Philosopher Patrick Derr teaches courses on medical and environmental ethics. He is particularly interested in ethical issues surrounding HIV/AIDS and inadequacies in current codes of ethical conduct for medical research.
The AIDS Pandemic
"The AIDS Pandemic" in Homosexuality and
American Public Life, ed. Christopher Wolfe, Dallas, TX: Spence
Publishing Company, 1999. Used by permission.
- The U. S. Epidemic
- Viral Subtypes and HIV Transmission
and HIV in the U. S.
This paper offers a sketch of the global HIV pandemic, with special attention
to the ways in which the politics of homosexuality in the U.S. has distorted
both our perception of and our national response to that pandemic. This
introduction covers a few preliminary points regarding epidemiology,
scientific uncertainty, and the human heart.
Readers unfamiliar with epidemiological data will need a brief precis of
key terms: Incidence is a measure of new cases; Prevalence is a measure of
existing cases; Cumulative cases is a measure of the total number of cases,
whether new, existing, or deceased, since the beginning of the pandemic. Thus,
HIV incidence in a given region in a given year is a measure of the new
infections occurring in that region in that year, while HIV prevalence is a
measure of total number of infected persons alive in that region in that year.
Incidence and prevalence are typically reported as rates per 100,000
population per year.
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.
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
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
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.
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.
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.
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
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
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
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
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, 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
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
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
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
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
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
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
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
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.
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
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
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
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
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.
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
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.
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.
Agency for Health Care
Policy and Research (AHCPR)
Global Information System (AEGIS)
(The single most comprehensive online HIV/AIDS database in the world.)
AEGIS News Digest
A daily digest of approximately 15 to 20 leading articles from
government and other publications delivered directly to your email account.
African Search Engine
A powerful online search engine with especially rich connections to
South African information sources.
Francois Xavier Bagnoud (FXB)
Especially good international data on children and HIV.
The World Bank
US Food and Drug
HIV AIDS Program (HAP)
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.
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
Still, arguably, the definitive social history of the early years of the
HIV epidemic in the United States.
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.
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.
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.
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
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
10. For an introductory survey of the problem see "The
Lost Children," Peter Cordingley and Alison Dakota Gee, Asiaweek
Magazine, 7 February, 1997.
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
This introductory discussion is based in part on the excellent, although now
dated, "Status And Trends Of The Global HIV/AIDS Pandemic,"
Satellite Symposium, XI International Conference on AIDS, Vancouver, July
1996. The 1998 successor to this comprehensive report should appear soon
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
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).
"Grim Aids forecast: 40,000 dead," Huw Watkin, Phnom Penh Post,
October 31, 1996, pp. 2
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 mid 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
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.
All the subtypes of HIV-1 are quite efficient at infecting circulating T4
lymphocytes, and are therefore able to establish HIV infection if they are
injected directly into the blood by medical transfusion, injection drug use,
solid organ transplantation, or other means.
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.
These and related issues are treated in detail in the Garrett volume cited
A good survey of the problem is "The Lost Children," Peter
Cordingley and Alison Dakota Gee, Asiaweek Magazine, 7 February,