The AIDS Epidemic
How to Have Sex in an Epidemic: One Approach
Gay Men’s Health: A Guide to the AID Syndrome and Other Sexually Transmitted Diseases
Since it was first recognized in 1979 and until very recently, the incidence of the diseases grouped under the acronym AIDS (Acquired Immune Deficiency Syndrome) roughly doubled every six months, with about five cases being reported a day in the US (and about two a day in New York City). The overall national mortality rate has been 39 percent; half of all AIDS patients die before the end of the first year of the illness and nearly all before the end of the third year. According to a spokesman for the Centers for Disease Control (CDC), as of July 1, 1983, 1,737 people have been afflicted by the disease, and 678 of them have died.
The AIDS Epidemic presents a disturbing picture of the epidemiological, etiological, and clinical aspects of the disease as it is currently known, as well as discussion of a number of special problems, such as the protection of health workers, guidelines for blood donation, the direction of future AIDS research, and government funding for that research.1 The book is a collection of reports on various aspects of the illness presented at a symposium held at Lenox Hill Hospital in New York City last April. It is edited by the senior member of the New York City Board of Health and a specialist in tropical medicine, and among the authors are such distinguished authorities as Dr. William H. Foege, director of the CDC; Dr. Donald P. Francis, chief coordinator, AIDS Laboratory Activities, Center for Infectious Diseases at the CDC; Dr. Donald S. Fredrickson, former director of the National Institute of Health; Dr. David J. Sencer, New York City commissioner of health and former director of the CDC; Dr. R. Ben Dawson, director, Blood Transfusion Services and Research Laboratories, University of Maryland School of Medicine and Hospital; and Dr. Robert A. Good, former president and scientific director of the Memorial Sloan-Kettering Cancer Center.
As Dr. Foege explains in his account of the history of the disease in the US, most of its victims thus far have been homosexual men under fifty—the median age is thirty-six—who live in large cities on the East and West coasts. According to the latest CDC figures, 47.9 percent of these are from New York (and 44.5 percent from New York City), 9.5 percent from San Francisco, and 6 percent from Los Angeles. Cases have occurred in thirty-eight states, the District of Columbia, and Puerto Rico; and there have been 121 cases in twenty-one other nations.
While the disease was first diagnosed in promiscuous homosexual men with previous histories of sexually transmitted diseases, it was subsequently discovered among other groups—intravenous drug abusers, hemophiliacs, and Haitians recently arrived in the US who apparently had no history of either drug abuse or homosexuality. These account for some 94 percent of the cases. Of the remainder, who are not in these “high-risk” groups, in half of the cases information pertaining to risk factors is unknown or incomplete; the rest are sex partners of AIDS patients (principally drug abusers), recipients of blood transfusions, and a number of cases with no ascertainable risk factors.
These statistics do not include reputed infant cases—there are about ten of these in New York, eight of them children of drug abusers—but according to the CDC’s Morbidity and Mortality Weekly Report (June 24, 1983), “infant cases are recorded separately because of the uncertainty in distinguishing their illnesses from previously described congenital immunodeficiency syndromes.”
The cause of AIDS has not been identified. For purposes of surveillance the CDC has defined it as the presence of a disease suggestive of underlying “cellular immunodeficiency.” The immune system, when normal, responds to infection by the operation of lymphocytes, a species of white blood cells. One class of these, B-lymphocytes, defends the body by creating antibodies to bacteria and viruses before they have invaded cells; another, T-lymphocytes, is the central defense of the “cellular” immune system: among other functions, T-lymphocytes detect cells already invaded by infection (e.g., malignant cells) and are responsible for transplant rejection. In AIDS, the cellular immune system fails. Although new information about the disease regularly emerges, one finding that has not been impugned is that AIDS patients usually have abnormally low ratios of the T-cells that increase the immune system’s efficacy (“helper cells”) to those T-cells that inhibit it (“suppressor cells”); occasionally there is a reversal of the ratios of helper to suppressor cells found in the normal body, and often a low absolute number of T-cells altogether.
The result is a persistent and, at least in full-blown cases, an apparently irreversible immunological imbalance which current chemotherapeutics and antibiotics cannot restore to normal; the patient becomes deeply vulnerable to “opportunistic” infections that would not have developed otherwise and are rarely seen except in patients whose immune systems have been disabled by genetic deficiency, chemotherapy, or age. Such infections include Pneumocystis carinii pneumonia, rare herpes viruses and others, even various “zoonoses,” parasites previously observed only in animals. AIDS patients are also prone to malignant disorders such as Kaposi’s sarcoma and Hodgkin’s disease. Even if one of these secondary diseases is treated successfully in an AIDS patient, because of the underlying disorder another usually follows until one occurs that cannot be treated, and the patient dies.
From what is currently known, airborne spread of the disease through upper respiratory tract secretions (as in colds), or transmission through fecal contamination of food (as in hepatitis A) or through insects (as in malaria), is unlikely. As Dr. Francis claims, many researchers believe that AIDS is an infectious disease caused by a virus and transmitted in a manner akin to that of hepatitis B, which many AIDS patients appear to have had and which often spreads sexually. The “viral agent” theorists base their claim on the facts that the syndrome has occurred in various groups without common patterns of life, and that a cluster of cases was found in Los Angeles, nine of whom had sex contacts in common. Since it is estimated that between 200,000 and 400,000 homosexuals live in the Los Angeles area, transmission of the disease by other means than sexual contact in this case would have been improbable.
Furthermore, as its occurrence among intravenous drug abusers and hemophiliacs would suggest, AIDS appears to be blood-borne, and spread either through sexual contact, or by administration of infectious blood or blood products, or by skin punctures for other reasons—Dr. Francis mentions several possible routes of this kind, including tattooing, ear piercing, etc. Some physicians contend that when the infectious agent of AIDS is transmitted through anal intercourse, the passive partners are at greater risk, since this form of intercourse often causes “traumatic” inflammation of tissue and small breaks in the mucosal lining of the rectum, thereby affording easy access to the bloodstream.
As with hepatitis B, again, individual vulnerability to AIDS appears to be variable. It may be that many hundreds or even thousands have been exposed to the infectious agents of AIDS and yet developed only a milder, perhaps asymptomatic, form of the illness. Confirmed cases of AIDS would then correspond to that small number of hepatitis B patients who develop severe and chronic, sometimes mortal, cases. Some physicians have speculated that the generalized lymphadenopathy (lymph-node swelling) widely observed among urban homosexuals may, in some cases, be a mild form of AIDS; others say that it may be a precursor or (like night sweats and unexplained weight loss) just an early symptom.
But what is the infectious agent of AIDS? The viral theorists argue that the disease, which is believed to have an average incubation period of twelve months or more, may derive from a common virus, a new virus in combination with a common one, or a new one altogether. None, however, has been identified, although candidates have included CMV (cytomegalovirus, which is relatively common) and the human T-cell leukemia virus, which appears to be transmitted from person to person and to alter T-cell function from that of helper to suppressor.
“The pursuit of an infectious agent for AIDS,” Dr. Francis writes, “has been hampered by a disbelief that AIDS was (is) an infectious disease.” At first, he notes, it was thought that the volatile nitrates or “poppers” sniffed by many homosexuals to enhance orgasm, or the presumed immunosuppressive effects of sperm introduced into the body either orally or through anal intercourse, might be the cause. (One doctor mentioned as a possible factor the immuno-suppressive steroids used by some body builders.)
These hypotheses have gradually been abandoned, but a number of doctors—none of them represented in Cahill’s volume—have persisted in proposing an etiology for AIDS according to which it is not infectious. According to the most prominent of these views, the “immune overload” theory, the disease results from repeated infections by viruses such as CMV, bacteria, and parasites common not only among malnourished Haitians, drug abusers, and others, perhaps in conjunction with other factors such as the antibiotic therapies used in treating these diseases, or poor diet and sanitation. These factors cause a “breakdown” of the immune system. On this view, although the ways in which a person may become immunologically compromised may be varied, the resulting syndrome may be identical.
Immune overload theorists contend that the explosion of homosexual promiscuity in the late Sixties and during the Seventies produced extraordinarily high levels of relatively common viruses and predisposed homosexuals to immune breakdown. Supporters of this view argue that no new virus causing AIDS has been found (as the viral theory would imply), either in bodily fluids and tissues of AIDS patients or in laboratory chimpanzees, dogs, mice, and marmosets injected with these samples. They also note that the disease has remained confined to a relatively narrow segment of the population (and even to a segment of homosexuals). And the high risks that viral theorists assign to the passive partners in anal intercourse could also apply under the immune overload theory.
Viral agent theorists may respond to these claims that while the evidence does not conclusively confirm either view, their research has not shown that all AIDS patients had histories of repeated infections before the onset of the disease; nor need they deny that factors such as drug use, previous infections, poor nutrition, and so on may play secondary or predisposing roles. They point out that discovering a viral agent can take years.
Dr. Donald Fredrickson decries “the generation of suspicion or fear that is not based on adequate information,” and offers the counsel that “the official pronouncements and the coverage by the media require unusual sensitivity in the instance of this disease.” By these criteria, however, much of the government and press reception of AIDS has been inexcusable. Members of the press exaggerated the scope and infectiousness of the illness: they spoke, to cite a characteristic example, of a “gay plague” “spreading like wildfire.”2 Even as late as last June, the director of the Office of Gay and Lesbian Health of the New York City Health Department felt it necessary to remind us that “fewer than one in 1,000 gay men actually have the disease” and that “many are not even at increased risk.”3