The AIDS Epidemic, Part 2

Continued from previous file

The virus revisited

Most doctors are sceptical about this line of argument, even though the data cited above suggests that all the factors Callen and Berkowitz indict may play some part in the process. What causes the scepticism is the fact that AIDS has now spread out to, or has been detected in, populations who cannot possibly have acquired it in the way Callen and Berkowitz suggest. Heterosexual women from Zaire, elderly haemophiliacs in Alabama, ten-week-old babies, whole families of Haitians, certainly did not contract AIDS through the backroom bars of Manhattan or from using too many poppers. They contracted it either through heterosexual sexual intercourse, or through blood transfusions, or congenitally or perinatally, and these are classic pathways of viral infection.

AIDS has now been detected in both homosexual and heterosexual sexual partners of people who subsequently developed AIDS themselves, and in their sexual partners, and so on. These findings include the famous "Los Angeles cluster," - a group of nine gay AIDS patients in Los Angeles with interlocking sexual contacts, including a sexual contact in New York shared by three of the Los Angeles men who were strangers to each other. AIDS has developed in gay men with very few sexual partners (as few as two per year), who do not use drugs, who have not had a history of common infections. Furthermore, as the number of cases increases, the lower the percentage of gay men in the total becomes. In 1981 it was virtually 100%. Now it is only about 70% (Baphron May 1983). The lower that figure falls, the less tenable the "promiscuity overload" theory becomes. This is the significance of the fact, referred to above, that New York, the early focus of the epidemic with the highest number of cases, has a lower percentage of gay male cases than San Francisco; As the infection progresses in a particular community, it spreads out from the original at-risk group (gay men), to other, interfacing groups (drug users, bisexual men, women, children, blood recipients).

Even if AIDS is a viral infection the correlation and relationships cited above do not lose their significance; merely their place in the Callen/Berkowitz calendar of horrors. It would remain true, if AIDS were a sexually transmitted virus, that a promiscuous lifestyle would greatly increase your chances of contracting it; simply because the larger the number of sexual contacts you have, the greater the chance you have of contracting whatever infection happens to be going around. As the BAPHR figures suggest, gay men who contract AIDS have an average of more than twice as many sexual partners as non-AlDS gay control groups of the same age and ethnic structure (Lancet, 1 January 1983). Callen and Berkowitz quote the CDC as having reported the average life-time number of sexual partners of gay AIDS patients as being 1,160, although I have not been able to find the article they refer to. If this is so, and if this represents an average of 15 years' sexual activity (the average age of gay AIDS patients being 34), it represents about 77 new sexual partners a year, or just under 1.5 new sexual partners per week (every week, for 15 years). It is certainly hard to think of another group of people as sexually active as this. Prostitutes are the only obvious possibility. Sure enough, Dr Joyce Wallace has diagnosed depressed T-cell ratios in a group of eight New York City women prostitutes; one of these women had full-blown AIDS (PCP, herpes simplex and thrush), and seven had prodromic symptoms. The woman with AIDS estimated she had had 15,000 sexual partners over seven years (Lancet, 23 April 1983).

How widespread is AIDS among gay men, and how high therefore is the chance of contracting it from any sexual encounter? Dr Andrew Rose of the UCSF Department of Epidemiology has tabulated the AIDS cases in America's most concentrated gay community, San Francisco, and compared them by census district with the number of gay men in each district (which he has estimated as being roughly equivalent to the number of never-married men over 15, on the assumption that the married gay men will cancel out the unmarried straight men). In 17 census districts, embracing the heart of the San Francisco gay ghetto, he found a rate of 285 cases per 100,000 never-married men over 15, or a rate of 0.285%.

This suggests that very sexually active gay men are running a measurable, significant risk of contracting a disease that will probably kill them if they do. This risk may be multiplied if their sexual practices involve taking in a lot of semen, particularly rectally, or if they use nitrites, or if they indulge in practices such as fistfucking that damage the rectal mucosa, or if they have faecal-oral contact or if they contract CMV or other common infections repeatedly. It is possible that some or all of these things contribute to immune deficiency, either by making the body more vulnerable to the AIDS virus, if there is one, or by heightening its immunosuppressive impact once it is contracted. It is possible that the virus acts in concert with one or other of these factors, in a variant of the "bugs and drugs" theory that has been put forward. It is possible that none of these things is true. At present, we have no way of knowing. We can only weigh up the possible risks, and take our chances.

2. Facing the epidemic

The politics of sickness

"We Know Who We Are: Two Gay Men Declare War on Promiscuity," was the title of Michael Callen and Richard Berkowitz's devastating article in the New York Native in November 1982. This was the article that triggered the bitter "AIDS debate" in the north American gay press. Their main thesis was that AIDS is not caused by a single virus, but by a cumulative overload of the immune system as a result of sexual promiscuity and its attendant abuses of the body and multiple venereal infections. This position flies in the face of most of the epidemiological evidence and I for one do not accept it. More importantly, most medical researchers and writers in the field do not accept it. But even if their medical thesis is wrong, Callen and Berkowitz have gone to the heart of the political and ethical problems the AIDS epidemic has confronted gay men with. Even if AIDS is caused by a virus, it remains a fact that the more sexual partners you have, the more likely you are to catch it. It must also therefore be a fact that the virus is being spread by people who have contracted it but are not aware of being ill, or at least not ill enough to make them sexually inactive - in other words by asymptomatic or prodromic AIDS cases. Nobody knows how many of these there are, or how infectious they are, or for how long they are infectious.

It has been suggested that AIDS has a latency period of up to two years. If this is so, it is likely that it has already been spread very widely - that there are perhaps tens of thousands of latent, asymptomatic or prodromic cases, and that most of these people are still busy infecting other people at an exponential rate. In these circumstances, the likelihood that there will be many more than the current handful of dangerous cases in a country like Australia must be very high.

This frightening prospect raises deep and difficult questions about the gay urban lifestyle that gay men in western countries have constructed for ourselves over the past decade. If the network of bars, saunas and backrooms that make up the sexual "circuit" have now become the means of spreading an infectious disease with devastating symptoms and a high mortality rate among the gay men that use it, and if those gay men are then unwittingly spreading it out into wider communities, then the question has to be asked: would we be better off without that network, either until a vaccine for the virus is developed (if there is a virus), or for ever (if the overload theory or a variant of it is correct)?

Michael Callen has no doubts about this. He has renounced promiscuity, and called on other gay men to do the same. He writes:

"Promiscuity has become a narcotic for many promiscuous gay men and AIDS is merely the logical conclusion of a decade of the epidemic rise of common diseases which have resulted from unprecedented promiscuity. This is not a function of any moral certainty; this is a medical and mathematical fact. . . Denying that promiscuity is the cause of AlDS-related deaths is going to decimate the gay male community. By refusing to see that the promiscuous lifestyle is potentially fatal, we may permit the ultimate triumph of the Moral Majority: we will kill ourselves."

Not everyone is convinced. If the New York Native has been the main mouthpiece of the anti-promiscuity line (Callen and Berkowitz's physician, Dr Sonnabend, also writes for the Native, and the paper's other regular medical writers, Dr Larry Mass and Dr Dan Williams, have adopted similar, if less strident, positions), the Toronto Body Politic has provided a platform for the opposition. In a major article called "Living with Kaposi's," which appeared at the same time as Callen and Berkowitz's first salvo in the Native, Michael Lynch attacked the New Yorkers' positions. The New York leadership position has, in his opinion, overreacted to the AIDS epidemic and has played into the hands of those who would use it to push back the gains that gays have made.

"The illnesses, deaths and uncertain prognosis of my gay brothers grieve me deeply," he writes. "They grieve us all. But my unease comes from another base than grief. I suspect that our response to this 'health crisis' has involved a communal self-betrayal of gargantuan proportions and historical significance. Have we wielded, ourselves upon ourselves, a major setback in the cause of what we used to call gay liberation?

"Another crisis co-exists with the medical one. It has gone largely unexamined, even by the gay press. Like helpless mice we have peremptorily, almost inexplicably, relinquished the one power we fought so long for in constructing our modern gay community: the power to determine our own identity. And to whom have we relinquished it? The very authority we relinquished it from: the medical profession.

". . . [The medical moralists] seek to rip apart the very promiscuous fabric that knits the gay male community together and that, in its democratic anarchism, defies state regulation of our sexuality. . . Gays are once again allowing the medical profession to define, restrict, pathologise us. . .

"How is it that New York, that centre of our artistic and intellectual life, tumbled so easily and swiftly into the medicalisation trap? We will debate this for years to come, but I propose two explanations now. The first I have mentioned already - deep within ourselves lingered a readiness to find ourselves guilty. We were ripe to embrace a viral infection as a moral punishment. The media nourished this readiness, but did not create it.

"Perhaps we still mirror our larger culture in that readiness; we certainly do in what I propose as a second explanation - the gay community, like many other urban communities, simply cannot deal with sickness, dying and death in a humane way. Over the years we have become able to handle death by violence. . . but not death by illness. . . Gay men drink and trick together, but die alone. . .

"Once we see this, we may take our lives and our self-definition back into our own hands. We have to make illness gay, and dying gay, and death gay, just as we have made sex and baseball and drinking and eating and dressing gay. This is the challenge to us in 1982." (Body Politic, November 1982) Other articles in Body Politic have taken a similar position. Body Politic's own position was made clear in an editorial in May:

"Already we are being urged by many in the medical profession to make drastic changes in our sexual and social lives. Even as we each make decisions about our own sexual behaviour, even if we decide that it is prudent to lessen exposure to risk by reducing the number of our sexual partners, we must also carefully weigh what these changes mean for us in both medical and political terms. There are those who would deny the political dimension, who say that because people are dying it is irresponsible to raise political questions. But as yet the medical experts have very little concrete knowledge about AIDS and we have every reason at this stage to be sceptical of definitive pronouncements from that quarter. Especially when they dovetail with a disapproving sexual ethic that has sought to control our lives for other reasons." (Body Politic, May 1983)

The New York school hit back with great venom at this line of argument. Michael Callen accused Michael Lynch and Dr Bill Lewis (Body Politic's medical writer and a strong opponent of the promiscuity theory) of "shocking ignorance and insensitivity." Attacking Body Politic's coverage of the AIDS epidemic, he wrote "the articles. . . provide no useful information about risks, prevention or sexual alternatives to promiscuity, little insight into being ill, and no references. . . Lewis and Lynch confuse medicine and morality by defining their reactions to a disease in terms of an anticipated moral backlash. AIDS is a disease: it does not know or care about morality or politics. However much gay people have suffered at the hands of medicine, we cannot allow our kneejerk defensiveness to delay urgently needed, rational discussion about the health dangers of promiscuity. I'll wager that I've had more lifetime sexual partners than Lewis and Lynch combined. I don't have problems with sex or with my gayness. I have problems with disease. I am sick of being sick. I have been sick almost continuously since I began to be promiscuous." (Body Politic, February 1983)

Treating the unknown

Because nobody knows what AIDS is, nobody knows how to treat it; AIDS is at present an incurable disease. The harsh truth is that not one of the perhaps 1,600 people who have now contracted one or more of the AlDS-related infections in the west has yet recovered from them and been declared "cured." A number of patients have been successfully treated for one or other of the less severe opportunistic infections, only to relapse later or to succumb to another, perhaps more severe, infection. A number of patients have had their conditions stabilised, and are not getting any sicker (these are mainly KS cases: cancers are easier to stabilise than infections like PCP). But nobody has been cured.

Since most researchers and physicians believe AIDS to be caused by an infective agent, probably a virus, that is where research is being primarily directed. AIDS is now, after a deplorably slow start, attracting research funding in the US. Cynics might suggest that this has something to do with the fact that AIDS is now killing little babies and respectable heterosexuals, and not just queers, junkies and black immigrants. Be that as it may, Congress members sensitive to gay issues (mostly those with lots of gay voters in their districts) have begun to steer AIDS research money bills through Washington's maze of funding subcommittees.

However, gay activists in the US, particularly in New York, have been bitterly critical of the slowness with which research funding has been distributed, particularly by the National Institutes of Health (NIH): even after Congress has approved it. Larry Kramer write in the Native of March 1983:

"For over a year and a half the National Institutes of Health has been 'reviewing' which from among some $55 million worth of grant applications for AIDS research money it will eventually fund. There is no question that if this epidemic were happening to the straight, white, non-intravenous drug-using, middle-class, that money would have been put into use almost two years ago when the first alarming sign of this epidemic were noticed by Dr Alvin Friedman-Kien and Dr Linda Laubenstein at New York University Hospital.

"During the first two weeks of the Tylenol scare, the government spent $10 million to find out what was happening.

"Every hospital in New York that's involved in AIDS research has used up every bit of the money it could find for researching AIDS while waiting for grants to come through. These hospitals have been working on AlDS for up two years and are now desperate for replenishing funds. Important studies that began last year, like Dr Michael Lange's at St Luke's-Roosevelt, are now going under for lack of money. Important leads that were and are developing cannot be pursued."

From the research that has been done, there have been some leads, but no breakthroughs. However, another possible suspect has been unearthed. Adult T-cell Leukemia Virus (ATCLV). This virus, which-causes a rare form of leukaemia affecting the T-lymphocytes, has been previously suggested as a possible agent, (Lancet, 2 April 1983) but without evidence. Now research teams at the Harvard School of Public Health, the US National Cancer Institute and the Pasteur Institute have all reported finding ATCLV antibodies (not the virus itself, but an indication that the virus has at some stage been present) in the bloodstreams of AIDS patient. (The Age, Melbourne, 14 May 1983). This finding has been described as "provocative," "intriguing" and "a very strong lead," but it is most unlikely that it will lead anywhere but to more research for at least a year. Immunological and virological research is a slow process, even when people are dying. The HBV vaccine took 15 years to develop, even when the virus was well-understood.

[The virus here called ATCLV was later known as HTLV-III and then HIV, and was ultimately identified as the cause of AIDS.]

All the opportunistic infections that AIDS patients suffer from are known to medicine, and all have established treatments. KS for example, can be treated with chemotherapy, a standard cancer treatment, and PCP is usually treated with a drug called trimethoprim-sulfamethoxazole (TMPŃSMZ). But in the past patients with these diseases were able to recover because their underlying immune systems were intact. AIDS patients who are treated by these methods are unable to protect themselves from re-infection or from relapse. Where patients have multiple infections, treatment is even harder. Chemotherapy, for example, is often immunosuppressive, and seems to cause more problems than it solves in AIDS. The obvious need is for a treatment for the underlying deficiency itself.

[Here I have omitted a section describing developments in two experimental treatments, interferon therapy and plasmaphoresis, since these did not turn out to be significant developments.]

Can AIDS be avoided?

The answer to this question depends largely on what view you take about the cause of AIDS. If, as Callen and Berkowitz and others argue, you believe that AIDS is due to the cumulative overload of the immune system by the effects of a promiscuous gay male urban lifestyle, and if you are a sexually active gay man, then your course of action is clear. You must radically reduce the number of different sexual partners you have. You must abandon sexual contact with people you do not know to be healthy (ie, anyone you don't know). You must modify your sexual practices to avoid the rectal intake of semen. You must abandon fisting, analingus and similar practices. You must forswear nitrates and other recreational drugs. You must improve your diet and general state of health and avoid stress. You will thus take the strain off your system and prevent your immune system from collapsing.

If, on the other hand, you, like this writer and like the majority of researchers and writers in this field, believe that AIDS is spread by a virus or similar infective agent, you and I have a harder choice to make. Because in this case our chances of catching AIDS are exactly the same at every sexual contact, whether we have one a year or whether we have 1,000 a year. Reducing the number of sexual partners we have will only reduce our overall risk of catching AIDS. The only ways of eliminating that risk are to have no sex at all (or at least no sex that involves contact sufficient to transfer a virus, which is very difficult to judge), or to only have sex with people we know to be AlDS-free - which at present is unknowable. Following all the other restrictions listed above, while probably good for us in other ways, will only reduce our chances of contracting AIDS if these factors do in fact contribute in some way to an individual's susceptibility to the AIDS virus. This is, as we have seen, quite unknown one way or the other.

What should we be doing now?

Whatever the cause of AIDS, three things about it are clear. The first thing is that it is spreading, that it is going to go on spreading, and that its rate of spread is going to go on increasing for some time yet. The second thing is that there will be no cure, and probably not even a reasonably effective treatment, for AIDS in the immediate future, and that therefore it will go on killing people at a rate equal to or greater than its present rate of 41%. The third thing we know is that, given the realities of travel and the realities of gay life in Australia, it is only a matter of time, and probably not a long time, before AIDS starts to kill gay men in Australia in significant numbers. The time for Australian gay movement and community to prepare itself for this is now, and not when it starts happening.

The lives of sexually active gay men in Australia are at risk. Australian gay men are entitled to accurate information about what the risk is, about what might be done to avoid or reduce that risk, about what to look for in their bodies and their health, what to do if they think they are ill. Those gay men who get sick are entitled to expect that the gay community will support and defend them, and not allow them to be stigmatised, shunned or forgotten. Those who die are entitled not to have to do so abandoned to alien families or hostile health authorities. Let us determine now that no gay man in Australia will die believing that he or his gayness is responsible to his death, or cut off from his friends, lovers and community.

All gay people in Australia, lesbians as well as gay men, sexually active or not, monogamous or promiscuous or anything in between, are at risk of being slandered, pathologised, quarantined and stigmatised. They are entitled to see their community leaders, their press, their political organisations prepared to lead an effective resistance to this attack, which has already begun. They are entitled to have their rights articulately defended in the public media and in political debate, against attacks from whatever quarter. These rights include the right to sexual freedom and the right to maintain sexual meeting places for gay men (the attack on gay saunas and bars as health risks has already begun in the US and Canada), the right to proper health care, the right to a share of research funding commensurate with the scale of the medical emergency we face allocated to AIDS research without delay, the right to recognition by public hospitals, health authorities and health insurers of the unique nature of this crisis and of the particular emotional needs of gay people, the right to give blood (not necessarily for transfusion) without discrimination or stigmatisation. If we want these rights defended during the coming storm, we'd better get ourselves organised to defend them right now, because nobody else is going to defend them for us.