This truth can be tickled from numbers provided by Philip Rosenberg in Science magazine. The numbers show that even good news about the epidemic is infected with alarming connotations. His good news has two parts, one of which is that previous estimates of the prevalence of HIV–the virus that is the precursor of AIDS–among Americans were too high. Rather than 800,000 to 1.2 million infected persons, there probably were 630,000 to 900,000 as of Jan. 1,1993. The second part of the good news is that the incidence of AIDS has slowed and the epidemic seems to be approaching a plateau.
But the bad news also has two parts. One is that the plateau is terribly high, particularly for a disease transmitted almost entirely by behavior that, for more than a decade, has been abundantly publicized as putting people at risk. (The median incubation from HIV infection to the onset of AIDS seems to be about nine years.) This year approximately 50,000 people will die of AIDS-related diseases. Between 40,000 and 80,000 will be infected with HIV. Less than 5 percent of them will live long enough to be examples of “long-term nonprogression” in the destruction of their immune systems. The epidemic is too young for us to know its trajectory, but people in even that “long-term nonprogression” category probably will succumb.
The other part of the bad news is that the epidemic’s dynamism is now devastating a different cohort of the population. From the first appearance of AIDS in America in the late 1970s, through the middle of the 1980s, the epidemic was driven by white homosexual men in major metropolitan areas, particularly New York, Los Angeles and San Francisco. Now it is increasingly concentrated among racial minorities, involving more and more women, not only in cities but in rural areas, especially in the South, and is increasingly linked with drugs. That is, it is spreading among people inadequately constrained by social norms, including the criminal law pertaining to drugs, and impervious to even the aggressive dissemination of public health information.
The arrival of AIDS was shocking. R struck, Nuland says, just as biomedical science was beginning to believe that the conquest of infectious bacterial and viral diseases was in sight. It is doubly shocking that today the disease has become endemic even though it is difficult to acquire and is almost entirely preventable. “AIDS is a disease of low contagion,” writes Nuland. “HIV is a very fragile virus–it is not easy to become infected with it.” It has been transmitted only by blood, semen, vaginal fluid and breast milk.
Yet in early public commentary about AIDS, there were absurd comparisons to the Black Death of the 14th century. People contracted that plague by eating food, drinking water, breathing the air. In the United States, AIDS is contracted primarily by anal receptive sex among men having sex with men, by .dirty needles used by IV drug abusers and by people who have heterosexual sex with infected bisexuals or IV drag abusers. Worldwide, heterosexual sex is the dominant mode of transmission and before long may be in America.
In the last two years the proportion of newly reported AIDS cases among men having sex with men fell below 50 percent and 27 percent of newly reported AIDS cases were ascribed to drug injections. The spread of AIDS is further linked to drugs by women who turn to prostitution to support crack habits. HIV-related illness is the leading cause of death among young adults between 25 and 44 years old. In 1994, a third of all deaths among black men in that age group were the result of such illnesses. Rosenberg estimates that by 1998 3 percent of black men and 1.5 percent of Hispanic men between the ages of 80 and 44 and 1 percent of black women in their late 20s and early 30s were infected with HIV. In something of an understatement, Rosenberg calls it “sobering” that one of every 50 black men 18 to 59 may be infected.
The Economist notes that black Americans, even more than most Americans, are having sex at younger ages. “By the age of 14, more than a third of black males have had sex, five times the rate among white and Hispanic boys.” The earlier one starts, the more partners one is likely to have. That fact, and the fact that most Americans have sex with people of the same race and socio-economic condition, and the fact that many HIV eases are diagnosed only after the onset of AIDS, mean that there could be an explosive spread of AIDS among inner-city blacks. But not only there. For example, in Georgia the prevalence of HIV among childbearing women in some rural areas exceeds that in Atlanta.
The main reason for hope regarding AIDS is what it has always been: an epidemic driven by behavior can be contained by changing behavior. But one reason for not hoping extravagantly is the experience we have had with another, simpler behavior-driven epidemic, that of smoking-related diseases such as lung cancer. Smoking involves the powerful pull of nicotine. But AIDS often involves a tangle of sexual impulses and heroin or cocaine addiction. Thirty-two years have passed since the first surgeon general’s report asserting a causal connection between smoking and cancer, and one lesson is clear: knowledge is not enough. A full-court-press campaign of public education has achieved considerable success in curtailing smoking, but in the process it has demonstrated something depressing. Aggressive public education and stigmatization have made smoking less common but also have made it increasingly concentrated among poorer and poorly educated Americans who are more susceptible to tobacco marketing than to medical warnings. Life really is regressive.
