhere cut into by ravines, which, though short, are hundreds of
yards in depth. In consequence of the loose stratification of these
beds, not only are the walls of these ravines nearly vertical, but their
upper end is closed by an equally steep escarpment, so that the
western edge of the Makonde plateau is hemmed in by a series of
deep, basin-like valleys. In order to get from one side of such a ravine
to the other, I cut my way through the bush with a dozen of my men.
It was a very open part, with more grass than scrub, but even so the
short stretch of less than two hundred yards was very hard work; at
the end of it the men’s calicoes were in rags and they themselves
bleeding from hundreds of scratches, while even our strong khaki
suits had not escaped scatheless.

NATIVE PATH THROUGH THE MAKONDE BUSH, NEAR

MAHUTA

I see increasing reason to believe that the view formed some time
back as to the origin of the Makonde bush is the correct one. I have
no doubt that it is not a natural product, but the result of human
occupation. Those parts of the high country where man—as a very
slight amount of practice enables the eye to perceive at once—has not
yet penetrated with axe and hoe, are still occupied by a splendid
timber forest quite able to sustain a comparison with our mixed
forests in Germany. But wherever man has once built his hut or tilled
his field, this horrible bush springs up. Every phase of this process
may be seen in the course of a couple of hours’ walk along the main
road. From the bush to right or left, one hears the sound of the axe—
not from one spot only, but from several directions at once. A few
steps further on, we can see what is taking place. The brush has been
cut down and piled up in heaps to the height of a yard or more,
between which the trunks of the large trees stand up like the last
pillars of a magnificent ruined building. These, too, present a
melancholy spectacle: the destructive Makonde have ringed them—
cut a broad strip of bark all round to ensure their dying off—and also
piled up pyramids of brush round them. Father and son, mother and
son-in-law, are chopping away perseveringly in the background—too
busy, almost, to look round at the white stranger, who usually excites
so much interest. If you pass by the same place a week later, the piles
of brushwood have disappeared and a thick layer of ashes has taken
the place of the green forest. The large trees stretch their
smouldering trunks and branches in dumb accusation to heaven—if
they have not already fallen and been more or less reduced to ashes,
perhaps only showing as a white stripe on the dark ground.
This work of destruction is carried out by the Makonde alike on the
virgin forest and on the bush which has sprung up on sites already
cultivated and deserted. In the second case they are saved the trouble
of burning the large trees, these being entirely absent in the
secondary bush.
After burning this piece of forest ground and loosening it with the
hoe, the native sows his corn and plants his vegetables. All over the
country, he goes in for bed-culture, which requires, and, in fact,
receives, the most careful attention. Weeds are nowhere tolerated in
the south of German East Africa. The crops may fail on the plains,
where droughts are frequent, but never on the plateau with its
abundant rains and heavy dews. Its fortunate inhabitants even have
the satisfaction of seeing the proud Wayao and Wamakua working
for them as labourers, driven by hunger to serve where they were
accustomed to rule.
But the light, sandy soil is soon exhausted, and would yield no
harvest the second year if cultivated twice running. This fact has
been familiar to the native for ages; consequently he provides in
time, and, while his crop is growing, prepares the next plot with axe
and firebrand. Next year he plants this with his various crops and
lets the first piece lie fallow. For a short time it remains waste and
desolate; then nature steps in to repair the destruction wrought by
man; a thousand new growths spring out of the exhausted soil, and
even the old stumps put forth fresh shoots. Next year the new growth
is up to one’s knees, and in a few years more it is that terrible,
impenetrable bush, which maintains its position till the black
occupier of the land has made the round of all the available sites and
come back to his starting point.
The Makonde are, body and soul, so to speak, one with this bush.
According to my Yao informants, indeed, their name means nothing
else but “bush people.” Their own tradition says that they have been
settled up here for a very long time, but to my surprise they laid great
stress on an original immigration. Their old homes were in the
south-east, near Mikindani and the mouth of the Rovuma, whence
their peaceful forefathers were driven by the continual raids of the
Sakalavas from Madagascar and the warlike Shirazis[47] of the coast,
to take refuge on the almost inaccessible plateau. I have studied
African ethnology for twenty years, but the fact that changes of
population in this apparently quiet and peaceable corner of the earth
could have been occasioned by outside enterprises taking place on
the high seas, was completely new to me. It is, no doubt, however,
correct.
The charming tribal legend of the Makonde—besides informing us
of other interesting matters—explains why they have to live in the
thickest of the bush and a long way from the edge of the plateau,
instead of making their permanent homes beside the purling brooks
and springs of the low country.
“The place where the tribe originated is Mahuta, on the southern
side of the plateau towards the Rovuma, where of old time there was
nothing but thick bush. Out of this bush came a man who never
washed himself or shaved his head, and who ate and drank but little.
He went out and made a human figure from the wood of a tree
growing in the open country, which he took home to his abode in the
bush and there set it upright. In the night this image came to life and
was a woman. The man and woman went down together to the
Rovuma to wash themselves. Here the woman gave birth to a still-
born child. They left that place and passed over the high land into the
valley of the Mbemkuru, where the woman had another child, which
was also born dead. Then they returned to the high bush country of
Mahuta, where the third child was born, which lived and grew up. In
course of time, the couple had many more children, and called
themselves Wamatanda. These were the ancestral stock of the
Makonde, also called Wamakonde,[48] i.e., aborigines. Their
forefather, the man from the bush, gave his children the command to
bury their dead upright, in memory of the mother of their race who
was cut out of wood and awoke to life when standing upright. He also
warned them against settling in the valleys and near large streams,
for sickness and death dwelt there. They were to make it a rule to
have their huts at least an hour’s walk from the nearest watering-
place; then their children would thrive and escape illness.”
The explanation of the name Makonde given by my informants is
somewhat different from that contained in the above legend, which I
extract from a little book (small, but packed with information), by
Pater Adams, entitled Lindi und sein Hinterland. Otherwise, my
results agree exactly with the statements of the legend. Washing?
Hapana—there is no such thing. Why should they do so? As it is, the
supply of water scarcely suffices for cooking and drinking; other
people do not wash, so why should the Makonde distinguish himself
by such needless eccentricity? As for shaving the head, the short,
woolly crop scarcely needs it,[49] so the second ancestral precept is
likewise easy enough to follow. Beyond this, however, there is
nothing ridiculous in the ancestor’s advice. I have obtained from
various local artists a fairly large number of figures carved in wood,
ranging from fifteen to twenty-three inches in height, and
representing women belonging to the great group of the Mavia,
Makonde, and Matambwe tribes. The carving is remarkably well
done and renders the female type with great accuracy, especially the
keloid ornamentation, to be described later on. As to the object and
meaning of their works the sculptors either could or (more probably)
would tell me nothing, and I was forced to content myself with the
scanty information vouchsafed by one man, who said that the figures
were merely intended to represent the nembo—the artificial
deformations of pelele, ear-discs, and keloids. The legend recorded
by Pater Adams places these figures in a new light. They must surely
be more than mere dolls; and we may even venture to assume that
they are—though the majority of present-day Makonde are probably
unaware of the fact—representations of the tribal ancestress.
 The references in the legend to the descent from Mahuta to the
Rovuma, and to a journey across the highlands into the Mbekuru
valley, undoubtedly indicate the previous history of the tribe, the
travels of the ancestral pair typifying the migrations of their
descendants. The descent to the neighbouring Rovuma valley, with
its extraordinary fertility and great abundance of game, is intelligible
at a glance—but the crossing of the Lukuledi depression, the ascent
to the Rondo Plateau and the descent to the Mbemkuru, also lie
within the bounds of probability, for all these districts have exactly
the same character as the extreme south. Now, however, comes a
point of especial interest for our bacteriological age. The primitive
Makonde did not enjoy their lives in the marshy river-valleys.
Disease raged among them, and many died. It was only after they
had returned to their original home near Mahuta, that the health
conditions of these people improved. We are very apt to think of the
African as a stupid person whose ignorance of nature is only equalled
by his fear of it, and who looks on all mishaps as caused by evil
spirits and malignant natural powers. It is much more correct to
assume in this case that the people very early learnt to distinguish
districts infested with malaria from those where it is absent.
This knowledge is crystallized in the
ancestral warning against settling in the
valleys and near the great waters, the
dwelling-places of disease and death. At the
same time, for security against the hostile
Mavia south of the Rovuma, it was enacted
that every settlement must be not less than a
certain distance from the southern edge of the
plateau. Such in fact is their mode of life at the
present day. It is not such a bad one, and
certainly they are both safer and more
comfortable than the Makua, the recent
intruders from the south, who have made USUAL METHOD OF
good their footing on the western edge of the CLOSING HUT-DOOR
plateau, extending over a fairly wide belt of
country. Neither Makua nor Makonde show in their dwellings
anything of the size and comeliness of the Yao houses in the plain,
especially at Masasi, Chingulungulu and Zuza’s. Jumbe Chauro, a
Makonde hamlet not far from Newala, on the road to Mahuta, is the
most important settlement of the tribe I have yet seen, and has fairly
spacious huts. But how slovenly is their construction compared with
the palatial residences of the elephant-hunters living in the plain.
The roofs are still more untidy than in the general run of huts during
the dry season, the walls show here and there the scanty beginnings
or the lamentable remains of the mud plastering, and the interior is a
veritable dog-kennel; dirt, dust and disorder everywhere. A few huts
only show any attempt at division into rooms, and this consists
merely of very roughly-made bamboo partitions. In one point alone
have I noticed any indication of progress—in the method of fastening
the door. Houses all over the south are secured in a simple but
ingenious manner. The door consists of a set of stout pieces of wood
or bamboo, tied with bark-string to two cross-pieces, and moving in
two grooves round one of the door-posts, so as to open inwards. If
the owner wishes to leave home, he takes two logs as thick as a man’s
upper arm and about a yard long. One of these is placed obliquely
against the middle of the door from the inside, so as to form an angle
of from 60° to 75° with the ground. He then places the second piece
horizontally across the first, pressing it downward with all his might.
It is kept in place by two strong posts planted in the ground a few
inches inside the door. This fastening is absolutely safe, but of course
cannot be applied to both doors at once, otherwise how could the
owner leave or enter his house? I have not yet succeeded in finding
out how the back door is fastened.

MAKONDE LOCK AND KEY AT JUMBE CHAURO

 This is the general way of closing a house. The Makonde at Jumbe
Chauro, however, have a much more complicated, solid and original
one. Here, too, the door is as already described, except that there is
only one post on the inside, standing by itself about six inches from
one side of the doorway. Opposite this post is a hole in the wall just
large enough to admit a man’s arm. The door is closed inside by a
large wooden bolt passing through a hole in this post and pressing
with its free end against the door. The other end has three holes into
which fit three pegs running in vertical grooves inside the post. The
door is opened with a wooden key about a foot long, somewhat
curved and sloped off at the butt; the other end has three pegs
corresponding to the holes, in the bolt, so that, when it is thrust
through the hole in the wall and inserted into the rectangular
opening in the post, the pegs can be lifted and the bolt drawn out.[50]

MODE OF INSERTING THE KEY

With no small pride first one householder and then a second

showed me on the spot the action of this greatest invention of the
Makonde Highlands. To both with an admiring exclamation of
“Vizuri sana!” (“Very fine!”). I expressed the wish to take back these
marvels with me to Ulaya, to show the Wazungu what clever fellows
the Makonde are. Scarcely five minutes after my return to camp at
Newala, the two men came up sweating under the weight of two
heavy logs which they laid down at my feet, handing over at the same
time the keys of the fallen fortress. Arguing, logically enough, that if
the key was wanted, the lock would be wanted with it, they had taken
their axes and chopped down the posts—as it never occurred to them
to dig them out of the ground and so bring them intact. Thus I have
two badly damaged specimens, and the owners, instead of praise,
come in for a blowing-up.
The Makua huts in the environs of Newala are especially
miserable; their more than slovenly construction reminds one of the
temporary erections of the Makua at Hatia’s, though the people here
have not been concerned in a war. It must therefore be due to
congenital idleness, or else to the absence of a powerful chief. Even
the baraza at Mlipa’s, a short hour’s walk south-east of Newala,
shares in this general neglect. While public buildings in this country
are usually looked after more or less carefully, this is in evident
danger of being blown over by the first strong easterly gale. The only
attractive object in this whole district is the grave of the late chief
Mlipa. I visited it in the morning, while the sun was still trying with
partial success to break through the rolling mists, and the circular
grove of tall euphorbias, which, with a broken pot, is all that marks
the old king’s resting-place, impressed one with a touch of pathos.
Even my very materially-minded carriers seemed to feel something
of the sort, for instead of their usual ribald songs, they chanted
solemnly, as we marched on through the dense green of the Makonde
bush:—
 “We shall arrive with the great master; we stand in a row and have
no fear about getting our food and our money from the Serkali (the
Government). We are not afraid; we are going along with the great
master, the lion; we are going down to the coast and back.”
With regard to the characteristic features of the various tribes here
on the western edge of the plateau, I can arrive at no other
conclusion than the one already come to in the plain, viz., that it is
impossible for anyone but a trained anthropologist to assign any
given individual at once to his proper tribe. In fact, I think that even
an anthropological specialist, after the most careful examination,
might find it a difficult task to decide. The whole congeries of peoples
collected in the region bounded on the west by the great Central
African rift, Tanganyika and Nyasa, and on the east by the Indian
Ocean, are closely related to each other—some of their languages are
only distinguished from one another as dialects of the same speech,
and no doubt all the tribes present the same shape of skull and
structure of skeleton. Thus, surely, there can be no very striking
differences in outward appearance.
 Even did such exist, I should have no time
to concern myself with them, for day after day,
I have to see or hear, as the case may be—in
any case to grasp and record—an
extraordinary number of ethnographic
phenomena. I am almost disposed to think it
fortunate that some departments of inquiry, at
least, are barred by external circumstances.
Chief among these is the subject of iron-
working. We are apt to think of Africa as a
country where iron ore is everywhere, so to
speak, to be picked up by the roadside, and
where it would be quite surprising if the
inhabitants had not learnt to smelt the
material ready to their hand. In fact, the
knowledge of this art ranges all over the
continent, from the Kabyles in the north to the
Kafirs in the south. Here between the Rovuma
and the Lukuledi the conditions are not so
favourable. According to the statements of the
Makonde, neither ironstone nor any other
form of iron ore is known to them. They have
not therefore advanced to the art of smelting
the metal, but have hitherto bought all their
THE ANCESTRESS OF
THE MAKONDE
iron implements from neighbouring tribes.
Even in the plain the inhabitants are not much
better off. Only one man now living is said to
understand the art of smelting iron. This old fundi lives close to
Huwe, that isolated, steep-sided block of granite which rises out of
the green solitude between Masasi and Chingulungulu, and whose
jagged and splintered top meets the traveller’s eye everywhere. While
still at Masasi I wished to see this man at work, but was told that,
frightened by the rising, he had retired across the Rovuma, though
he would soon return. All subsequent inquiries as to whether the
fundi had come back met with the genuine African answer, “Bado”
(“Not yet”).
 BRAZIER

Some consolation was afforded me by a brassfounder, whom I

came across in the bush near Akundonde’s. This man is the favourite
of women, and therefore no doubt of the gods; he welds the glittering
brass rods purchased at the coast into those massive, heavy rings
which, on the wrists and ankles of the local fair ones, continually give
me fresh food for admiration. Like every decent master-craftsman he
had all his tools with him, consisting of a pair of bellows, three
crucibles and a hammer—nothing more, apparently. He was quite
willing to show his skill, and in a twinkling had fixed his bellows on
the ground. They are simply two goat-skins, taken off whole, the four
legs being closed by knots, while the upper opening, intended to
admit the air, is kept stretched by two pieces of wood. At the lower
end of the skin a smaller opening is left into which a wooden tube is
stuck. The fundi has quickly borrowed a heap of wood-embers from
the nearest hut; he then fixes the free ends of the two tubes into an
earthen pipe, and clamps them to the ground by means of a bent
piece of wood. Now he fills one of his small clay crucibles, the dross
on which shows that they have been long in use, with the yellow
material, places it in the midst of the embers, which, at present are
only faintly glimmering, and begins his work. In quick alternation
the smith’s two hands move up and down with the open ends of the
bellows; as he raises his hand he holds the slit wide open, so as to let
the air enter the skin bag unhindered. In pressing it down he closes
the bag, and the air puffs through the bamboo tube and clay pipe into
the fire, which quickly burns up. The smith, however, does not keep
on with this work, but beckons to another man, who relieves him at
the bellows, while he takes some more tools out of a large skin pouch
carried on his back. I look on in wonder as, with a smooth round
stick about the thickness of a finger, he bores a few vertical holes into
the clean sand of the soil. This should not be difficult, yet the man
seems to be taking great pains over it. Then he fastens down to the
ground, with a couple of wooden clamps, a neat little trough made by
splitting a joint of bamboo in half, so that the ends are closed by the
two knots. At last the yellow metal has attained the right consistency,
and the fundi lifts the crucible from the fire by means of two sticks
split at the end to serve as tongs. A short swift turn to the left—a
tilting of the crucible—and the molten brass, hissing and giving forth
clouds of smoke, flows first into the bamboo mould and then into the
holes in the ground.
The technique of this backwoods craftsman may not be very far
advanced, but it cannot be denied that he knows how to obtain an
adequate result by the simplest means. The ladies of highest rank in
this country—that is to say, those who can afford it, wear two kinds
of these massive brass rings, one cylindrical, the other semicircular
in section. The latter are cast in the most ingenious way in the
bamboo mould, the former in the circular hole in the sand. It is quite
a simple matter for the fundi to fit these bars to the limbs of his fair
customers; with a few light strokes of his hammer he bends the
pliable brass round arm or ankle without further inconvenience to
the wearer.
SHAPING THE POT

SMOOTHING WITH MAIZE-COB

CUTTING THE EDGE

 FINISHING THE BOTTOM

LAST SMOOTHING BEFORE

BURNING

FIRING THE BRUSH-PILE

 LIGHTING THE FARTHER SIDE OF
THE PILE

TURNING THE RED-HOT VESSEL

NYASA WOMAN MAKING POTS AT MASASI

Pottery is an art which must always and everywhere excite the
interest of the student, just because it is so intimately connected with
the development of human culture, and because its relics are one of
the principal factors in the reconstruction of our own condition in
prehistoric times. I shall always remember with pleasure the two or
three afternoons at Masasi when Salim Matola’s mother, a slightly-
built, graceful, pleasant-looking woman, explained to me with
touching patience, by means of concrete illustrations, the ceramic art
of her people. The only implements for this primitive process were a
lump of clay in her left hand, and in the right a calabash containing
the following valuables: the fragment of a maize-cob stripped of all
its grains, a smooth, oval pebble, about the size of a pigeon’s egg, a
few chips of gourd-shell, a bamboo splinter about the length of one’s
hand, a small shell, and a bunch of some herb resembling spinach.
 Nothing more. The woman scraped with the
shell a round, shallow hole in the soft, fine
sand of the soil, and, when an active young
girl had filled the calabash with water for her,
she began to knead the clay. As if by magic it
gradually assumed the shape of a rough but
already well-shaped vessel, which only wanted
a little touching up with the instruments
before mentioned. I looked out with the
MAKUA WOMAN closest attention for any indication of the use
MAKING A POT. of the potter’s wheel, in however rudimentary
SHOWS THE a form, but no—hapana (there is none). The
BEGINNINGS OF THE embryo pot stood firmly in its little
POTTER’S WHEEL
depression, and the woman walked round it in
a stooping posture, whether she was removing
small stones or similar foreign bodies with the maize-cob, smoothing
the inner or outer surface with the splinter of bamboo, or later, after
letting it dry for a day, pricking in the ornamentation with a pointed
bit of gourd-shell, or working out the bottom, or cutting the edge
with a sharp bamboo knife, or giving the last touches to the finished
vessel. This occupation of the women is infinitely toilsome, but it is
without doubt an accurate reproduction of the process in use among
our ancestors of the Neolithic and Bronze ages.
There is no doubt that the invention of pottery, an item in human
progress whose importance cannot be over-estimated, is due to
women. Rough, coarse and unfeeling, the men of the horde range
over the countryside. When the united cunning of the hunters has
succeeded in killing the game; not one of them thinks of carrying
home the spoil. A bright fire, kindled by a vigorous wielding of the
drill, is crackling beside them; the animal has been cleaned and cut
up secundum artem, and, after a slight singeing, will soon disappear
under their sharp teeth; no one all this time giving a single thought
to wife or child.
To what shifts, on the other hand, the primitive wife, and still more
the primitive mother, was put! Not even prehistoric stomachs could
endure an unvarying diet of raw food. Something or other suggested
the beneficial effect of hot water on the majority of approved but
indigestible dishes. Perhaps a neighbour had tried holding the hard
roots or tubers over the fire in a calabash filled with water—or maybe
an ostrich-egg-shell, or a hastily improvised vessel of bark. They
became much softer and more palatable than they had previously
been; but, unfortunately, the vessel could not stand the fire and got
charred on the outside. That can be remedied, thought our
ancestress, and plastered a layer of wet clay round a similar vessel.
This is an improvement; the cooking utensil remains uninjured, but
the heat of the fire has shrunk it, so that it is loose in its shell. The
next step is to detach it, so, with a firm grip and a jerk, shell and
kernel are separated, and pottery is invented. Perhaps, however, the
discovery which led to an intelligent use of the burnt-clay shell, was
made in a slightly different way. Ostrich-eggs and calabashes are not
to be found in every part of the world, but everywhere mankind has
arrived at the art of making baskets out of pliant materials, such as
bark, bast, strips of palm-leaf, supple twigs, etc. Our inventor has no
water-tight vessel provided by nature. “Never mind, let us line the
basket with clay.” This answers the purpose, but alas! the basket gets
burnt over the blazing fire, the woman watches the process of
cooking with increasing uneasiness, fearing a leak, but no leak
appears. The food, done to a turn, is eaten with peculiar relish; and
the cooking-vessel is examined, half in curiosity, half in satisfaction
at the result. The plastic clay is now hard as stone, and at the same
time looks exceedingly well, for the neat plaiting of the burnt basket
is traced all over it in a pretty pattern. Thus, simultaneously with
pottery, its ornamentation was invented.
Primitive woman has another claim to respect. It was the man,
roving abroad, who invented the art of producing fire at will, but the
woman, unable to imitate him in this, has been a Vestal from the
earliest times. Nothing gives so much trouble as the keeping alight of
the smouldering brand, and, above all, when all the men are absent
from the camp. Heavy rain-clouds gather, already the first large
drops are falling, the first gusts of the storm rage over the plain. The
little flame, a greater anxiety to the woman than her own children,
flickers unsteadily in the blast. What is to be done? A sudden thought
occurs to her, and in an instant she has constructed a primitive hut
out of strips of bark, to protect the flame against rain and wind.
This, or something very like it, was the way in which the principle
of the house was discovered; and even the most hardened misogynist
cannot fairly refuse a woman the credit of it. The protection of the
hearth-fire from the weather is the germ from which the human
dwelling was evolved. Men had little, if any share, in this forward
step, and that only at a late stage. Even at the present day, the
plastering of the housewall with clay and the manufacture of pottery
are exclusively the women’s business. These are two very significant
survivals. Our European kitchen-garden, too, is originally a woman’s
invention, and the hoe, the primitive instrument of agriculture, is,
characteristically enough, still used in this department. But the
noblest achievement which we owe to the other sex is unquestionably
the art of cookery. Roasting alone—the oldest process—is one for
which men took the hint (a very obvious one) from nature. It must
have been suggested by the scorched carcase of some animal
overtaken by the destructive forest-fires. But boiling—the process of
improving organic substances by the help of water heated to boiling-
point—is a much later discovery. It is so recent that it has not even
yet penetrated to all parts of the world. The Polynesians understand
how to steam food, that is, to cook it, neatly wrapped in leaves, in a
hole in the earth between hot stones, the air being excluded, and
(sometimes) a few drops of water sprinkled on the stones; but they
do not understand boiling.
To come back from this digression, we find that the slender Nyasa
woman has, after once more carefully examining the finished pot,
put it aside in the shade to dry. On the following day she sends me
word by her son, Salim Matola, who is always on hand, that she is
going to do the burning, and, on coming out of my house, I find her
already hard at work. She has spread on the ground a layer of very
dry sticks, about as thick as one’s thumb, has laid the pot (now of a
yellowish-grey colour) on them, and is piling brushwood round it.
My faithful Pesa mbili, the mnyampara, who has been standing by,
most obligingly, with a lighted stick, now hands it to her. Both of
them, blowing steadily, light the pile on the lee side, and, when the
flame begins to catch, on the weather side also. Soon the whole is in a
blaze, but the dry fuel is quickly consumed and the fire dies down, so
that we see the red-hot vessel rising from the ashes. The woman
turns it continually with a long stick, sometimes one way and
sometimes another, so that it may be evenly heated all over. In
twenty minutes she rolls it out of the ash-heap, takes up the bundle
of spinach, which has been lying for two days in a jar of water, and
sprinkles the red-hot clay with it. The places where the drops fall are
marked by black spots on the uniform reddish-brown surface. With a
sigh of relief, and with visible satisfaction, the woman rises to an
erect position; she is standing just in a line between me and the fire,
from which a cloud of smoke is just rising: I press the ball of my
camera, the shutter clicks—the apotheosis is achieved! Like a
priestess, representative of her inventive sex, the graceful woman
stands: at her feet the hearth-fire she has given us beside her the
invention she has devised for us, in the background the home she has
built for us.
At Newala, also, I have had the manufacture of pottery carried on
in my presence. Technically the process is better than that already
described, for here we find the beginnings of the potter’s wheel,
which does not seem to exist in the plains; at least I have seen
nothing of the sort. The artist, a frightfully stupid Makua woman, did
not make a depression in the ground to receive the pot she was about
to shape, but used instead a large potsherd. Otherwise, she went to
work in much the same way as Salim’s mother, except that she saved
herself the trouble of walking round and round her work by squatting
at her ease and letting the pot and potsherd rotate round her; this is
surely the first step towards a machine. But it does not follow that
the pot was improved by the process. It is true that it was beautifully
rounded and presented a very creditable appearance when finished,
but the numerous large and small vessels which I have seen, and, in
part, collected, in the “less advanced” districts, are no less so. We
moderns imagine that instruments of precision are necessary to
produce excellent results. Go to the prehistoric collections of our
museums and look at the pots, urns and bowls of our ancestors in the
dim ages of the past, and you will at once perceive your error.
MAKING LONGITUDINAL CUT IN
BARK

DRAWING THE BARK OFF THE LOG

REMOVING THE OUTER BARK

 BEATING THE BARK

WORKING THE BARK-CLOTH AFTER BEATING, TO MAKE IT

SOFT

MANUFACTURE OF BARK-CLOTH AT NEWALA

To-day, nearly the whole population of German East Africa is
clothed in imported calico. This was not always the case; even now in
some parts of the north dressed skins are still the prevailing wear,
and in the north-western districts—east and north of Lake
Tanganyika—lies a zone where bark-cloth has not yet been
superseded. Probably not many generations have passed since such
bark fabrics and kilts of skins were the only clothing even in the
south. Even to-day, large quantities of this bright-red or drab
material are still to be found; but if we wish to see it, we must look in
the granaries and on the drying stages inside the native huts, where
it serves less ambitious uses as wrappings for those seeds and fruits
which require to be packed with special care. The salt produced at
Masasi, too, is packed for transport to a distance in large sheets of
bark-cloth. Wherever I found it in any degree possible, I studied the
process of making this cloth. The native requisitioned for the
purpose arrived, carrying a log between two and three yards long and
as thick as his thigh, and nothing else except a curiously-shaped
mallet and the usual long, sharp and pointed knife which all men and
boys wear in a belt at their backs without a sheath—horribile dictu!
[51]
Silently he squats down before me, and with two rapid cuts has
drawn a couple of circles round the log some two yards apart, and
slits the bark lengthwise between them with the point of his knife.
With evident care, he then scrapes off the outer rind all round the
log, so that in a quarter of an hour the inner red layer of the bark
shows up brightly-coloured between the two untouched ends. With
some trouble and much caution, he now loosens the bark at one end,
and opens the cylinder. He then stands up, takes hold of the free
edge with both hands, and turning it inside out, slowly but steadily
pulls it off in one piece. Now comes the troublesome work of
scraping all superfluous particles of outer bark from the outside of
the long, narrow piece of material, while the inner side is carefully
scrutinised for defective spots. At last it is ready for beating. Having
signalled to a friend, who immediately places a bowl of water beside
him, the artificer damps his sheet of bark all over, seizes his mallet,
lays one end of the stuff on the smoothest spot of the log, and
hammers away slowly but continuously. “Very simple!” I think to
myself. “Why, I could do that, too!”—but I am forced to change my
opinions a little later on; for the beating is quite an art, if the fabric is
not to be beaten to pieces. To prevent the breaking of the fibres, the
stuff is several times folded across, so as to interpose several
thicknesses between the mallet and the block. At last the required
state is reached, and the fundi seizes the sheet, still folded, by both
ends, and wrings it out, or calls an assistant to take one end while he
holds the other. The cloth produced in this way is not nearly so fine
and uniform in texture as the famous Uganda bark-cloth, but it is
quite soft, and, above all, cheap.
Now, too, I examine the mallet. My craftsman has been using the
simpler but better form of this implement, a conical block of some
hard wood, its base—the striking surface—being scored across and
across with more or less deeply-cut grooves, and the handle stuck
into a hole in the middle. The other and earlier form of mallet is
shaped in the same way, but the head is fastened by an ingenious
network of bark strips into the split bamboo serving as a handle. The
observation so often made, that ancient customs persist longest in
connection with religious ceremonies and in the life of children, here
finds confirmation. As we shall soon see, bark-cloth is still worn
during the unyago,[52] having been prepared with special solemn
ceremonies; and many a mother, if she has no other garment handy,
will still put her little one into a kilt of bark-cloth, which, after all,
looks better, besides being more in keeping with its African
surroundings, than the ridiculous bit of print from Ulaya.
MAKUA WOMEN