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MISLEADING IMPRESSION
AIDS Fight is Skewed by Federal
Campaign Exaggerating Risks
By Amanda Bennett and Anita
Sharpe
Wall Street Journal, 1 May 1996
http://www.virusmyth.net/aids/news/abaswsjcdc.htm
In the summer of 1987, federal health officials made the fateful
decision to bombard the public with a terrifying message: Anyone
could get AIDS.
While the message was technically true, it
was also highly misleading. Everyone certainly faced some
danger, but for most heterosexuals, the risk from a single act
of sex was smaller than the risk of ever getting hit by
lightning.
In the U.S., the disease was, and remains,
largely the scourge of gay men, intravenous drug users, their
sex partners and their newborn children.
Nonetheless, a bold public-relations
campaign promised to sound a general alarm about AIDS, lifting
it from a homosexual concern to a national obsession and
accelerating efforts to eradicate the disease. For people
devoted to public health, it seemed the best course to take.
But nine years after the America Responds
to AIDS campaign first hit the airwaves, many scientists and
doctors are raising new questions. Increasingly, they worry that
the everyone-gets-AIDS message -- still trumpeted not only by
government agencies but by celebrities and the media -- is more
than just dishonest: It is also having a perverse, potentially
deadly effect on funding for AIDS prevention.
No Allocation for Gays
The emphasis on the broad reach of the
disease has virtually ensured that precious funds won't go where
they are most needed. For instance, though homosexuals and
intravenous drug users now account for 83% of all AIDS cases
reported in the U.S., the federal AIDS-prevention budget
includes no specific allocation for programs for homosexual and
bisexual men. And needle-exchange programs, widely seen as among
the most effective methods available in fighting infection among
drug users, are denied any federal funding.
Much of the Centers for Disease Control's
$584 million AIDS-prevention budget goes instead to programs to
combat the disease among heterosexual women, college students
and others who face a relatively low risk of becoming infected.
Federally funded testing programs alone, which primarily serve
low-risk groups, account for roughly 20% of the entire budget.
Some scientists charge that tens of
thousands of infections a year could be averted if only
practical assistance were directed to the right people. Instead
of aiming general warnings at non-drug-using heterosexuals,
these critics say, the government should use the bulk of its
anti-AIDS money to teach homosexual men to avoid unprotected
anal sex and to dissuade addicts from sharing infected needles.
Shifting Strategies
"You can't stop this epidemic if you spend
the money where the epidemic hasn't happened," says Ron Stall,
associate professor of epidemiology at the University of
California in San Francisco.
Helene Gayle, who is in charge of AIDS
prevention at the CDC, agrees that "increasingly, it is
important to shift strategies to meet the epidemic." She says
that the CDC, by giving communities more freedom to decide how
to spend federal AIDS money, is now seeking to direct more help
to those who need it most.
But she defends the CDC's pivotal decision
in 1987 to emphasize the universality of AIDS: "One should not
underestimate the fear and confusion this disease caused early
on," Dr. Gayle says. "We needed to build a base of understanding
before we could go for the jugular."
Certainly, powerful political and social
forces at work nine years ago made it nearly impossible for
health officials to focus attention on those most at risk, a
reconstruction of events of that year shows. And though, as Dr.
Gayle says, the CDC is now trying to revamp its AIDS-prevention
efforts, the same forces that shaped public policy in 1987 are
making it difficult for the government to change directions,
even now.
Clear Picture of Risks
By 1987, CDC officials already had a fairly
clear picture of where and how AIDS was spreading -- and how
much risk different groups faced. The disease was proving less
likely to be transmitted through vaginal intercourse than many
had feared. A major study that was just being completed put the
average risk from a one-time heterosexual encounter with someone
not in a high-risk group at one in five million without use of a
condom, and one in 50 million for condom users.
Homosexuals, needle-sharing drug users and
their sex partners, however, were in grave danger. A single act
of anal sex with an infected partner, or a single injection with
an AIDS-tainted needle, carried as much as a one in 50 chance of
infection. For people facing these risks, it was fair to say
AIDS was truly a modern-day plague.
A key player in the CDC's earliest
AIDS-prevention efforts was Walter Dowdle, a virologist who was
a veteran of the war on herpes and had helped create the CDC's
anti-AIDS office in the early 1980s. Like most people in his
operation, he understood that AIDS had to be fought hardest in
the places it was most prevalent.
But by the spring of 1987, Dr. Dowdle had
already been rebuffed repeatedly in efforts to prepare AIDS
warnings aimed directly at high-risk groups. TV networks were
refusing to air announcements advocating the use of condoms. And
Dr. Dowdle had failed in his attempt to disseminate a brochure
that mentioned condoms as effective in slowing the spread of
AIDS. At the time, all AIDS material had to be cleared by the
president's Domestic Policy Council, and the Reagan White House
objected to pro-condom messages on moral grounds. The 1986
brochure went into the White House for review and never came
out.
Help on Marketing
Searching for clues about how to proceed,
CDC officials began a series of internal meetings at their
red-brick headquarters on Clifton Road in Atlanta. They also
reached outside for high-powered marketing help, retaining Steve
Rabin, then a senior vice president of the advertising giant
Ogilvy & Mather. In August, Mr. Rabin, openly gay and deeply
committed to the effort, ran focus groups in a half-dozen cities
to gauge attitudes toward the disease.
The results were discouraging: In city
after city, the focus groups made clear that concern about AIDS
hadn't taken hold in much of the country, despite the widely
publicized announcement two years earlier that Rock Hudson had
the disease. With some exceptions in big cities like New York
and San Francisco, homosexuals continued to engage casually in
unprotected sex, as did heterosexuals everywhere. The prevailing
attitude: It was somebody else's problem.
For gays and drug users, this view was
flatly wrong and potentially fatal. Moreover, the focus-group
results highlighted a huge policy issue: Would the public
support funding for AIDS prevention and research if the majority
of heterosexuals believed they and their families were only
minimally at risk? Would they be compassionate toward the
victims of the disease?
Poll data suggested otherwise. A 1987
Gallup Poll showed that 25% of Americans thought that employers
should have the right to fire AIDS victims. In that same poll,
43% felt that AIDS was a punishment for moral decline. In
meetings within the CDC, many people, including Messrs. Dowdle
and Rabin, expressed particular concern about the growth of
housing and job discrimination against people with AIDS.
Equal-Opportunity Scourge
It was in this environment that the idea of
presenting AIDS as an equal-opportunity scourge began to form.
Politicians, including Republican Sen. Jesse Helms of North
Carolina, were blocking campaigns aimed at gays anyway. And
homosexual and minority groups were concerned about being linked
too closely with the disease. Some CDC scientists, watching the
spread of the disease among heterosexuals in Africa, worried
that AIDS might yet make inroads among non-drug-using
heterosexuals in the U.S. In any event, CDC officials believed
that fighting AIDS was everyone's responsibility, even if
everyone wasn't equally at risk of getting it.
"We were drawing on gut instinct," recalls
Paula Van Ness, who had come to the CDC after serving as chief
executive of the AIDS Project, a community program in Los
Angeles. "The aim was, we thought we should get people talking
about AIDS and we wanted to reduce the stigma." Earlier, in Los
Angeles, she had reached out directly to high-risk groups:
"Don't go out without your rubbers!" warned a motherly woman in
one announcement the AIDS Project had sponsored. But now, on the
national scene, she too felt that such a direct approach was
impossible.
Dr. Dowdle, burned by the response to his
earlier, more targeted efforts, agreed with his colleagues that
the CDC's best bet was to present AIDS as everyone's problem:
"As long as this was seen as a gay disease or, even worse, a
disease of drug abusers, that pushed the disease way down the
ladder" of people's priorities, he says.
After considerable soul-searching and
debate, officials fixed on a dramatic approach they believed
would do the most good in the long run: a high-powered PR and
advertising campaign to spread a sobering yet politically
palatable message nationwide.
Touching Their Hearts
In subsequent meetings in the summer and
fall of 1987, the CDC team developed the idea of filming people
with AIDS and building a series of public-service announcements
around what they had to say. Subjects wouldn't be identified as
gay, and the dangers of intravenous drug use would get little
attention.
Early on, the staffers stumbled on their
defining slogan when they interviewed the son of a rural Baptist
minister. As Ms. Van Ness recalls it, the man said, "If I can
get AIDS, anyone can." His remark "wasn't scripted. That's what
he actually said." Other similar public-service announcements
were prepared, all with the same personal approach. "If you want
your audience to be more receptive about this, you had to touch
their hearts," Ms. Van Ness says.
The CDC's award-winning campaign, deftly
pitched to a general audience, was launched in October 1987 and
featured 38 TV spots, eight radio announcements and six print
ads. The initial ads steered clear of specific advice on how to
avoid AIDS, instead focusing on the universality of the disease
and counseling Americans to discuss it with their families.
It wasn't until the spring of 1988, when
the government mailed its "Understanding AIDS" brochure to 117
million U.S. households, that the risks of anal sex and drug
abuse were underlined. But even this brochure accentuated the
broader risk; it featured a prominent photo of a female AIDS
victim saying that "AIDS is not a 'we-they' disease, it's an
'us' disease."
As public relations, the CDC campaign and
parallel warnings from other groups proved to be remarkably
effective, particularly because these messages were reinforced
by various public agencies and the media. According to one poll,
during the last three months of 1989, 80% of U.S. adults said
they saw an AIDS-related public-service announcement on
television.
Everyone at Risk
Millions of people were thus sold and
resold on the message: Though AIDS started in the homosexual
population it was inexorably spreading, stalking high-school
students, middle-class husbands, suburban housewives, doctors,
dentists and even their unwitting patients.
In late 1991, Magic Johnson dramatically
boosted the perception that everyone was at risk when he
announced that his infection was due to promiscuous heterosexual
behavior. Talk shows and magazines pursued the theme
relentlessly. Even late last year, Redbook magazine -- written
for a largely middle-class female audience -- carried a major
story about married women called, "Could I have AIDS?" In it,
the author wrote: "My mind automatically telescopes to AIDS
every time I get sick."
Meanwhile, the CDC itself was producing
research that made clear that heterosexual fears were
exaggerated. And some CDC scientists, including
then-epidemiology chief Harold W. Jaffe, publicly railed against
the everyone-gets-AIDS message and urged that assistance be
targeted to those who most needed it. But his opinion, along
with the internal research on which it was based, was typically
drowned out by the countervailing mass-media campaign.
Fear of AIDS spread -- and remains. Gallup
surveys show that by 1988, 69% of Americans thought AIDS "was
likely" to become an epidemic, compared with 51% a year earlier,
before the PR campaign got in full swing. By 1991, most thought
that married people who had an occasional affair would
eventually face substantial risk.
Misleading Impression
Yet, as CDC officials well knew, many of
the images presented by the anti-AIDS campaign created a
misleading impression about who was likely to get the disease.
The blonde, middle-aged woman in the CDC's brochure was an
intravenous drug user who had shared AIDS-tainted needles,
although she wasn't identified as such in the brochure. The
Baptist minister's son who said, "If I can get AIDS, anyone
can," was gay, although the public-service announcement
featuring him didn't say so.
Ryan White, perhaps the epidemic's most
compelling symbol, had been diagnosed in 1984, at the age of 13,
after receiving a transfusion from an AIDS-tainted
blood-clotting agent used in the treatment of hemophilia. Barred
by his school, shunned by neighbors, he emerged with his family
as a forceful opponent of discrimination against AIDS patients.
But five years before he died in 1990, the availability of a
blood test for the human immunodeficiency virus, which causes
AIDS, had nearly eliminated the infection from America's
blood-products supply. (Similarly, activist Elizabeth Glaser,
who spoke at the 1992 Democratic Convention, was infected
through a blood transfusion well before AIDS testing began.)
Meanwhile, Kimberly Bergalis became famous
for a particularly rare case: She and five other Florida
patients apparently acquired their infections from their
dentist, who later died of AIDS. But although the CDC has
tracked down and tested thousands of patients of hundreds of
HIV-positive doctors and dentists, that single Florida dentist
remains the only documented case in the U.S. of a health
professional's passing the virus on to patients.
Research continued to show that AIDS among
heterosexuals had largely settled into an inner-city nexus, a
world bounded by poverty and poor health care and beset by
rampant drug use. AIDS was also on the rise in some poor rural
communities. Yet government ads typically didn't address the
heterosexual group at greatest risk, a group that a CDC
researcher would later define as "generally young, minority,
indigent women who use 'crack' cocaine, have multiple sex
partners, trade sex for 'crack' or other drugs or money, and
have [other sexually transmitted diseases] such as syphilis and
herpes."
'Less Likely to Fool Around'
Though scientists and anti-AIDS activists
knew that the government-nurtured fear of AIDS among upscale,
non-drug-using heterosexuals was exaggerated, not everyone
thought this was a bad thing. Indeed, many credited rampant fear
with achieving pro-family goals that no amount of moralizing
alone could have accomplished. In a 1991 Gallup Poll, 57% of
respondents said they believed that AIDS had already made their
married friends "less likely to fool around." Singles reported
being less apt to have one-night stands and more reluctant to
date more than one person.
Moreover, there was no question that even
mainstream heterosexuals bore some risk of AIDS and that greater
caution would reduce their already-low rate of infection. "I
don't see that much downside in slightly exaggerating [AIDS
risk]" says John Ward, chief of the CDC branch that keeps track
of AIDS cases. "Maybe they'll wear a condom. Maybe they won't
sleep with someone they don't know."
The marketing campaign also appeared to be
having another key desired effect: to mobilize support for
public funding of AIDS research and prevention. Federal funding
for AIDS-related medical research soared from $341 million in
1987 to $655 million in 1988, the year after the CDC's campaign
began. (This year, the figure stands at $1.65 billion.)
Meanwhile, the CDC's prevention dollars leapt from $136 million
in 1987 to $304 million in 1988; $584 million was allocated for
1996.
Even the gay community, though not
specifically targeted for assistance, began to see the wisdom of
the everyone-gets-AIDS campaign. "This was a time of decreases
in government funding," according to Jeff Amory, who headed the
San Francisco AIDS Office in the 1980s. "Meanwhile, AIDS money
was increasing."
Rush to Testing
It took a while before people realized that
much of the money pouring in wasn't reaching the groups most at
risk. In 1990, Mr. Amory took part in a telephone survey of
about 50 HIV/AIDS groups funded by the CDC. Fewer than 10% even
mentioned gay men as among their constituencies. (Mr. Amory died
in November, after his interview with this newspaper.)
Meanwhile, the rush to testing meant that
people at low risk were using up more and more of the available
AIDS-prevention money just to discover they weren't infected. In
1994, 2.4 million tests were administered at government-funded
locations, more than 10 times the number in 1985. Only 13% of
those tests were given to homosexual or bisexual men or
intravenous drug users.
As the CDC's biggest single prevention
program, AIDS testing in 1995 accounted for about $136 million
of the agency's total $589 million AIDS-prevention budget for
that year. "It was not efficient or effective in picking up
HIV-positive people," says Eric Goosby, director of the HIV/AIDS
Policy Office of the U.S. Public Health Service, which oversees
the CDC and other health agencies.
Moreover, because treating drug-addiction
wasn't directly part of the CDC's mandate, stopping the spread
of AIDS among needle-sharing addicts fell "between the cracks,"
says Dr. James W. Curran, who was director of the anti-AIDS
office at the CDC until late last year and is now dean of the
School of Public Health at Emory University in Atlanta.
Funding for Prevention
State funding for AIDS prevention --
tracking public attitudes toward the disease -- was also being
directed largely toward low-risk groups, says Patricia E.
Franks, a senior researcher at UCSF, who spearheaded a study of
California AIDS spending between 1989 and 1992. The study found
that while 85% of AIDS cases were concentrated among men who had
sex with men, programs targeting this group received only 9% of
all state AIDS prevention dollars.
Spending for women, in contrast, grew to
29% of the state money in 1992 from 13% in 1989, even though HIV
rates among women of childbearing age held steady at less than
one-tenth of 1% from 1988 through 1992.
California health officials say they
believe spending on high-risk groups has improved in the past
few years. But Wayne Sauseda, director of the California Office
of AIDS, concedes that "it's hard to take money away from groups
already receiving grants." In California's last three-year state
funding cycle, "we were being deluged by proposals from low- and
no-risk population groups," Mr. Sauseda says. "We got two
proposals for every one from a high-risk group."
Typical of the requests from low-risk
groups, he says, were proposals to offer education on college
campuses. "No one would say coeds are not at any risk," says Mr.
Sauseda. "But in California, that's not our first priority."
Tough to Redirect Funds
AIDS officials in other states report
similar frustrations. In 1994, the CDC turned to a community-
planning process for dispensing AIDS funds, a system that
theoretically allows local people to allocate dollars to groups
most in need. But various community planners say it has been
tough to redirect the funds, in large part because public
attitudes have become so entrenched.
In Oregon, for example, many community AIDS
workers "are unwilling to acknowledge that youth who are truly
at risk [are] young gay men," says Robert McAlister, the state's
HIV program manager. Thus, most of Oregon's AIDS-prevention
money is still spent on counseling and testing that primarily
serves low-risk individuals. "When Magic Johnson made his
statement, we got overwhelmed with clients demanding service,"
Dr. McAlister says. "You start to cut corners. If we try to
serve everybody, we wind up serving everybody poorly."
Having helped shape current attitudes and
set AIDS-prevention policies in motion, the Centers for Disease
Control finds itself in a serious bind. So far, AIDS has killed
320,000 Americans, according to the CDC. Between 650,000 and
900,000 others are currently infected with the virus that causes
the illness.
Overall, rates of new HIV infections appear
to be declining from their peak in the mid-1980s. Nonetheless,
as many as 40,000 people, mostly gay men, drug users and their
sex partners, will contract the virus this year alone. Despite
this, the CDC aims its current education campaign, called
"Respect Yourself, Protect Yourself," at a broad spectrum of
young adults, rather than targeting the high-risk groups. A
current focus of the campaign is to discourage premarital sex
among heterosexuals.
Women at Risk
The CDC also has been emphasizing that
women constitute a growing proportion of AIDS cases. But close
analyses of the data indicate that the vast majority of these
victims are drug users or sex partners of drug users. Also, the
data partly reflect a statistical quirk: Because the number of
infections among gay men has declined, other groups -- such as
women -- now represent a larger percentage of victims. Yet the
infection rate among women not in high-risk groups appears to be
holding roughly steady.
Meanwhile, unpublished research by the CDC
itself concludes that "the most effective efforts to reduce HIV
infection will target injecting drug users on the Eastern
seaboard, young and minority homosexual and bisexual men, and
young and minority heterosexual women and men who smoke crack
cocaine and have many sexual partners."
Numerous studies have shown significant
behavior changes in gay men who have been counseled by
gay-outreach programs. Susan M. Kegeles, a behavioral scientist
at UCSF's Center for AIDS Prevention Studies, reports that an
eight-month program in Eugene, Ore., reduced one of the
highest-risk acts, unprotected anal intercourse, by 27% in young
gay men. The program used leaders in the gay community to
demonstrate and consistently reinforce safe-sex practices.
Other studies have shown that drug users
need even more intense behavioral counseling to break their
addiction. But "only 15% of active drug users are in treatment
on any given day, and there are not enough treatment slots to
meet the demand from drug users, according to, a report by the
Federal Office of Technology Assessment. Further, the ban of
federal funding for needle exchanges continues, even though most
reports conclude that locally funded efforts to distribute
sterile needles or needle-cleaning supplies have been effective
in reducing the spread of the infection.
An epidemiologist at UCSF, James G. Kahn,
recently created an academic model which, he says, shows that
over five years, $1 million spent in a high-risk population
averts 154 infections, compared with two or three infections if
the money is spent in a low-risk population. Moreover, he argues
that reducing infections in high-risk groups will "almost
certainly" benefit low-risk groups by reducing the pool of
people who could potentially infect others.
Then there is the separate issue of honesty
in government: Shouldn't the public hear the truth, even if
there might be adverse consequences? "When the public starts
mistrusting its public health officials, it takes a long time
before they believe them again," says George Annas, a medical
ethicist at Boston University.
Yet many both inside and outside the
government fear that speaking more directly about AIDS
transmission, and seeking federal programs to match, poses the
same dangers it did nine years ago. Congress controls the purse
strings, and Sen. Helms, in particular, still monitors every
AlDS-related bill. Says a Helms staff member, "We would
certainly have a problem" with money going to gay-activist
groups or to produce materials that illustrate gay sex acts.
"There is a real concern that funding won't
be shifted, it will be cut, that if most people in the U.S. feel
they are at very low risk, there will be little support for any
AlDS-prevention efforts," says Don Des Jarlais, director of
research at the Chemical Dependency Institute of Beth Israel
Medical Center in New York. Still, he and many others believe
that prevention experts have no choice-and that it is time to
fight for programs based on candor. "You can't build a good
prevention program on bad epidemiology," he says.
Even back in the 1980s, Stephen C. Joseph,
who was commissioner of public health for New York City from
1986 to 1990, blasted the notion that AIDS was making major
inroads into the general population.
Today Dr. Joseph, who is assistant
secretary of defense for health affairs at the Pentagon, says:
"Political correctness has prevented us from looking at the
issue squarely in the eye and dealing with it. It is the
responsibility of the public-health department to tell the
truth.''
SCIENTISTS HONE KNOWLEDGE OF HOW VIRUS SPREADS
Scientists once feared that the AIDS would
become an epidemic among non-drug-using heterosexuals. Today,
there is a broad consensus among experts that it probably won't.
"Over 90% of the population is
heterosexual. and most people are at zilcho or very low risk."
says Lyle Petersen, until recently chief of the CDC branch that
estimates the prevalence of HIV, the virus that causes AIDS.
This doesn't mean heterosexuals shouldn't
take precautions, including condom use. Cases have been
documented of people contracting AIDS after a single
heterosexual encounter. Any individual's risk of contracting a
disease is very different, and much more specific, than the
overall risk to a large group of people.
For a person to become infected with HIV,
scientists believe the virus must pass from the blood, semen or
vaginal secretions of an infected person into the cells or
bloodstream of another.
People who share infected needles
accomplish that quite readily: in one Connecticut study. as many
as 70% of drug-users needles contained HIV, which could be
injected directly into the blood of the next user. Between 1%
and 2% of infections with. HIV-tainted needles appear to result
in infection, according Don Des Jariais. director of research at
the Chemical Dependency Institute of Beth Israel medical Center
in New York.
HIV is also transmitted fairly readily to
the receptive partner in anal intercourse, whether that partner
is male or female. Scientists believe such transmission occurs
largely because the sex practice frequently leads to anal tears
and abrasions. Scientists estimate that O.5% to 3% of such acts
with an infected person will lead to infection.
HIV apparently can also infect vaginal
cells but, at least in the U.S. and Western Europe. it doesn't
appear to do so easily. Studies of couples in which only one
partner is infected show that about one in every 1,000 sexual
acts results in infection. Women appear to be infected during
vaginal sex several times as often as men, although still not,
on average, very frequently.
For both men and women, it is much harder
to transmit AIDS than to pass on other, less serious sexually
transmitted diseases. Some studies suggest that gonorrhea. for
example, passes from men to women in as many as 9O% of ail
encounters with an infected person, and from women to men about
one-quarter of the time.
There is an insidious link, though. between
venereal diseases and AIDS: people with diseases such as
syphilis and herpes, which may produce open sores, are much more
likely to become infected with AIDS or to transmit the disease
to a partner.
Scientists also now believe that most
people with HIV are most infectious during two periods: before
any symptoms appear and later in the disease when the person
maybe very ill. Therefore, many scientists believe for
widespread transmission to take place, infected people have to
have sexual contact with a large number of partners in a fairly
short period of time.
This is one of the reasons that AIDS spread
rapidly among homosexuals in the early days of the epidemic, as
gay bath houses provided the venue for large numbers of sexual
contacts. In one San Francisco study published in 1987, for
example. nearly 40% of the gay men studied had had 10 or more
sexual partners in the previous two years; an additional 25% had
had more than 5O partners. Of those reporting more than 5O
partners, more than 70% had been infected.
All this also helps explain why AIDS hasn't
spread rapidly among non drug-using heterosexuals in the U.S.
but has made bigger inroads in parts of Africa and Asia.
For one thing, prostitution is more widely
practiced in the developing world. This means that random
heterosexual encounters in which partners may be infected with a
venereal disease are more widespread. "Good studies in Thailand
show that roughly one in five men reported visiting a prostitute
in the last 12 months,' says Bruce G. Weniger, a medical
epidemiologist at the CDC who has studied the Asian epidemic.
Even when prostitutes aren't involved, the
developing world has a higher incidence of venereal disease: in
addition, in some areas, local sexual practices lead to tearing
of the skin, which contributes to the more-rapid spread of AIDS,
many scientists believe.
In the U.S., the use of prostitutes is low
by comparison. In a major survey of sexual practices, centered
at the University of Chicago, fewer than 1% of the 3,432 people
surveyed said they had paid for sex in the previous year. Even
those who think the true rate is much higher don't believe it
approaches the level found in developing countries. Moreover, in
the U.S., outside of drug using communities, HIV prevalence
among prostitutes isn't as high as in developing countries.
The situation, however, is far different in
inner-city neighborhoods where drug use is high, access to good
medical care is insufficient and trading sex for drugs is
relatively common. A recent study of crack users in New York.
.Miami and San Francisco, for example, found that more than
one-third of the women and 15% of the men had a history of
syphilis; more than two-thirds of the women had traded sex for
money or drugs. More than 40% of the women who recently had
engaged in unprotected sex for pay were HlV positive.
But large surveys that systematically
exclude drug users and gay men indicate that the spread of HIV
infections in the U.S. has either been leveling off or dropping.
In a 1992 CDC study at blood banks, which seek to block
high-risk individuals from donating, 0.0067% of blood donors
were HIV-infected, down from 0.0223% in 1985. Moreover,
subsequent research shows that the rate has continued to drop.
Further, says the CDC's Dr. Petersen. who
studied the bloodbank results, most of the HIV-positive donors
turn out, on investigation, to have engaged in some high-risk
behavior.
Meanwhile, blood tests of newborns, which
indicate the HIV status of the mother, show that the overall
percentage of infected women has remained stable nationally for
several years, and has actually begun dropping in New York, New
Jersey and Florida, three states with very high HIV/AIDS rates.
Nationally, the HIV-infection rate for women is 1.6 per 100.000
women.
Other surveys support the suggestion that
most heterosexuals aren't seriously at risk. The University of
Chicago's sexual- practices survey turned up six people out of
the 3.432 surveyed who credibly reported themselves HIV
positive. Of those six. three were bisexual men, one a woman who
injected drugs and one a woman who had had more than 100
lifetime sex partners.
Some scientists argue that the U.S. still
faces a big threat from strains of HIV that are much more
readily transmitted heterosexually than the strains that exist
here today. Max Essex, a professor of virology at Harvard
University and chairman of the Harvard AIDS Institute, says his
research suggests that such strains are contributing to the
extensive heterosexual threat in Africa and Asia
But after attending a European conference
on the topic, Roy Anderson, professor of epidemiology at Oxford
University, is unconcerned. "I find it plausible but, as yet,
scientifically unsubstantiated' that such strains exist, he
says. Even if they do, he adds, they probably won't lead to a
heterosexual epidemic in the U.S. or Western Europe.
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