SOPHIA IS FRANTIC: HER HUSBAND WAS UNFAITHFUL, AND NOW she may have HIV. Even worse, she may have given it to her daughter, who is nursing. Sobbing loudly, she covers her face and rocks back and forth. I can only hand her tissues and wait.
Slowly, she’s able to tell her story. Sophia is studying film, Ken is a dentist, and the baby is fourteen months old. Last week, while arguing, Ken told Sophia he’s been with other women—she didn’t ask how many, or when.
Since then, Sophia hasn’t been able to eat, sleep, or concentrate. Driving to school yesterday, she rear-ended someone and was so upset she missed a class. Today it came to a head—Sophia was suddenly seized with terror, she was dizzy and short of breath, her hands shook, her heart pounded. What was it? An asthma attack? She didn’t have asthma. A heart attack? But she’s only twenty-six!
A friend took her to the emergency room. After blood work and an EKG, Sophia was told that the cause of her palpitations and hyperventilation was emotional: it had been a panic attack. The friend walked her to the campus counseling center, where an on-call therapist judged her distress and dysfunction to be severe enough for an emergency psychiatric evaluation—appointments usually reserved for suicidal or psychotic students.
I explore with Sophia what part of all this is most distressing to her. She is hurt by her husband’s confession, and the marriage—troubled for years, and now in crisis—may not survive. But what’s put her over the edge is the terror of HIV. This is Sophia’s prime concern: her health, and the health of her baby. Everywhere she looks, it seems, is the warning “HIV is transmitted through bodily fluids: blood, semen, vaginal secretions, breast milk.” When Sophia sees that, she’s paralyzed with fright.
My first priority with this patient is to treat the anxiety that is interfering with her functioning. Sophia needs to be able to return to her jobs: mother and student (her wifely responsibilities have been put on hold). Because of fear of infection, Sophia has stopped nursing—in any case, her milk all but disappeared due to her stress—so I can safely prescribe a short trial of medication. This will help Sophia calm down, and to sleep, eat, and keep her panic at bay. She’ll feel better in a day or two.
My plan is that during her next appointment, scheduled for later in the week, we can speak more about her health concerns, and I might assess to what degree she, her husband, and her child are at risk. This will be harder than giving her pills; I’ll need to ask about some intimate matters that will make both of us feel awkward. So as I write the Ativan prescription for Sophia, and tell her how to use it, I’m aware that it’s only partial treatment—the easy part.
In the meantime, I do some homework. Assuming the worst, that Ken had relations with an HIV-infected woman, how likely is it that he was infected, that he passed the virus to Sophia, and she to their daughter? How likely is this whole horrific scenario? I’m not sure. But if my patient is overestimating the ease of HIV transmission, the facts may reassure her, and I’d like to be able to provide them to her. Having access to a virtual library at my fingertips, with archives of hundreds of scientific and medical journals, it shouldn’t be hard to sort this out.
In Sophia’s drama, there are three routes of infection to consider: female to male, male to female, and mother to child. From the nearly universal warnings that “anyone can get HIV,” one would conclude, as Sophia has, that the virus spreads in an equal-opportunity manner. But the first thing I learn from the medical literature is that the various routes of infection carry vastly different risks, and must be considered separately.
To begin, consider Ken and his female companions. Assuming he starts out uninfected, 1 how easy is it for him to get the virus from one of them?
There are two factors to consider. First, how common is HIV in women? Of the current living cases of AIDS2 in my state through 2003, only 8 percent are women. The number of women with AIDS is less than a tenth of the number of women who have been diagnosed with cancer. So the chance of Ken meeting an infected woman is low: there just aren’t that many of them around.
Second, how common is female-to-male transmission? This has been studied by looking at monogamous heterosexual couples in which the woman is infected, the man is not, and condom use is inconsistent. In one such study conducted over ten years, only two of eighty-two men were infected. 3 In an earlier, similar study, only one of seventy-two men was infected. 4 Of a total of almost 21,000 men with AIDS in New York City, in 1989, only eight were unequivocally infected by sexual transmission from a woman. 5
It may be instructive for Sophia to hear about the first woman in the country known to have been infected with HIV. 6 Some call this an urban legend, but my source tells me it’s valid. 7 She was a prostitute in San Francisco who used intravenous drugs. In 1977 she gave birth to a child, one of three, all of whom died of AIDS. 8 From before the birth of her first child until her death in 1987—a period of at least ten years—this woman was an active prostitute in the heart of the city’s red-light district. If transmission from an infected woman to an uninfected man was a common event, many infected heterosexual men would have surfaced. But at that time, only two heterosexual men in San Francisco were infected.
Since the 1980s, HIV has remained concentrated in the same high-risk groups, at least in the United States. In public health surveillance reports, HIV and AIDS cases are placed in categories of “transmission risk factor,” such as MSM (men who have sex with men), intravenous drug use, pregnancy, and so on. Under the “heterosexual” risk factor, the numbers often look high, sometimes up to 30 percent of the total number of cases. But look closely: heterosexual is defined in small print as including HIV/AIDS cases traced to sexual contact with bisexual men and drug users.
So it’s unlikely Ken is HIV-positive—so unlikely that some would say the risk is close to zero. But for the sake of argument, let’s say he is. How safe is Sophia? Here I must consider a delicate issue—their sexual behavior. HIV, like any self-respecting microbe, has one goal: to find a home and reproduce. And about this there is no doubt: the virus has an easier time doing this in the rectum than anywhere else.
It’s not unusual for college women to have anal intercourse. 9 If Ken is HIV-positive, this behavior is dangerous; the studies confirming this are voluminous. 10 The reason is biology—actually, to be more precise, histology. Histology is the study of cells, what they do and how they are organized. This may be beyond what Sophia is capable of, or even interested in learning about, but to fully understand how HIV is transmitted, a comparison of the histology of the vagina with the histology of the rectum is mandatory.
For infection to occur, keep in mind that HIV must either enter the bloodstream or gain access to deeper tissues. This makes it a relatively difficult bug to pass along. Consider, for example, the highly contagious viruses that cause conjunctivitis. 11 They are easily transmitted on your finger, when you touch one eye and then the other. They can also live on inanimate surfaces, like towels or pillows, and infect you from there.
In contrast, for HIV to infect Sophia, it must reach a group of cells in her immune system referred to as “target cells.” Only here can the virus make a home and reproduce. To reach target cells, the HIV must either bypass, or pass through, a barrier. For example, the addict sharing a dirty needle infects himself by injecting the virus directly into his bloodstream, bypassing the natural barrier, skin. The same is true for persons infected through blood transfusions. The infant nursed by an HIV-positive mother is infected when the virus passes through the lining of the digestive system. So the barrier is important to look at: it is the wall the virus must breach to succeed.
Assuming Sophia is healthy—without any STDs or conditions that would weaken her immunity—her vagina has some built-in properties that are protective from the get-go. 12 In fact, one of the functions of the vaginal lining is protection from infection. 13 The pH is low, which inactivates HIV. 14 Its mucus has anti-HIV proteins. 15 Its lining is twenty to forty-five cells thick, increasing the distance to be traversed by the virus. 16 Under the lining is a layer in which target cells are found; this area is rich in elastic fibers. Next is a layer of muscle, then more elastic fibers. This architecture allows for significant stretching of the vagina without tears or abrasions. Research has indicated that HIV is unable to reach target cells in the human vagina under normal circumstances. 17
The rectum has a different structure. As part of the gastrointestinal system, it has a lining whose primary function is absorption, bringing in molecules of food and water. The pH is higher. Most important, the rectal lining—the barrier to be breached—is only one cell thick. Below that delicate lining are blood vessels and target cells. Elastic fibers are absent.
Early in the epidemic, it was assumed that fragility of the rectal barrier accounted for the more common male-to-male transmission. But later in the 1980s came a discovery: infection could occur without disruption of the barrier. Specialized cells on the rectal surface were able to latch on to the virus, take it in, and deliver it to target cells. 18
M cells are abundant in a healthy human rectum. 19 Their function is to bring a sample of foreign, potentially dangerous particles for identification and response by the body’s defense system. An M cell wants to attract microbes, so its surface is sticky, and it can fold over a virus or bacteria, engulf it, and bring it inside in a pocket. 20 The pocket moves to the other end of the M cell, to immune cells that process the microbe and determine the appropriate response: ignore it or rally against it.
Along comes HIV. It subverts the system, turning M cells into an express lane for invasion. The virus is packaged, transported, and handed over to immune cells that are one and the same as the target cells the virus must reach to cause disease. So M cells facilitate the virus’s job. They FedEx HIV directly to a lymphocyte—delivery takes ten minutes. 21
There are no M cells in the vagina. This is not to say transmission of HIV cannot happen there—it can. But for infection to occur, there must be some weakening of the system—an infection, bleeding, an open sore, trauma, cancerous cells.
For this and other reasons, some researchers argue convincingly that vaginal transmission is very rare. 22 They are supported by studies of prostitutes, averaging two to three hundred contacts a year, usually unprotected, in which AIDS was found only in women who were also intravenous drug abusers. 23 And keep in mind, this was in prostitutes, a population considered a reservoir of STDs, a risk factor for infection.
When a man gets HIV from a woman and passes it to another woman, the second woman is called a tertiary case. Without tertiary transmission, there can be no epidemic. Because heterosexual tertiary transmission is so rare, the few cases that exist are famous. 24
Should Sophia worry? It boils down to this: unless Ken’s been sharing needles or spending time with a man, her chances of being HIV-positive are about 1 in 500 million. 25 And yes, that is less than the risk of her being hit by lightning. 26
What a waste of a nervous breakdown! Poor Sophia is a wreck—and for what? She and her baby are fine. This week from hell happened only because everywhere my patient turns, she’s fed distortions.
At the campus health center: “The following activities are considered risky for contracting HIV: Any sexual contact that includes the exchange of infected blood, semen, or vaginal secretions…. Any type of needle sharing…transfusions of blood…”
From a pamphlet at her gynecologist’s office: “Infection with HIV is a serious threat to the health of women in the United States…. HIV infection is spread through contact with the body fluids of an infected person. This can happen during sex or by sharing needles used to inject drugs.”27
From the CDC Web site:
These are the most common ways that HIV is transmitted from one person to another:
From the National Women’s Health Network: “HIV is colorblind. It’s contracted through unprotected sex—vaginal, oral, or anal—with an infected person. Someone can get HIV by sharing needles with someone who has it, and it can also be passed from an infected mother to her baby. Gay, bisexual, and straight people all get it. Black people, Latinos, and Asians. Young and old people get it. HIV does not discriminate…. HIV is here to stay, and anybody can get it. If you are sexually active or do drugs, it’s a good idea to get tested.”29
This is nuts! “Anybody can get it”? Lumping together a drug addict in a Bronx shooting gallery, a homosexual prostitute on Castro Street, and a coed and her first boyfriend? As if these three face the same risk, regardless of their behavior and whom they choose to do it with? One veteran AIDS researcher said, “It’s as if we don’t want to offend the tobacco companies, so we tell people—Lung cancer can be caused by radon, asbestos, tobacco, and air pollution.” It’s like advising people to get a chest X-ray if they’ve been exposed to anything on that list. You’d never see this, because 80 percent of lung cancers are related to tobacco. 30
No wonder Sophia had a meltdown. No wonder she can’t eat or sleep: the warning “Anybody can get it” is ringing in her ears. Luckily, I’ll see Sophia soon and explain that she has exaggerated her risk. Other people aren’t so lucky. They are so terrified they have AIDS they kill themselves.
A study of suicides in Finland during 1987 and 1988 revealed that twenty-eight were people with those concerns. 31 Many of them could identify the source of their worry—a recent sore throat, fatigue, loss of sleep or appetite—symptoms that had been publicized as warning signs in the intense AIDS information campaigns in the Finnish media. In two cases the trigger event was an AIDS-related television program. Most of the victims were depressed. 32 Many left notes expressing their belief that they had HIV and had infected their significant others. On autopsy, none was positive.
The authors conclude: “These figures probably underestimate the numbers. Fear of AIDS…is a problem triggered by the vast publicity given to AIDS-related symptoms in the mass media and by sexual guilt…. Health care personnel should bear in mind the potential effects of sensationalized and unbalanced reporting on health issues. AIDS in the 1980’s may not have been the last media-boosted phenomenon to raise the fear of illness in vulnerable depressed people.”
Well, of course the media is boosting our fears—the warning “Anybody can get it” is pushed at us relentlessly by the medical and public health establishment. “AIDS does not discriminate”? Duh! Of course it doesn’t! It’s bound by the laws of nature, not the EEOC! It’s a virus, remember? HIV is more common in gays and drug addicts not because it’s homophobic or racist, but because these groups have behaviors that put them at risk. It’s what you do, and whom you choose to do it with. Is that so complicated a point to get across?
I guess it must be. And how did all this politics, sociology, and loaded rhetoric get into a discussion about a tiny bit of RNA, anyhow? The story was told in a Pulitzer Prize–winning article in the Wall Street Journal. 33
In 1987, the CDC had a problem. Nearly all AIDS victims were homosexuals, bisexual men, drug addicts, and their girlfriends. Polls showed that most of America didn’t see the disease as “their” problem, and some saw it as a punishment for immorality. There were fears of widespread housing and job discrimination. Life magazine had proclaimed on its cover, “Now No One Is Safe from AIDS,” and Oprah had opined that one in five heteros would die of AIDS in the following three years. 34 Aside from that, the media wasn’t too interested, and for sure Washington wasn’t. But people were dying, and funds were needed for prevention and research. In some countries, AIDS seemed to have spread more easily among non-drug-using heterosexuals. CDC officials wondered, If Americans think the virus is someone else’s problem, how sympathetic can they be toward the victims? And who will support funding? They hired a Madison Avenue advertising firm to help design a public relations campaign. An idea took form: present AIDS as an equal-opportunity virus. That would wake up America. They met, debated, and did some soul-searching. Their decision? The America Responds to AIDS campaign, in which the public would be bombarded with a terrifying message: Anyone can get AIDS.
A series of dramatic public service announcements were designed, featuring AIDS victims who looked like middle America. They were featured on television, radio, and print, in ads that were broadcast over and over in late 1987. A middle-aged, blond woman and the young son of a rural Baptist minister looked at the camera and declared, “If I can get AIDS, anyone can.” Omitted from the script: she had used intravenous drugs; he was gay.
Not everyone agreed with the plan. These public health professionals knew that the ads were misleading, but given their predicament, they decided it was worth it, thinking the campaign would do the most good in the long run. 35 The Left was happy—finally the nation would notice the plague that had hit gays hard. Stigma would decrease, and money would come. The Right was happy because the message would promote their “pro-family” agenda.
The problem is, it wasn’t true. And twenty years later, it’s still not true. In the United States, the great majority of HIV transmission can still be traced to high-risk behavior. When the surgeon general sent a four-page brochure out to 107 million households in 1988 with the warning that “Everyone is at risk,” it was overstating the danger. 36 Is there harm in doing so? 37 Consider these points: first, the misappropriation of scarce health funds. Among women, the group at significant risk for infection is those who inject drugs, or whose partners do. These women also suffer from other diseases, poverty, and malnutrition. Wiser to send the money their way, instead of “educating” yuppie white women not at risk and urging them to be tested. Among men, many at high risk now believe there is nothing uniquely dangerous about their behavior, because after all, everybody is at risk. In fact, there is an unrealistic optimism in young men engaging in dangerous activities, among both the infected and the uninfected. 38
“Anybody can get HIV”—perhaps technically correct, but profoundly misleading, because all the “anybodies” have widely varying risks of getting it, probably a million-fold differences. 39 The warning does more harm than good. Half the U.S. population has been tested for HIV, most of them like Sophia and Ken, but more than 300,000 other people, like Brian, are HIV-positive and don’t know it. 40 To engage in high-risk behavior with multiple people, to have a false sense of optimism about being healthy, all the while being highly infectious—this constitutes a lethal combination for Brian, the gay community, and public health. To say nothing of the obvious: the public deserves to know the truth, especially from people whose salaries they pay.
This fiasco has been written about at length; as noted earlier, it was the topic of the 1996 Wall Street Journal article that won a Pulitzer Prize. 41 And ten years earlier, the intrepid San Francisco Chronicle journalist Randy Shilts explained,
nothing captured the attention of editors and news directors like the talk of widespread heterosexual transmission of AIDS. Such talk could be guaranteed air time and news space, which, in the AIDS business, quickly translated into funds and resources. Thus, even though epidemiological support for fears of a pandemic spread of AIDS among heterosexuals was scant, few researchers would say so aloud. There was no gain in taking such a position, even if it did ultimately prove to be honest and truthful.”42
So he wrote in his classic 1987 book And the Band Played On, which was called “a heroic work of journalism” by the New York Times. 43 Heroic it certainly was—the author bravely indicted persons large and small, from the White House down; anyone who in his opinion had failed to deal with the epidemic, because he considered it a “robust journalistic duty to tell the whole story.”44 But for his integrity he paid a price. For example, because Shilts dared to suggest that bathhouses—where one in eight patrons had syphilis or gonorrhea, and the average guest had 2.7 sexual encounters a night45—were breeding grounds for HIV, he was jeered and spat upon by radical gays. 46
But for my young patients this is ancient history; they have never heard of Randy Shilts. And twenty years after his death from AIDS, the truths he exposed don’t reach them either. Instead, the CDC’s 1987 “Anybody can get it” campaign is etched in their brains, causing Sophia to have a meltdown, while guys like Brian don’t even get tested. So why is the myth still with us? Because it serves a purpose: it supports the preposterous notion that male and female are the same, and their unions equivalent. It’s a social agenda—don’t believe it. Consider instead our anatomy, histology, and immunology. What spreads HIV is anal sex, shared needles, or a partner who does those things. If Randy Shilts were with us, that’s what he’d want us to know. Isn’t it time we forgot the Left and the Right, and just told it like it is?