HIV infection in MSM's

As noted, AIDS first spread primarily among certain portions of the male "gay community".

Around half of identified, asymptomatic MSM's being followed by the CDC had antibody to HIV in the mid-1980's. Of course, the CDC study, and other like it, were of MSM's in selected populations, such as venereal disease clinics. Obviously, members of longstanding "monogamous" partnerships are not at risk.

Among MSM in epidemic areas, the geometric increase ended in the mid-1980's, almost entirely due to people paying attention to the news, and the MSM community organizing and educating itself, with no money from Uncle Sam. In San Francisco, the annual rate of new infection in MSM's dropped to 1% in 1985 (Am. Med. News Jan. 24/31, 1986), and in Europe the prevalence of antibody became stable (Br. Med. J. 298: 415, 1989). Unprotected "fast-lane" MSM lifestyles disappeared -- see JAMA 255: 171, 1986, Am J. Pub. Health 77: 578, 1987; Br. Med. J. 298: 215 & 218, 1989), though some unsafe behavior persists (Am. J. Pub. Health. 81: 1321 & 1586, 1991, lots more). In the early 1990's, safety was on everybody's mind, and the rate of transmission dropped greatly in the civilized world (Br. Med. J. 305: 561, 1992). Even among young MSM's cruising in the public-meeting-places, only around 10% were positive (JAMA 272: 449, 1994). Even the people at Harvard, not noted for conservatism, now talk about "warning widely and spending wisely", and give free condoms to teens and poor folks (NEJM 331: 1451, 1994). Disturbingly, there has been an upsurge in the gay community, perhaps because of "complacency" or the expectation that the infection will be curable; and today in the developed nations, about 44% of new infections are transmitted by M's having S with M's (Lancet 364: 4, 2004).

Receptive anal intercourse is still the best predictor for seropositivity, especially if multiple partners have been involved ( Am. J. Pub. Health 83: 79, 1993).

According to both the prospective San Francisco Men's Health Study (JAMA 257: 321, 1987), and to a British study (Lancet 1: 345, 1987; also JAMA 255: 1703, 1986 and Br. Med. J. 294: 5, 1987), receptive anal intercourse is the only sexual practice that seems to transmit the epidemic with much efficiency. Douching was an ancillary sex practice that contributed to risk, probably by damaging the rectal mucosa. Fisting was also a likely risk factor. Ulcerative genital disease (chlamydia, herpes) also clearly increases risk (JAMA 260: 1429, 1988; Am. J. Pub. Health 81: 1576, 1991), and probably does for straight M's also.

Contrary to common-sense, insertive anal intercourse and swallowing semen or stool were not demonstrable as risk factors in these studies. ("The absence of detectable risk for seroconversion due to receptive oral-genital intercourse is striking" -- Lancet, above). This was disputed only anecdotally (Lancet 1: 1395, 1988; Lancet 338: 830, 1991) until very recently, when 4 of 12 MSM's with acute HIV infection supposedly had only unprotected oral sex as a risky behavior (Ann. Int. Med. 125: 257, 1996) and monkeys proved easy to infect by orally-administered virus (Science 272: 1421, 1996). In 1990, UCSF researchers who interviewed newly-positive MSM's reported that 8% said they got it from oral sex. In Australia, self-reports disclose a high rate from oral sex: AIDS 17: 2269, 2003. By contrast, UCSF researchers who actually sought out and tested MSM's only engaging in oral sex found the risk to be "extremely low" (AIDS 16: 2350, 2002); this disparity fits with previous work and the not-so-surprising discovery that when you interview partners separately, sexual histories are discordant (Am. J. Ep. 147: 1153, 1998).

*Chilling reading: the contemporary male CSW (Soc. Sci. Med. 32: 535, 1991) providing CS for other men. About 1 in 6 is HIV-positive, many have wives or girlfriends (often also CSW's), and surprisingly, most say that most of their customers are "straights" looking for variety, and around 40% of customers are married. (This is confirmed in Arch. Sex. Behav. 21: 347, 1992). This sounds like an extremely dangerous thing for "straight men" and their wives, and something physicians should know about. Male CSW's in this study were mostly teens looking for extra spending money (Adolescence 27: 69, 1992). Los Angeles boys surviving on the streets by giving sexual favors: Arch. Ped. Adol. Med. 149: 513, 1995.

*Amyl and butyl nitrites ("poppers", "pig pokers", others), used by MSM's having receptive anal intercourse, were once rumored to be carcinogens for Kaposi's "sarcoma"; see Am. J. Med 78: 811, 1985; NEJM 317: 1603, 1987. This was simply wrong, but you'll still hear about this occasionally.

*A few articles I wish I'd read before I started caring for MSM's on my clerkships:

Arch. Gen. Psych. 37: 349, 1980. Cross-cultural and inter-species studies; provocative. "Exclusive homosexuality" seems to occur only in humans. However, in most other mammalian species, there is a certain amount of courtship-type and play behavior among individuals of the same gender. Cultures that stigmatize all male same-sex thoughts and acts as "making you different and bad" end up generating a lot more "male homosexuals".

BMJ 297: 308, 1988. As above, the more you stigmatize male same-sex fantasy and exploring, the more "gay men" your society produces; "Oh gosh, I guess I'm not like other men...."

Am. J. Psych. 141: 173, 1984. Masters and Johnson treatment for the gay man who wants to be able to love a woman/women, too. This is out of fashion nowadays, i.e., it's more important that a man fully identify as a member of an identity group than that he fulfill his desire to enjoy the best of both worlds, to be a father in an ordinary family, etc., etc. Anyway, the world's foremost sex researchers found that almost all "gay" men who wanted to try would spontaneously start having, and thoroughly enjoying, the regular kind of sexual intercourse with a woman if they got familiar and personal and cozy enough with her. Obviously this is a selected group, but this confirms (at least for me) the common-sense idea that "exclusive homosexuality" has more to do with stereotypes generated by both gay and anti-gay rhetoric than it does with who any guy really is. In the 1970's, the American Psychiatric Association had enough wisdom and courage to drop "homosexuality" as a psychiatric category, though it retained "ego-dystonic homosexuality" for the gay or bi- man uncomfortable with his sexuality. But you'll find nothing except identity-group politics stuff on the subject since Masters & Johnson.

Med. Clin. N.A. 70, May, 1986: Entire issue on gay men's medical problems. Eye-opener.

Science 243: 338, 1989. Many, if not most, men have experimented a little at one time or another, typically "safe stuff" in an established friendship, and most men fantasize at least some, mostly about "safe stuff". For the vast majority of men, this is nowhere near as important as the fascination that women exercise over us, but it's still part of the male experience. Recently I brainstormed with a group of about 30 gifted college students, mostly men, about what would be the most-frequently-asked health questions for teens. After acne, birth control, drugs, alcohol, and a few others, one student said, "How do I know whether I am gay?" I asked, "What percent of teenaged men have to deal with that?", expecting the standard 5-10%. Almost every male in the group chimed in, "Gawwd! We ALL had to deal with THAT one!" Considerable discussion followed, indicating that rhetoric from culture warriors on both sides ("That's unnatural and sinful and a biological error and we can cure you" / "Yeah, that means you're definitely gay, join us") is far-removed from reality. Even the Left is now starting to talk about "homosexuality" as a social construct (Soc. Sci. Med. 52: 707, 2001). Despite the prevalence of feeling and past experimentation, only around 3% of men have a male partner now (Am. J. Psych. 157: 1843, 2000).

Science 261: 291 & 321, 1993; Xq28, a gene linked to male homosexual behavior; this can't be the whole story. A gay-pride shirt now reads: "Xq28 Thanks for the Genes, Mom!": Lancet 347: 1739, 1996; no correlation found Science 284: 571, 1999. The case against heredity: Sci. Am. 270(5): 50, 1994. A twin study finds both heredity and environment to be factors: Am. J. Psych. 157: 1843, 2000.

Science News 145: 159, 1994. Another brain study, this one on the amygdala of male sheep; generally, same-sex courtship-type and sex-play stuff is common in non-human mammals, some individuals much more than others, and this seems to be in the brain wiring. This is now a robust finding (Endocrinology 145: 475, 2004). However, exclusive homosexuality (let-alone male-male pair-bonding) doesn't occur in sheep.

More reading: J. Nerv. Ment. Dis. 179: 356, 1991; Br. Med. J. 297: 554, 1988; JAMA 262: 501, 1989. There's plenty of empirical support for the common-sense idea that many (most?) of these men are simply looking for friendship and for masculinity. In our crazy world, perhaps this is the real explanation rather than "some men just being born different", and the stigma of being friendless precedes the entry into an "alternative lifestyle." The CDC found that many (but not the majority) of gay men had been molested as kids (often young kids, often forcibly, often anal sex; most victims seem to have been underclass kids; Child. Abuse Neg. 16: 855, 1992). When I was a lay prison minister, I learned from my reading on situational homosexuality that men who victimize others behind bars generally return to heterosexual function after release, while men who are victimized typically become "gay" regardless of previous heterosexual interests and activities. Perhaps the sense of being stigmatized precedes, rather than follows, the sense of being "different". Depending on your study, anywhere from 1.5% (Uncle Sam, go figure) to 40+% (Doctor Kinsey) of men were comfortable telling a total stranger about having been brought to orgasm at least once through physical contact with another man. Today's numbers suggest that even that 40% figure is low (Psych. Bull. 124: 22, 1998). Most often this happens in the setting of an established close friendship, usually with a peer, and as long as this is the case, such exploring apparently has little or no impact on later function (i.e., this is not "the cause of homosexuality"; these boys typically leave all that stuff behind when they find out about girls). By contrast, where coercion or the misuse of authority is involved, or a teen or adult takes advantage of a pre-pubertal boy, serious harm is much more likely (JAMA 280: 1855, 1998; it is hard to sort out how much is the sexual stuff itself, and how much is the overall chaotic, abusive environment). Post-pubertal teenaged boys may form close bonds with grown men that eventually may include some sexual exploring: Arch. Sex. Behav. 30: 345, 2001; despite the author's surprisingly optimistic conclusions, I can't think that introducing sexuality here is really good for anybody. NEJM 331: 94, 1996: Review, avoiding controversy. Society is much less tolerant of gay-bashing today than in the past, which is good, but it is still politics-as-usual in many goofball right-wing circles. In the clinic, I ran into one violent-offender who assaulted gay men "because" he had the same feelings. And a man who says to another man for no obvious reason, "I think so-and-so is a MSM" or whatever may simply be sounding the listener out as a possible partner. As usual, the best hope I can offer is science, truth, and common kindness.

People NOT at great risk for AIDS:

The virus is very seldom transmitted except through sex or infusion of blood or blood products (NEJM 314: 344 and 380, 1986; Hospital Practice June 15, 1986, p. 127; JAMA 255: 213, 1986; JAMA 259: 1338, 1988).

People don't seem to get infected with HIV through casual contact with victims (in the home Ped. 85: 210, 1990; also South. Med. J. 82: 1071 & 1075, 1989 -- missionaries in mosquito-ridden endemic areas almost never get infected; Arch. Int. Med. 151: 1328, 1991 -- Peace Corps types aren't getting it by "unusual routes", either). The virus does not multiply in the mosquito and cannot get into the salivary glands. The health institute in New Guinea actually looked at this in depth and decided that you'd need to be btten by ten million mosquitoes, each fresh from an AIDS patient, to be injected with a single HIV virus (Papua New Guinea Med J. 39: 205, 1996). It is apparently safe to share handshakes, hugs (WHEWWW!!!! -- Ed), drinking glasses, toilets, classrooms, living quarters, and dialysis machines. (Dialysis was once quite a concern; see Ann. Int. Med. 104: 805, 1986; JAMA 225: 2324, 1986).

Health care workers routinely handling the blood and excretions of AIDS patients almost never seroconvert (NEJM 314: 1127, 1985). People seldom seroconvert even after contaminated needlesticks or knife cuts (maybe one HIV-positive needle-stick in 300; NEJM 312: 1, 1985; Science 241: 161, 1988 -- but there have been a few cases). The first (and so far only) conversion after an autopsy nick occurred at Vanderbilt in 1997 (Arch. Path. Lab. Med. 121: 64, 1997). Today, post-exposure prophylaxis for health-care workers is routine and usually involves two anti-retrovirals (MMWR 50: 1-52, June 29, 2001). With the advent of HAART, post-exposure prophylaxis following needlesticks will need to be tailored to the particular source (J. Infect. 43: 12, 2001). Prophylaxis following rape is also routine. No one knows quite how to handle requests for prophylaxis after other risky sexual contacts (Emerg. Med. J. 18: 242, 2001). Other transmission in the health-care setting is very rare (Ann. Int. Med. 104: 644, 1986; JAMA 259: 2817, 1988). Dentists aren't catching it, at least from drilling teeth (NEJM 318: 86, 1988). Surgeons are inventing super-safe surgical techniques (Br. Med. J. 296: 80, 1988).

There is no documented case of AIDS being transmitted by a human bite (well, probably not: NEJM 332: 444, 1995). Nobody seems to be getting HIV from mosquito bites either, at least in the US. People in Belle Glade, Florida, "who got AIDS from mosquitoes" didn't (Science 239: 193, 1988, not a pretty story).

* Sports for the HIV-positive: Med. Clin. N.A. 78: 377, 1994 (also includes everything that any of you wanted to know about exercise-and-immunology, for what it's worth). The whole world has talked about Greg Louganis's bleed into the swimming pool at the Olympics.

Heterosexual transmission:

Worldwide, this is probably the major means of transmission nowadays. But it is still less common in the U.S. than some people had feared. Most regular heterosexual sex partners of infected people have not seroconverted, though some do (Br. Med. J. 296: 526, 1988; NEJM 320: 183, 1989). Your viral load determines how catching you are: NEJM 342: 921, 2000, others.

Husbands and wives usually do not infect each other, even after many years (JAMA 259: 55, 1988; Am. J. Med. 85: 472, 1988 -- risk factors for the woman seem to be anal intercourse, other sexually transmitted diseases/genital ulcers, or if the man has full-brown AIDS, see Br. Med. J. 298: 411, 1989; confirmed at least in Uganda Lancet 357: 1149, 2001 & NEJM 342: 921, 2000). Most women who contract AIDS from sexual contact do so from a bisexual or drug-injecting man, rather than a straight man. And despite the ongoing media concerns, there is clearly no self-sustaining AIDS epidemic in the entirely-straight community (Lancet 341: 863, 1993). "Estimates of risks" for various situations: JAMA 259: 2428, 1988 (they made several assumptions....) Some of the more recent work confirms the low level of transmissibility between straights in the rich nations, and the effectiveness of using condoms (NEJM 331: 341, 1994).

The main lab predictor for risk of infectivity is viral load; if there are fewer than 1500 copies of HIV-1/mL, transmission is unlikely (NEJM 342: 921, 2000.)

Whatever the real rates, men seem to have much more difficulty catching AIDS from women than vice-versa.

* One old army study "showed" that men are catching AIDS easily from women during normal sex -- a finding that contradicts the good civilian studies. But the soldiers who reported "being with female CSW's" may have simply diverted attention from practices that would at that time have resulted in a less-than-honorable discharge. See Ann. Int. Med. 104: 115, 1986; JAMA 254: 2094, 1985 (army); 254: 2599, 1985 (New York City, others).

Ulcerative genital disease (i.e., herpes, syphilis, and those others) seems to place a man at greater risk; in one study, the only husband of an HIV-positive wife who turned positive had frequent bleeding during intercourse (JAMA 266: 1664, 1991).

In 1998 in these notes, I predicted the explosion in HIV deaths in India during the following five years. About a third of a million people in India will die of HIV this year (CIA figures). The former Soviet bloc's epidemic is fueled largely by needle drug use (Lancet 361: 1035, 2003). China: Lancet 361: 2125, 2003 (in addition to the usual routes, many people became positive from poorly-sterilized needles at the plasma donor centers).

So far, evidence that lesbian practices can transmit AIDS remain conspicuous by its absence (Science 272: 1421, 1996).

Condoms:

A tisket, A tasket / A condom or a casket....

-- Truck stop graffiti, 1991

Using a condom provides pretty good protection against infection (JAMA 255: 1706, 1986). If a married couple uses condoms regularly, HIV apparently doesn't get transmitted: NEJM 331: 331, 1994). The problem is getting people to use them. See Science News 140: 141, 1991; the estimate that only 8% of sexually-active people have more than one partner in a year seems low, but I'm not surprised by the report that only 1/3 of such people use condoms even 50% of the time.

Safe sex: NEJM 316: 1139 1987. Surprisingly (?), many people who know they are HIV-positive don't volunteer this information to those with whom they exchange body fluids (Am. J. Pub. Health. 81: 1586, 1991.) I doubt anyone was surprised by an article that people with sexually-transmitted diseases continue to catch new ones even after solemn warnings (JAMA 267: 843, 1992).

*Catching AIDS from the dentist: MMWR 40: 21, 1991; evidence for transmission by a Florida dentist looks pretty convincing (Science 255: 392, 1992; how the genetic stuff was done: Science 256: 1164, 1992). The remaining mystery is how HE transmitted it; he might even have intentionally committed homicide.

Human aspects of AIDS (update NEJM 347: 357, 2002)

Worldwide, about 57 million people have the HIV virus on board, and there have been 22 million deaths (2002) . There will be about 3 million deaths and 5 million new infections this year. It's worst in the "AIDS Belt". (The countries are South Africa, Botswana, Zimbabwe, Malawi, Zambia, Tanzania, Burundi, Rwanda, Kenya, Uganda, and the south half of the Sudan.)

Botswana has the highest infection rate, with 39% of adults being positive (CIA 2004). For total numbers, South Africa has the most (5.3 million, 2004 figures); India will soon catch up and pass this.

* The impact of AIDS on world economies isn't the best way to measure its human cost (J. Inf. Dis. 174 S2: S-253, 1996). The author of this very interesting paper suggests that the greatest impact of HIV is the breakdown of social structures. In Rwanda, which may very well have the highest percentage of HIV-positive young men, people who saw themselves as having no hope for the future may have seen no reason not to lash out over ethnic grievances, causing the longstanding race war to flare. I'd blame poverty, kleptocracy, and overpopulation too, but AIDS is not helping.