The AIDS Pandemic

HIV (Human Immunodeficiency Virus) is the virus which causes AIDS; it is a blood-borne virus, and, like most blood-borne viruses, is generally transmitted by blood, sexual contact, or mother-child contact during pregnancy or lactation. AIDS (Acquired Immune Deficiency Syndrome) is the result of long-term HIV infection. In order to understand the epidemiological data below, it is critical to remember that the average time required for initial HIV infection to progress to AIDS (the so-called latency period) is approximately than ten years. Data on AIDS incidence, thus, is properly understood as a ten year old report on HIV incidence: to know that the AIDS incidence in Washington D.C. was 232 per 100,000 in 1996, is to know, roughly, that in 1986 -- when the epidemic was much younger and smaller -- HIV incidence (the new HIV infection rate) in Washington D.C. was 232 per 100,000.[1]

The account which follows draws on almost two hundred sources, most of which will be almost one year old as this book goes to press. In some, and perhaps most, developing countries, actual HIV prevalence will, by early 1999, be as much as double the levels reported here. Moreover, the surveys, reports, estimates and projections assembled here -- although drawn from the best sources, national and international, public and private -- are collectively incomplete and often mutually inconsistent. This account must not be considered definitive. At best, it is a prudent and well-informed approximation. The sad but utterly uncontroversial truth is that no one knows the exact size, shape, or trajectory of the global HIV pandemic. In some areas, such as China, it is possible that the best reports err by whole orders of magnitude.

Finally, beneath all the numbing epidemiological data which follow, we are confronted by a human tragedy of unprecedented scope and intensity, a global catastrophe which will soon claim more lives than all the wars that mankind has fought from the beginning. Dismissed as alarmist only five years ago, expert projections of more than five hundred million AIDS deaths by 2050 are now common and sadly credible. It is for us, the educated adults of the world's industrial democracies, to confirm or refute Adolph Eichmann's claim that a few deaths are a tragedy, but a million are just a statistic.

The Global Pandemic

The Developing World
In mid-July 1996, an estimated 21.8 million adults and children worldwide were living with HIV/AIDS, of whom 20.4 million (94 percent) were in the developing world. 19 million of these adults and children (86 percent of the world total) were living with HIV/AIDS in sub-Saharan Africa or in South and Southeast Asia. Of the adults, 12.2 million (58 percent) were male and 8.8 million (42 percent) were female.

Worldwide during 1995, there were 2.7 million new adult HIV infections (roughly 7,400 new infections per day); about 1 million of these (nearly 3,000 per day) occurred in Southeast Asia, and 1.4 million (roughly 4,000 per day) in sub-Saharan Africa. The entire industrialized world -- including Western Europe, Japan, and the U.S. -- accounted for only about 55,000 new HIV infections (about 2 percent of the global total) in 1995.

Also in 1995, approximately 500,000 children were born with HIV infection. Of these children, 67 percent were in sub-Saharan Africa, 30 percent in South and Southeast Asia, and 2 to 3 percent in Latin America and the Caribbean. Only a small fraction of 1% were born in Western Europe, Japan, and the U.S.

From the beginning of the pandemic until mid-1996, an estimated 27.9 million people worldwide have been infected with HIV, including 19 million (68 percent of the global total) in sub-Saharan Africa and 5 million (18 percent of the global total) in South and Southeast Asia. Since the beginning of the pandemic, 93 percent of all HIV infections -- 26 million -- have occurred in the developing world. Worldwide, the cumulative number of HIV infections among adults more than doubled between 1990 (about 10 million) and mid-1996 (25.5 million).

uly 1996, more than 7.6 million persons had progressed from HIV infection to AIDS, and 75% (4.5 million adults and 1.3 million children) had already died. Of the 6 million adults, 4.5 million (75 percent) were in sub-Saharan Africa; 0.4 (7 percent) million were in Latin America and the Caribbean; 0.75 million (12 percent) were in North America, Western Europe and Japan. In South and Southeast Asia, where the pandemic has only recently gained intensity, 0.33 million adults have already progressed to AIDS. Of the 1.6 million children, 1.4 million (85 percent) were in sub-Saharan Africa.[2]

According to the World Health Organization, the number of AIDS orphans in developing countries may reach 10 million by the year 2000. Also by the year 2000, 40 to 50 million men, women, and children will be infected with HIV, nearly all in developing countries.

By the end of 1995, the AIDS pandemic had already deeply undermined national development in many sub-Saharan nations. On the UNDP Human Development Index (HDI), Zambia had lost more than 10 development years, Tanzania eight years, Rwanda seven years and the Central African Republic more than six years. Burundi, Kenya, Malawi, Uganda and Zimbabwe had lost between three and five years.[3] Hard-won gains in child survival, life expectancy, and economic development are rapidly being erased.

These aggregated statistics give some indication of the scope of the global HIV pandemic and of its profoundly disproportionate impact on the peoples of the developing world. The global pandemic, however, is composed of dozens of distinct national and regional epidemics, each with its own features and force. The following sections of this report will survey some of these distinct regional and national epidemics.

Asia
HIV is spreading rapidly in Asia, which contains sixty percent of the worlds adult population and had barely been touched by HIV ten years ago. An estimated 3 million to 6 million people in India and 0.8 million to 1 million people in Thailand are now infected with HIV. Cambodia, Malaysia, Myanmar, Vietnam, and China all have rapidly growing epidemics. The World Health Organization projects 10 to 12 million HIV cases in Asia by the end of 1999. India alone is expected to have at least 5 million cases. Especially dramatic is the spread of HIV among young adults, adolescents and children. In many Asian countries, the number of infected women now roughly equals that of men. WHO projects that sometime in 1998 or 1999, HIV incidence in Asia will equal and then surpass HIV incidence in Africa. By the year 2000, 42% of the world's projected 40 to 50 million HIV-infected persons are expected to live in Asia.

Burma/Myanmar -- The heroin trade in Southeast Asia's 'Golden Triangle' is fueling an exploding HIV epidemic in Myanmar and three northeastern Indian states. In August 1996, HIV infections in Myanmar were estimated to total 350,000 to 500,000 persons.

The UN reports that 60% to 70% of injection drug users (IDUs) in Myanmar are HIV-positive. WHO estimates that there are 500,000 IDUs in Myanmar (1% of the national population); some Asian NGOs estimate that IDUs may number 1 to 2 million, or up to 4% of the Myanmar population. In Hpa Kant in Kachin State, about 50 percent of the youth are thought to be IDUs. Over the Indian border in Manipur, HIV prevalence among IDUs jumped from zero in 1988 to nearly 70 percent in 1992, according to US Census Bureau research.

Cambodia -- Cambodia had virtually no AIDS cases in 1991. By 1996, it had the highest HIV prevalence rate in Asia. Health officials estimate that between 100,000 and 150,000 of Cambodia's 10.5 million people, including 2.5 percent of pregnant women, were infected with HIV by the end of 1996. Of these, only about 2,000 had yet progressed to AIDS.

In 1991, 0.08% of blood donors in Phnom Penh tested positive for HIV. In 1992, the figure was 0.8%. In 1994, 4.3%. By early 1995 the rate 6.1%. And by the end of 1995, 8.6% -- a one-hundred-fold increase in just four years. In 1995, 8% of Cambodian police tested were HIV infected compared to zero percent in 1992. Also in 1995, 8% of Cambodian TB patients, over 8% of Cambodian government soldiers, and 33% of prostitutes tested HIV positive. By mid 1996, infection among prostitutes had risen to 41%.

Cambodian authorities expect the HIV epidemic to severely retard their country's economic and social development. Dr. Hor Bun Leng, Director of the National AIDS Program, said Cambodia's HIV epidemic is the most severe in south-east Asia and will begin to claim large numbers of lives in 1998. He writes, "We are looking at a tragedy in 1998 or 1999 -- we cannot avoid it."[4] By the year 2000 -- in just the ninth year of its epidemic -- the Cambodian Ministry of Health and the WHO expect 40,000 AIDS deaths and 250,000 to 500,000 persons infected. In sum, HIV is spreading faster in Cambodia than in any other Asian nation, except Burma and India.

China -- By August 1996, Chinese authorities had reported 4,305 HIV-positive cases. The actual number of HIV-positive people in China could be ten or even a hundred times higher; official estimates range from 50,000 to 200,000. All but two of China's 30 provinces, regions and municipalities have reported HIV/AIDS cases. The Ministry of Health estimates that 10,000 people are infected with HIV, but the Chinese Academy of Preventive Medicine estimated that there were 100,000 HIV-infected persons in China at of the end of 1995, and that HIV prevalence was doubling annually. If the Academy is correct, HIV prevalence could reach 800,000 by 1999. By 1997, some Chinese health officials warned that an uncontrolled AIDS epidemic might be unavoidable.

India -- According to the United Nations AIDS program, India now has more HIV-infected persons than any other country. At the end of 1994, WHO estimated that India had 1.75 million HIV infections. By mid-1996, 3 million infections had been diagnosed. By late 1996, 5 million persons may have been infected.

In Bombay, HIV prevalence in STD clinics was 36 percent in 1994. HIV prevalence among prostitutes rose from 1 percent to 51 percent between 1987 and 1993. Antenatal clinic patients tested positive at a 2.5 percent rate in 1994. In Vellore, HIV prevalence at STD clinics was 15 percent in 1995. In Manipur, HIV prevalence among IDUs was 60 percent in 1992, and 1 percent of women attending antenatal clinics in Manipur were infected with HIV. In India generally, annual incidences (new HIV infections) in sex workers as high as 25 percent and in clients of almost 10 percent have been documented. Surveys found 5 to 10 percent of truck drivers in the country infected with HIV by 1995.

Indonesia -- The Indonesian government officially reports 449 HIV cases in late 1996. Independent experts estimate that the actual number was between 95,000 and 200,000 persons. Both groups project up to 2.5 million Indonesians infected by the year 2000.

Japan -- The Japanese Ministry of Health and Welfare, AIDS Surveillance Committee, reported 112 new HIV cases in 1997. If this figure is correct, Japan would have the lowest documented HIV prevalence in Asia.

Malaysia -- In Malaysia, HIV prevalence among IDUs reached 20 percent in 1994. Among prostitutes, prevalence reached 10 percent in 1994. The Malaysian government reported 16,963 HIV infections in 1996; Asian and international NGOs estimate that the actual figure was 35,000 to 75,000.

Nepal -- In 1996, WHO estimated that 10,000 persons in Nepal were HIV infected. No other credible data seems to be available.

Pakistan -- Seroprevalence surveys performed between in mid-1995 in Lahore and Peshawar found 3.7% of STD clinic patients HIV infected. The rate at the Quetta tuberculosis clinic was 2.8%. Among Lahore IDUs, HIV prevalence was 11.5%.

Taiwan -- Serum antibody testing of male homosexuals in southern Taiwan found that 9.5% were HIV infected in late 1995.

Thailand -- In August, 1996, HIV infections in Thailand were estimated to total 750,000 to 800,000 persons. By 2000, more than one million persons will be infected, 300,000 will have died, and almost 50,000 children will be orphaned by AIDS.

By mid-1996, HIV prevalence among IDUs was between 29 and 35 percent; with incidence estimated to exceed 10 percent per year, prevalence among IDUs will likely pass 50% in 1998. HIV prevalence among prostitutes was 33 percent in 1994. HIV prevalence among women attending antenatal clinics reached 2.3 percent in 1995 -- the highest antenatal rate in all of Asia according to the Thai Health Ministry. AIDS could quash Thailand's economic growth. Direct and indirect costs of the epidemic will probably exceed $10 billion by the year 2000.

Among Burmese girls rescued from Thai brothels, 74% (14 of 19) were HIV infected. Other studies of Thai sex workers have yielded HIV prevalences between 50% and 100%. Fear of AIDS in Thailand and other countries has increased the demand for child virgins in the commercial sex industry, and numerous NGOs report that brothel agents have intensified the kidnapping of very young girls from remote villages.

There is also good news in Thailand. Among young men drafted into the Royal Thai Army, HIV prevalence rose from 10.4% in 1991 to 12.5% 1993, but dropped to 6.7% in 1995. The percentage of draftees who had had sex with a prostitute in the previous year also decreased from 57% in 1991 to 24% in 1995.

Vietnam -- One percent of Vietnam's population was HIV infected at the end of 1996. HIV prevalence among IDUs was 32% in 1995. Prevalence among prostitutes was 38 percent in 1994-95. The National AIDS committee of Vietnam projects 300,000 cumulative infections by the year 2000, including 20,000 persons with AIDS and more than 15,000 dead.

Sub-Saharan Africa 
Sub-Saharan Africa, the original epicenter of the global HIV pandemic, accounted for 68 percent of the world's new HIV infections in 1995. By 1996, life expectancy had fallen from almost 70 to below 40 in some countries. The Southern Africa Development Community calculates that AIDS will reduce regional life expectancy to 40 years. In some large cities, 40 percent of pregnant women are HIV infected and 25 percent of those who die from AIDS are children. Regional prevalence was estimated to be 5% in 1995, and is expected to reach 20% in 1998. In 1996, new infections exceeded 3 million and deaths exceeded 1.5 million.

A French study of Central African armies in 1996 found that in seven of the armies surveyed, more than 50 percent of the troops tested were HIV-infected.

AIDS has orphaned hundreds of thousands of African children. Many will be forced into prostitution. Many will die of starvation or other causes and not be counted as AIDS casualties. UNAIDS projects that 9 million children will be orphaned in Africa by the year 2000.

Cote d'Ivoire -- HIV prevalence among adults was estimated to be between 15% and 20% in 1996. HIV prevalence among pregnant women was 14.8% in 1992. The UN projects that life expectancy will fall below 35 years by the year 2000.

Kenya -- In early 1996, Kenya reported that 1.2 million people were infected with HIV and that over 200,000 people had died of AIDS in both 1994 and 1995. Assistant Minister for Health Basil Criticos said that AIDS deaths in 1996 would probably reach 240,000, and that 1.7 million Kenyans would be living with HIV infection by early 1997. By the year 2010, average life expectancy is expected to fall from 68 to 40 years. Provincial Medical Officers report that the casualties include Kenya's most productive workers. The consequences for national development may be catastrophic.

Malawi -- AIDS has claimed 200,000 lives in Malawi since the first case was reported in 1985. According to WHO, the Malawian National AIDS Control Program, and the World Bank, about 10% million of Malawi's 11 million people were HIV-infected at the end of 1996. By the year 2000, 2 million will be infected and 350,000 children will have lost both their parents to the disease. In 1996, HIV prevalence among pregnant women was over 33 percent, and among prostitutes was nearly 98 percent. The average life span in Malawi is expected to decrease from 57 years to 33 years.

Namibia -- NGO's estimate that 200,000 persons (12.5% of the national population) was HIV-infected by mid-1996. Namibia's Health and Social Services Ministry estimates that 200,000 more will be infected each year. HIV prevalence could reach 30% in 1998 or 1999.

Nigeria -- According Nigeria's Federal Ministry of Health, at least 1 million of Nigeria's 118 million people were HIV infected in 1996; independent experts believe that the figure may be two to three times higher. Some studies of young educated urban adults have found prevalence rates as high as 70%. More than seven million Nigerians are expected to be infected with HIV by the year 2,000.

Republic of South Africa -- Between 1.8 million and 2.4 million South Africans (7.8% to 10.4% of all adults) were infected with HIV by 1997. Between 0.6 million and 1.4 million new infections were expected in 1997. In late 1996, nearly 20% of the population aged 30 to 45 was HIV infected. HIV infection in the work force is expected to reach 25% before 2000. By 2010, HIV prevalence among 30 to 45 year old adults is expected to reach 40%, and 22% of persons 35-44 years old are expected be dying of AIDS.

Surveys conducted by the South African Department of Health at antenatal clinics found that 7.6% of pregnant women in the country were infected with HIV at the end of 1994. By November 1995, more than 10% were infected, including more than 13% of women aged between 20 and 24. In kwaZulu/Natal, 20% of women attending antenatal clinics in 1995 were HIV infected, and government experts expect the figure to be reach 35% soon. 500,000 AIDS orphans are expected in kwaZulu/Natal alone by the year 2000.

Despite these grim figures, South Africa's exploding HIV epidemic is still so young that only approximately 50,000 South Africans had yet died of AIDS by early 1996.

Sudan -- Sudan reported more than 100,000 people infected with HIV at the end of 1996. According to the Sudanese Health Ministry, 14,000 children were AIDS orphans in 199, and the number will reach 90,000 in 1998.

Tanzania -- According to WHO, 1.5 million of Tanzania's 27 million people were HIV infected in 1996; 2.7 million will be infected by the year 2000; 400,000 have already progressed to AIDS.

Uganda -- Ugandan authorities estimate that roughly 2 million people (10% of its population) were HIV infected by 1997. Seroprevalence studies in 1991 found prevalence rates in some urban areas as high as 35%, and in semiurban areas as high as 23%. Since 1995, AIDS has caused the loss of more total years of productive life than all other causes added together. By the year 2010, average Ugandan life expectancy is expected to fall from 59 to 31 years, with catastrophic consequences for national development.

Against this grim background, Uganda -- which has dealt more openly with its HIV epidemic than many other governments -- has recently been able to report some modest progress: between 1992 and 1995, for example, HIV prevalence among pregnant women at two surveillance sites decreased from 24% to 15%.

Zambia -- By 1995, the HIV epidemic had reduced average life expectancy in Zambia from 62 to 51. Average Zambian life expectancy is expected to reach 45 by 2002, and 33 by 2010.

Zimbabwe -- An estimated 1 million of Zimbabwe's 10.5 million residents, including up to 30% of Zimbabwe's working adults, were HIV infected in mid-1996. More than 100,000 persons died from AIDS in 1997, most of them aged between 15 and 45. Infant mortality rate is expected to increase 500% by the year 2005, and the total national population is expected to begin dropping by about 1.5 percent a year. 150,000 AIDS orphans are expected in the country by the year 2000. By the year 2010, AIDS will have lowered the average life expectancy from 70 to 40 years.

The U. S. Epidemic

From the first reports of AIDS in 1981 through December 31, 1996, 581,429 persons with AIDS have been reported to the CDC by state and local health departments in the U.S. Of these, 84% were men, 15% were women, and 1 percent were children less than 13 years old. Among these cumulative cases, the proportion accounted for by men who have sex with men declined to 50% in 1996. Among women, heterosexual contact and injection drug use account for the vast majority of cases. 1996 AIDS incidence rates declined or leveled for whites, men who have sex with men, IDUs, and children under 13 years old; rates increased for blacks, women, and persons infected through heterosexual contact.

The number of Americans living with AIDS in mid-1996 was estimated to be at least 223,000. The total number of people who have died from AIDS in the U.S. since the beginning of the epidemic is roughly 360,000. The number of persons currently estimated to be HIV infected is between 1 and 0.8 million, or a little less than 0.5% of the population.

Putting all these data together, and using 900,000 as our estimate of current HIV prevalence, we get this picture: From the beginning of the American epidemic to 1 January 1997, approximately 1.3 million persons were infected with HIV. Of these, about 360,000 had died, at least 223,000 were living with AIDS, and about 700,000 were HIV infected but have not progressed to AIDS. Of these 700,000 many, perhaps the majority, did not know that they were infected.

Variation in AIDS incidence by location is enormous in the U.S. 1996 AIDS incidence rates (per 100,000) for major cities ranged from 8.3 in Pittsburgh to 95 in San Francisco, 120 in New York and 232 in Washington, D.C. Rates for states ranged from 1.5 in Wyoming to 68.1 in New York. For the entire United States, the rate was 25.6.

With each passing year, men who have sex with men account for a smaller and smaller percentage of new AIDS cases in the U.S. In 1995, they accounted for 43% of new cases; in 1996, 40% of new cases. But with an average interval between infection and AIDS of roughly ten years, what these data really mean is this: between 1985 and 1986 -- in the very early years of the U.S. epidemic -- the percentage of new HIV infections accounted for by men who have sex with men was already far below 50% and dropping rapidly.

As reported by the CDC, AIDS incidence rates for 1996 divide very sharply on racial lines: 178 for black men, 89 for Hispanic men, 30 for white-not-Hispanic men. Among women, the differences are even more dramatic: 62 for black women, 23 for Hispanic women, and only 3.5 for white-not-Hispanic women.

Annual U.S. deaths from AIDS appear to have peaked in 1994 at 47,000, but reporting delays and the life-prolonging effects of new (but unfortunately not curative) multi-drug anti-HIV treatments make this datum difficult to interpret.[5]

Viral Subtypes and HIV Transmission

There are two major genetic branches of HIV, called HIV-1 and HIV-2. HIV-2 is almost entirely confined to west Africa and appears to be less pathogenic than HIV-1. HIV-1 is found in eastern and southern Africa, Europe, Asia, and the Americas. Within the HIV-1 branch, there are nine viral subtypes (A, B, C, D, E, F, G, H, and O). The HIV epidemic in the United States has been almost exclusively fueled by subtype HIV-1/B. In most of Africa and Asia, subtypes HIV-1/A, HIV-1/C and HIV-1/E are dominant.

The process by which a virus infects a human cell is often explained by analogy to the process by which a space vehicle docks with an orbitting space station. An Apollo vehicle fitted to dock with Skylab 1, for example, could not dock with MIR: the hatches and other connections simply did not fit. The Shuttle Atlantis, on the other hand, although unable to dock with Skylab, is perfectly fitted to dock with MIR. HIV infects human cell through a "docking" process called membrane fusion. As with space vehicle docking, successful infection depends an exquisite 'fit' between the virus and the target cell. In the case of HIV, this fit requires both (i) an exact molecular match between the gp160 glycoprotein on the surface of the virus and the CD4 receptor on the surface of the human cell, and (ii) the presence on the human cell of a particular chemokine receptor which facilitates membrane fusion.[6] Because only a very few human cell types have CD4 receptors (T4 helper lymphocytes, Ti inducer lymphocytes, macrophages, and microglial brain cells being the most significant), only those very few human cell types can be infected by HIV.

Different populations of CD-4 bearing human cells have different chemokine receptors. In addition, the precise molecular structure of the CD-4 receptor (the "docking bay" in terms of our aeronautical analogy) will vary between populations of the same type of human cell at different locations in the body. Thus, epithelial langerhans cells in rectal mucosa have a slightly different CD-4 receptor and present a slightly different 'docking' problem for HIV than do the same cells in the oral or vaginal mucosa.

The precise structure of the gp160 molecule -- the main part of the virus' "docking mechanism" -- which is determined by HIV's env gene, a 1,800 nucleotide segment of HIV's complete 9,749 nucleotide genome. The env gene varies significantly between different subtypes of HIV-1, and, as a result, different subtypes of HIV-1 are better or worse 'fitted' to infect CD-4 bearing cells in different parts of the body.

Research since 1995 has shown that subtypes C and E (the dominant strains in India, sub-Saharan Africa, and Thailand) are better adapted to infect oral and genital mucosa than is subtype B (the dominant strain in the United States and Europe). Subtype B, on the other hand, is better adapted to infect rectal mucosa. In other words, subtypes C and E (the dominant strains in India, sub-Saharan Africa, and Thailand) are better adapted to heterosexual transmission during vaginal intercourse than is subtype B.[7]

These new findings suggest that the low incidence of heterosexual HIV transmission in the United States and Europe during the early years of their epidemics was due, at least in part, to biological rather than social factors: HIV-I/B, the strain present in the U.S., is simply not very efficient at infecting vaginal mucosa during heterosexual intercourse. Subtypes A, C, or E would -- as Soto-Ramirez and colleagues have warned -- pose a significantly greater threat to heterosexuals in the West than has so far been presented by subtype B.[8] Authorities such as Dr. Max Essex, chairman of the Harvard AIDS Institute, warn that the United States may soon face a second AIDS epidemic involving the non-B subtypes, especially C and E, that are common in Asia and Africa. If (or more properly, when) these non-B strains gain a foothold in the U.S., they may launch a second and significantly larger "heterosexual" epidemic.

Most experts believe that it is only a matter of time before subtypes C and E become established in America and Western Europe, joining the more familiar subtype B. Indeed, in late 1996, 73 cases of subtype E infection were diagnosed in Britain. Given the realities of international travel, and the presence of Western tourists and military personnel in many of the world's developing countries, the appearance of subtypes C and E in America and Western Europe seems inevitable.

Homosexuality and HIV in the U. S.

Most prudent public health authorities argue that HIV-related disease ought not to be treated differently than other similar infectious diseases. "AIDS Exceptionalism" is a very poor basis for sound public health policy. Yet, from the very beginning, AIDS exceptionalism has profoundly distorted America's response to its own HIV epidemic. Worse, by perpetuating the view that AIDS is largely or only a "homosexual" issue, AIDS exceptionalism has crippled America's response to the vastly more devastating pandemic now far advanced in the world's developing countries.

No one can deny that support and sympathy for a set of political and moral values which are commonly (but misleadingly) subsumed under the label of "gay rights" has had a destructive effects on the U.S. response to the HIV epidemic. Indeed, these effects have been exquisitely catalogued by such gay writers as Randy Shilts and Larry Kramer. But neither can any one deny that support and sympathy for a set of political and moral values which are commonly (but also misleadingly) subsumed under the label of "homophobia" has also had a destructive effect on the U.S. response to the HIV epidemic.

Some of the more flagrant instances of this latter type of AIDS exceptionalism are almost comic. The claim that the AIDS epidemic was sent by God to punish homosexuals, for example, replaces "God is dead" theology with "God is inept" theology: what bungling diety aiming thunderbolts at a few thousand adult males in San Francisco would miss by 10,000 miles and kill five million children in sub-Saharan Africa?

But the institutional effects of AIDS exceptionalism are not at all comic, and have permeated almost every sector of U.S. culture, with profoundly adverse results. Four brief examples may serve to illustrate this point.

If the New York Times and other mass media had given the first thousand AIDS victims even a fraction of the coverage given to the seven victims of poisoned Tylenol capsules, millons of Americans would have learned of the new disease much earlier, and tens or hundreds of thousands of Americans who are now dead might be living. Instead, the NYT published fifty-four stories on the Tylenol affair (several on the front page) and a total of three stories on AIDS -- none on which appeared on the front page, and none of which used the words 'sex' or 'homosexual'.

If the U.S. Public Health Service had given Dr. James Curran's KSOI (Kaposi's Sarcoma and Opportunistic Infections) Task Force at CDC any financial support, stalled lab research and field cluster studies could have been completed years earlier -- proving that the virus was blood-borne and sexually transmissible, and accelerating development of an antibody test -- and tens or hundreds of thousands of Americans who are now dead might be living. Instead, the same federal agencies which had assigned more than one thousand lab and field employees to work the Tylenol affair refused to fund even one part time secretary for the KSOI task force.

If the Mayor of New York, Ed Koch, had not for eighteen months refused all requests to meet with New York's gay health experts, his Public Health Department might have acted on early reports of vertical transmission in New York hospitals, and hundreds or thousands of American children who are now dead might be living. Instead, apparently fearful that rumors regarding his own sexual orientation might be reinforced, he agreed to such a meeting only in April of 1983, when he was politically cornered by the combined efforts of Larry Kramer, noted gay playwright, Dr. Kevin Cahill, prominent Irish Catholic physician, and His Eminence Terence Cardinal Cooke.

If the American blood products industry had accepted the conclusions of CDC experts showing that HIV was a blood-borne disease, tens or hundreds of thousands of Americans who are now dead might be alive. Instead, for almost two years -- hammered on the one side by gay activists arguing that screening would be discriminatory and on the other by concern for profit margins -- the Red Cross and other institutions resisted pleas to institute donor screening, killing thousands of transfusion recipients and nearly every American hemophiliac who received even a single dose of clotting factor between 1980 and 1985.

Honest scholars can disagree about precisely how attitudes toward homosexuality have distorted the American response to HIV. They can also disagree about whether the greatest damage was wrought by the "gay-rights" or by the "homophobic" variety of AIDS exceptionalism. But to rest of the world, and to the overwhelming majority of the tens of millions of human victims of the global HIV pandemic, this disagreement is unimportant and destructive. In different ways, both varieties of AIDS exceptionalism have perpetuated the uniquely American belief that the AIDS epidemic is a homosexual issue, and thereby helped to stifle any significant U.S. response to the real issues which the global HIV pandemic poses. A very brief sketch of just a few of these diverse issues follows.

Public Policy Problems

Vaccine Development
A vaccine that blocks HIV infection is urgently needed to stem the tide of HIV in developing nations. New multi-drug therapies promise better treatment for HIV disease in the developed world, but at $15,000 to $30,00 per person per year, these treatment regimens will never be available to citizens of developing countries with national health expenditures of less than two dollars per person. Nevertheless, despite the international importance of developing an HIV vaccine, and despite direct pleas by international authorities, including the head of the U.N. AIDS Program, less than 1% of all U.S. HIV research dollars has been spent on vaccine development. And even this 1% has been spent in ways which systematically disadvantage the developing world: the vaccine now being tested in Uganda, for example, is designed to protect against HIV subtype B -- not the subtypes A and D which predominate in Uganda.

These shortsighted policies might have a certain attractiveness to American citizens who believe that American tax dollars should be spend on American problems. But infectious diseases neither understand nor respect national boundaries. Failure to control the global HIV pandemic will inevitably result in new U.S. epidemics of the HIV subtypes now epidemic elsewhere.[9]

Sexual Exploitation of Children
The global HIV pandemic has exacerbated the already terrible problem of the sexual exploitation of children, often by tourists visiting from the developed world. First, by killing adults, the pandemic has left millions of children without parents and without nurture or protection. The World Health Organization has estimated that 10 million children under 10 years of age will be orphaned by 2000 as a result of AIDS. Fear of AIDS also fuels demand for child sexual partners. Some estimates put the number of under-age prostitutes in Thailand at 400,000; in the Philippines, at about 60,000; in India, at about 400,000; in Taiwan, between 40,000 and 60,000. A child can be bought for as little as $1.40 in Delhi. A virgin or a child under age six can cost $140. In Malaysia, the price of a child virgin is $2,000, in Singapore, $500. Once deflowered, the young girl's price drops to $10, and after a week's use, to $5. If she survives a year, sex may cost only $3; but by then, she will be HIV infected. Despite this terrible situation, specialized "tour services" in the U.S. and Europe continue openly to organize and advertise "sex adventure" tours to each of these developing countries.[10]

Population Policy No competent demographer who is familiar with the HIV pandemic believes that Sub-Saharan Africa now faces an overpopulation problem. On the contrary, Sub-Saharan Africa faces a potentially disastrous depopulation problem. Nevertheless, in its first year in office, the Clinton administration ordered the U.S. Agency for International Development to treat "population control", and not HIV control, as its first U.S. priority in Africa. Vocal African critics of US policy can be forgiven for wondering aloud whether current US policy aims at the depopulation of their continent.

Conclusion

The global HIV pandemic is not a "gay plague." It is not a "homosexual issue." It is a human tragedy of unprecedented magnitude. To the extent that Americans continue to view the HIV pandemic through a lens of sexual politics -- whether that lens is homosexual or heterosexual, conservative or liberal -- America will fail to respond to the greatest public health threat that mankind has faced since the beginning. We can do better. We must.

Sources and Resources (annotated)

For the most recent information on almost any aspect of the HIV pandemic, including epidemiological data, scientific and clinical developments, and the like, it is necessary to rely on electronic databases. Much of the material in these databases is never published in any other format, and most of what is published on paper is obsolete by the time that it appears. A select set of the most reliable and important such sources follows. Most of the information presented in the paper above was derived from these databases. The very latest data, which will supersede the grim data presented above, will appear on these sites.

Electronic Databases
Agency for Health Care Policy and Research (AHCPR) : http://www.ahcpr.gov:80/

AIDS Education Global Information System (AEGIS) : http://www.aegis.com/ (The single most comprehensive online HIV/AIDS database in the world.)

AEGIS News Digest : http://www.aegis.com/
A daily digest of approximately 15 to 20 leading articles from government and other publications delivered directly to your email account.

ANANZI South African Search Engine : http://www.ananzi.co.za/ 
A powerful online search engine with especially rich connections to South African information sources.

Association Francois Xavier Bagnoud (FXB) : http://fxb.org/
Especially good international data on children and HIV.

CDC HIV/AIDS Surveillance Report (updated): http://www.cdc.gov/ndhstp/hiv_aids/stats/hasrlink.htm
The definitive source for US HIV/AIDS epidemiology.

Centers for Disease Control and Prevention (CDC) : http://www.cdc.gov

Centers for Disease Control and Prevention (CDC), National Center for IV, STD, and TB Prevention (NCHSTP), Division of HIV/AIDS Prevention (DHAP) : http://www.cdc.gov/ndhstp/hiv_aids/dhap.htm

Department of Health and Human Services (DHHS) : http://www.os.dhhs.gov/

Joint United Nations Program on HIV/AIDS (UNAIDS) : http://www.unaids.org/
The best place to start a search for international epidemiological data, although the official reports tend to be somewhat outdated. North Americans should use the mirror site at http://www.us.unaids.org

National Institute for Allergy & Infectious Diseases (NIAID) : http://www.niaid.nih.gov/

National Institutes of Health (NIH), Office of AIDS Research (NIHOAR) : http://www.nih.gov/od/oar/index.htm

National Library of Medicine (NLM), Internet Grateful Med (IGM) : http://www.nlm.nih.gov/databases/medline.htm
The most powerful medical literature search engine on the web.

National Library of Medicine (NLM) : http://www.nlm.nih.gov/

Panos Institute London : http://www.oneworld.org/Panos/
Excellent materials on HIV/AIDS in less developed countries.

The Pan American Health Organization (PAHO) : http://www.paho.org/

The World Bank : http://www.worldbank.org

US Food and Drug Administration (FDA), HIV AIDS Program (HAP) : http://www.fda.gov/oashi/aids/hiv.htm

World Health Association (WHO) : http://www.who.org/
Useful, but consult the UNAIDS site first.

XI and XII International Conferences on AIDS: http://www.nlm.nih.gov/aidswww.htm
All of the thousands of abstracts from the XI conference, in computer searchable format; the abstracts of the XII conference should be appearing online here just as this book goes to print.

Print Sources
Several outstanding books can be consulted for historical discussions of the HIV pandemic. The most excellent are listed below.

Stine, Gerald J. AIDS Update 1998. Prentice-Hall, 1998.
The most comprehensive single volume on the pandemic, this book covers everything from the molecular biology of HIV and the human immune system to the latest therapeutic advances.

Shilts, Randy. And the Band Played on: Politics, People, and the AIDS Epidemic. Penguin Books, 1988.
Still, arguably, the definitive social history of the early years of the HIV epidemic in the United States.

Smith, James Monroe. AIDS and Society. Prentice-Hall, 1996.
An excellent complement to Stine's book: much less scientific material, but much more social, legal, and historical material.

Garrett, Laurie. The Coming Plague: Newly Emerging Diseases in a World Out of Balance. Farrar, Straus and Giroux, 1994.
A book which may do for public health concerns what Rachel Carson's Silent Spring did for environmental concerns. Chapter 14 includes a superb analysis of what has been learned about the origins of HIV.

Reamer, Frederic G., editor. AIDS and Ethics. Columbia, 1991.
The first, and perhaps still best, collection of important essays on the ethical and public policy problems raised by the HIV epidemic. Includes the superb "AIDS and the Obligations of Health Care Professionals" by Abigail Zuger, M.D.

Grmek, Mirko D. History of AIDS: Emergence and Origin of a Modern Pandemic. Translated by Russell C. Maulitz and Jacalyn Duffin. Princeton, 1990.
A superb scientific history of the pandemic.

Lapierre, Dominique. Beyond Love. Warner Books, 1990. Translated by Kathryn Spink.
Like Shilts' book, a social history, but from a very different social and national perspective.

Footnotes

1. Although ten years is a commonly accepted figure for the mean progression time from HIV infection to AIDS, individual progression time can vary significantly. For a thorough discussion of the factors which are currently believed to influence progression, see the Stine volume cited below.

2. Where more recent data was not available, this introductory discussion is based on the excellent but dated, "Status And Trends Of The Global HIV/AIDS Pandemic," Satellite Symposium, XI International Conference on AIDS, Vancouver, July 1996. By late 1998, a successor to this comprehensive report should appear among the abstracts of the XII International Conference, which will be available online through the National Library of Medicine at http://www.nlm.nih.gov/aidswww.htm

3. Research conducted for UNDP at Columbia University and the Harvard Institute for International Development and reported in the 1996 Human Development Report under the title "HIV/AIDS SETS BACK HUMAN DEVELOPMENT BY YEARS IN SOME COUNTRIES" (United Nations Development Program: Oxford University Press, 1996).

4. "Grim Aids forecast: 40,000 dead," Huw Watkin, Phnom Penh Post, October 31, 1996, pp. 2.

5. All the preceding data is from the Centers for Disease Control and Prevention, HIV/AIDS Surveillance Report, 1996;8 (no.2). Because of reporting delays and CDC follow-up on cases without reported risk factors, reasonably complete figures for 1997 will not be available until late 1998. The most recently updated surveillance data is always available from the CDC website at http://www.cdc.gov/ndhstp/hiv_aids/stats/hasrlink.htm

6. HIV-1/B uses the CKR-5 chemokine receptor to infect macrophages, the fusin chemokine receptor to infect T4 cells in the lymph nodes, the CKR-3 or CKR-5 chemokine receptor to invade microglial brain cells, and either the fusin or CKR-5 receptor to invade T4 cells circulating in the blood. For a thorough treatment of these and related issues, see the Stine volume cited below.

7. All subtypes of HIV-1 infect circulating T4 lymphocytes quite efficiently, and can thus establish HIV infection if injected directly into the blood by medical transfusion, injection drug use, solid organ transplantation, or other means.

8. The earliest report on this question seems to have been "HIV-1 Langerhans' Cell Tropism Associated with Heterosexual Transmission of HIV" Science (03/01/96) Vol. 271, No. 5253, P. 1291; Soto-Ramirez, Luis E.; Renjifo, Boris; McLane, Mary F.; et al.

9. These and related issues are treated in detail in the Garrett volume cited below.

10. For an introductory survey of the problem see "The Lost Children," Peter Cordingley and Alison Dakota Gee, Asiaweek Magazine, 7 February, 1997.