Changing Nature of AIDS Epidemic Makes Leadership More Vital but More Difficult

The AIDS epidemic is changing significantly in the United States. As a result, the need for effective political and medical leadership, which too often has been lacking, will be even more critical.

There is increasing evidence that for many people the threat of AIDS-virus infection from sexual intercourse is low and/or decreasing. Studies of blood donors, military recruits and hospital patients show that the virus has not spread widely among white heterosexuals. Further, a recent study of 72 call girls in New York City (83% were white), none of whom used IV drugs and each with an average of 1,000 sexual partners the past five years, showed none infected with human immunodeficiency virus (HIV).

While new infections are dramatically lower among gay men in San Francisco where there has been excellent leadership in developing prevention programs, the news is not as good in Los Angeles (and probably many other communities). Of those gay men who tested positive in 1988 at the L.A. Gay and Lesbian Community Services Center, about 8% to 10% had a prior negative test, meaning that they had a relatively recent AIDS-virus infection.

Nevertheless, in Los Angeles County, the number of reported people with AIDS diagnosed in 1988 apparently will be lower than in 1987, considerably below projections. One possible explanation is that physicians are not reporting cases of AIDS because of the punitive atmosphere created by Proposition 102, even though the reporting and mandatory contact-tracing initiative did not pass. More optimistic possible explanations include overestimates of people infected or of the percentage infected who will develop AIDS (a decrease possibly occuring because of the avoidance of other sexually transmitted diseases), and the fact that medications are succeeding in delaying or preventing the onset of AIDS.

In 1987 the drug AZT was approved; it has been shown not only to prolong life for people with AIDS but also to seemingly delay the development of AIDS in people with a severely impaired immune system. In 1988 various medications, including aerosolized pentamidine, have been shown in small studies and in reports from San Francisco and elsewhere, to prevent pneumocystis pneumonia, the most common life-threatening infection in people with AIDS. Since this infection establishes the diagnosis of AIDS in more than half the HIV-infected people, its prevention would decrease the number of people with AIDS.

Because the drug-approval process lacks effective leadership, aerosolized pentamidine has been distressingly slow in going through the experimental and approval process. This means it is still considered experimental, which has allowed many health-care insurers to refuse to cover it.

The last major change in 1988 has been the full appreciation of where the epidemic is heading. For years, heterosexual IV drug users consistently made up 16% of the new people with AIDS. In 1988 that has risen to 24%, with a corresponding decrease among gay men. This year, 41% of people with AIDS are black or Latino, compared with 38% in 1986. Among recent military recruits, blacks are seven times more likely than whites to be infected. Thus AIDS is becoming less a disease of gay white men and more a disease of minorities, IV drug users and their sexual partners. This will make leadership even more difficult but even more important.

Since 1984, when Dr. Edward N. Brandt Jr. resigned as assistant secretary for health, there has been no effective AIDS leadership in the U.S. Public Health Service in terms of developing and implementing major programs. There are many new drug treatments, in various stages of development. But no one has responsibility for assuring that drugs go through the experimental and approval process as quickly as possible. One of the most essential decisions that President-elect George Bush’s new assistant secretary for health could and should make would be to appoint an AIDS experimental-treatment coordinator. His or her responsibilities would include ensuring cooperation between the drug manufacturers, the National Institutes of Health AIDS researchers and the Food and Drug Administration regulators. This cooperation would certainly be useful for other diseases as well.

Physicians, many of whom have refused to do sexual counseling, must recognize the need to identify their patients at risk for AIDS, counsel about the HIV antibody test and, for those who test positive, assess the status of their immune systems. If the immune system is severely impaired AZT and medication to prevent pneumocystis pneumonia must be strongly considered (and sexual counseling provided).

Leaders of the medical community--the American Medical Assn., the California Medical Assn., and other national, state and local medical organizations must go beyond recognizing that fear of discrimination is the greatest barrier to the counseling, testing and treatment process. They must state publicly that they will urge physicians to ignore future laws that may require reporting of the names of people who test positive for HIV until anti-discrimination legislation is in place.

The gay community, which has been under siege both from evil homophobes and the devastating effects of this epidemic, must still find the strength to encourage safer sex practices for all homosexually active men.

School boards must aim AIDS prevention programs at the adolescents at greatest risk of infection--males who are or who may be sexually active with other males, those who may use IV drugs even once and the sexual partners of these adolescents.

For black and Latino leaders, the challenge is enormous. They have to deal constantly with racism, poverty, inadequate medical care, unemployment and so many other seemingly insolvable problems. Many have difficulty with AIDS because of their own intolerance of homosexuals and IV drug users. But it is the young of their community who will be hardest hit. Even if their main concern is only for the sexual partners and children of those currently infected, the leaders must take a more active role in demanding better prevention and treatment programs--programs developed by and for blacks and Latinos.

Finally, white heterosexual politicians must recognize that just because white heterosexuals who do not use IV drugs are relatively safe, the AIDS epidemic is not over. Until now, most politicians have been followers. It is time for them to become effective and positive leaders. This is perhaps the epidemic’s most difficult upcoming challenge.