PERSPECTIVES ON LIBERTY (1987)
Chapter 5 - AIDS
Perhaps no other problem, and no other tragedy, so relentlessly calls into question our most personal freedoms ¾ to be intimate with whom we choose (and who give consent). No other crisis makes us ponder about the possible eventual consequences of our actions and of the implications of the attitudes and values that promote these actions.
As of today, there are still only three ways in which HIV virus transmission (and therefore AIDS) have been documented. These are (1) sexual intercourse, vaginal, anal, and possibly oral; (2) direct exposure to infected blood or blood products, including blood exchanged by shared needles (drug addicts, medical injections in the third world) or, rarely, accidental needlestick injury; (3) from mother to child before or during birth, or possibly through mother's milk. All other notions about spread still remain speculative and, according to current epidemiology, at most extremely rare and unlikely.
I will repeat the advice that Dr. Neal Schram from the Association of Physicians for Human Rights gave on ABC "Nightline" on Jan. 9, 1987. Most of the transmission of the HIV virus causing AIDS could be prevented if, from this day forward, no one would share needles, and everyone would use a condom of "high quality" when having sexual intercourse (homosexual or heterosexual) with any person they were absolutely sure was not already infected. For most people, this would mean when having sex outside of an established monogamous relationship (if one knows that the partner is not infected). Since large numbers of people will still continue to have sexual contact with infected partners regardless of public policy, it is only common sense that bombarding the public with condom suggestions will save lives, at least for some number of years. For purely pragmatic reasons, I must come out in support of television and other media ads.
Why should I go on further, and probably stir up more fears and risk making some people about their ability to protect their own health? Partly, because I am concerned about the ethics of implementing personal choice and following one's own values, and AIDS raises ethical problems in this area like no other issue. Furthermore, can condoms be counted on by people who have repeated sexual contact with infected partners? It is quite clear that condoms do greatly reduce the risk in any one sexual encounter. Dr. Anthony Fauci of NIH told a television interviewer that condoms definitely provide a barrier to HIV in the laboratory (10). A recent study of prostitutes in Africa shows a dramatic reduction in transmission when they are used (11). In a recent domestic study of heterosexual couples (with one partner infected) diligently using condoms after enrollment, three spouses (seronegative at the time of enrollment) have developed a positive (Elisa) test, according to Dr. Margaret Fischl at the University of Miami Medical School, although it is possible that these persons could have been infected before the study began. Twelve spouses in fourteen additional couples not using condoms developed a positive test, however. (12, 13). At this point, it appears that any person who repeatedly has intercourse with infected persons even with condoms eventually runs some risk, probably because condoms can be misused during passion; "people are only human."
The "Religious Right" wants to make an inherently self-contradictory argument. It wants AIDS to be an intrinsically gay disease, yet it wants to claim that AIDS threatens the general population. This notion would make sense only if the virus, after "amplification," underwent mutations which increased its contagiousness, or if it spawned off satellite infectious diseases which gradually endanger the public. Such potentialities cannot be so easily dismissed. However, common sense would dictate that any disease becoming transmissble by less intimate contact will go through a period of being easily spread by "normal" heterosexual relations as well.
We should mention here one particular enigma that, as a manifestation of AIDS, Kaposi's sarcoma, in particular, has been experienced largely by gay men and not by other victims of AIDS. Some gay men have developed Kaposi's sarcoma with relatively intact immune function and without opportunistic infections. Why? There have been various theories, and no totally convincing explanation. "Poppers" or nitrite inhalers previously used by gay men to enhance sexual excitement have been suggested, and they are thought to stimulate endothelial cell proliferation; but recent epidemiology discounts a convincing association (30). There has been considerable evidence linking cytomegalovirus or similar DNA herpes-like viruses to the nuclear material of Kaposi's sarcoma "spindle cells" which give the tumor its substance (161). French researchers believe that HIV-infected T4 cells may release endothelia cell growth factors when responding to CMV or similar DNA viruses (340) (like Gallos's HTLV or Teas's /Beldakas's ASFV). Of course, about 40% of heterosexuals carry CMV antibody, too. But the most convincing cofactor may be antibody to sperm itself. Possibly, stimulation of HIV-infected t4 cells by sperm may particularly exacerbate endothelial proliferation which, after all, starts out as a basically healthful process. (350, 351).
The rhetoric over public policy towards AIDS masks a preoccupation with deeper problems, the "moral issues," the suspicion of what makes certain unconventional people tick. But there really is a serious policy question. "Right-wingers" are constantly pointing out, "what if…" scenarios where somehow an infection may be unnoticeably transmitted. More "responsible" sources will stress the general experience with infectious diseases, that it takes quantity and efficiency of exposure as well as the mere mechanical possibility. Yet, with most other infections with which we have experience (other than the bizarre prion or slow-virus neurological diseases that we are just starting to learn about) infinitesimal exposure can usually be overcome quickly by the body. (Maybe there are exceptions, like Lass fever and ebola). With slow viruses like the AIDS virus, containment of infection often may not occur once started, with catastrophic consequences down the road. So, with common sense, we have to hedge our bets on infection never starting in the first place, with the virus never finding a cell that it can infect. With HIV being so diluted in infected persons, this is probably a pretty good "bet": yet, ultimately we have a problem that seems indeterminant, and we look to medicine for a l'Hopital's rule. How to handle residual medical uncertainly really is a question of legal or public policy, not just medicine. I hope that society will se it in everyone's best interest not to deny persons their freedom or livelihood when all available evidence indicates that such dispassionate measures like quarantine really are not, by common sense, necessary.
(10) Fauci, Anthony, comments made on "This Week with David Brinkley," ABC News, February 15, 1987.
(11) Mann et. Al., CDC and NIAID letter, "Condom use and HIV infection among prostitutes in Zaire," New England Journal of Medicine, Feb. 5. 1987, 316:345.
(12) "Condoms not foolproof protection against AIDS, study says." The Washington Post, Feb. 6, 1987. Reprinted in the Dallas Times Herald, Feb. 6, 1987, page A4. According to this article, two of the three spouses using condoms seroconverted after the JAMA study was published.
(13) Fischl et. Al. "Evaluation of heterosexual partners, children, and household contacts of adults with AIDS." JAMA, Feb. 6, 1987, 257:640.
(30) Pol. Et al. "Predictors of Acquired Immune Deficiency Syndrome developing in a cohort of seropositive homosexual men." New England Journal of Medicine, Jan. 8, 1987, 316-2:61.
(161) Huang. "The Role of Cytomegalovirus Infection in Kaposi's Sarcoma." AIDS: The Epidemic of Kaposi's Sarcoma and Opportunistic Infections. Edited by Linda Laubenstein. Masson, New York, 1984.
(340) Leibowitch, J. A Strange Virus of Unknown Origin. Translation by Howard. Ballantine, New York, 1985, p 182-185.
(350) Sonnabend, J. Kaposi's Sarcoma. 1984 book available (to my knowledge) only at the National Medical Library at NIH in Bethesda, Md.
(351) Sonnabend, J. article in JAMA, May 6, 1983, discusses sperm antibody in conjunction with angiogenesis. Apparently research laboratories can test for exposure to sperm, a frightening prospect for development of more tests for "undesirable" behavior.