Dr. Marcus Conant on Modern AIDS Epidemiology

Jacksonville native and Air Force veteran Marcus Conant was a dermatologist working in San Francisco in 1981 when he began seeing young male patients exhibiting a rare skin cancer called Kaposi’s Sarcoma. Because KS was one of the first two opportunistic infections to be characteristically identified with AIDS-related immune suppression (the other was the fungally-induced pneumocystis pneumonia, or PCP), Conant’s specialty and proximity to the gay community put him directly in the path of a then-baffling new disease.

It was an interesting fit for him, as early in his career in San Francisco he worked at the Haight-Ashbury STD clinic triaging the fallout from the experimental free-love community. Conant says this clinic witnessed one of the first epidemics of genital herpes, an unfortunately common disease among sexually active Americans today.

(WordPress won’t let me embed the fora.tv video, so here is the link – it is absolutely worth watching.)

There’s a lot of fascinating stuff in here, from transmission patterns among truck drivers to the politics of foreign aid, doctors who don’t want to know if their patients are positive to the effect of crystal meth on casual sex to “black and Hispanic America have not yet come out of the closet.” Conant also gives specific medical recommendations – testing of every sample of blood that is drawn and aggressive monitoring of viral load in patients.

To head off questions I feel I need to disclaim my interest in the subject. I’m not gay, I’m not bi, I’m not bi-curious or anything like that. I’m not involved in any activism when I’m not blogging, and I’m not a doctor on the front lines. I became interested in the AIDS epidemic as a pre-teen and teen as it was a major factor in what they were teaching us in the the nascent “safe sex 90’s.” It was only after a full medical understanding that I became interested in the social environment and fallout of the disease, which dovetails nicely with my amateur study of sexual dynamics (otherwise known as this blog). AIDS is also interesting in that it’s one of the only diseases to completely emerge under the scope of modern medicine and epidemiology, meaning its origins could be rather conclusively traced and its various treatments completely recorded and studied.

While medically and socially it’s wrong to approach AIDS as a gay man’s disease, the fact is that since the first months of its appearance, AIDS has been an ever-present specter in the gay male community, a more singular demon than almost any threat facing any other first-world demographic group. I recently saw an estimate that even today, a sexually-active gay American man has a 1 in 5 risk of becoming infected with HIV in his lifetime.

AIDS, even before it was named such, quickly caught the notice of the Centers for Disease Control, which internally characterized it as the “4-H” disease – referring to its first classes of victims: homosexuals, heroin addicts, hemophiliacs and Haitian immigrants. It’s morbid to consider that AIDS fairly quickly shut down the fast-lane lifestyle of young gay communities in the Castro, New York’s Fire Island and a dozen other North American gay villages, for two reasons: the disease forced behavioral changes in risk groups, and many of the lifestyle’s evangelists themselves died of the disease. It’s fair to note that many young gay men were not participating in the hyper-promiscuous behavior the culture was known for, but after a certain point, it didn’t really matter; the second wave of cases started to hit relatively chaste men, who in the course of a sensible serial-monogamy lifestyle would come in contact with a “reformed bathhouser.”

Public health authorities have long played a tightrope game of trying to contain risky sexual behavior, but not shaming it so much that it simply goes underground where health and social services can’t reach them. This is something like what has happened in places like Washington DC where gay black men (“on the downlow”) are extremely circumspect in their behavior, difficult for public health services to find, and are trafficking the virus between gay and straight communities.

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8 Comments

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8 responses to “Dr. Marcus Conant on Modern AIDS Epidemiology

  1. Im interested on the AIDS as well

  2. deti

    Politically, AIDS was a firestorm and a lightning rod because in the epidemic’s infancy, it largely affected one specific and traditionally disadvantaged interest group: gay men. Money — lots and lots of money — was demanded for research and it was allocated. Few other medical diseases were treated with such urgency. It was given that priority for two reasons: first, because of the terrible political optics and toxicity associated with ignoring a disease almost exclusively affecting homosexuals, and second, because initially it was 100% fatal. When I was in college I worked for the university. We were trained on it, given history lessons, and were basically encouraged to become amateur infectious disease specialists.

    Then it was thought that epidemiologically, AIDS could explode into the general population. There were initial estimates focusing on possible models of young adult sexual behavior suggesting that anywhere from 10% to 50% of the entire adult population of the United States could eventually become infected. Of course that has not occurred and probably never will. Perhaps this is another demonstration of the apex fallacy, in which there isn’t really as much sex going on as people thought. In any case now, AIDS doesn’t seem to be on the minds of nearly anyone in the heterosexual SMP, and hasn’t been for at least 15 years.

    I am sure there are epidemiological reasons why AIDS did not make heavy inroads into the general population. It’s much easier to transmit the virus in semen to a receiving partner than it is for a man to become infected through vaginal or saliva secretions. I think it’s also been found that AIDS is a difficult virus to transmit and is not particularly hardy outside the host.

    It’s also interesting that in recent years, AIDS has become a manageable disease, something like diabetes or hepatitis C, but the maintenance medications are astronomically expensive. It’s fascinating that in few other diseases, efforts have been made and monies expended to control and contain an epidemic. The advances made in 30 years to diagnose, treat and manage AIDS are astounding. Almost no other disease, except perhaps breast cancer, has been given such attention in the medical and political communities.

  3. I feel I need to disclaim my interest in the subject. I’m not gay,…

    You just haven’t met the right man yet. Give yourself time.

  4. Ceer

    As a relatively strident observer of chastity, I always figured low value behavior that threatened my personal sexual strategy might be curtailed.

    I was surprised at the ferocity of the demands for society’s resources. They got what they wanted, mostly. It seems that while short of a cure, current aids treatments can help cover up the problem long enough for infected individuals to have a lot more goes at the promiscuous activities.

    The community’s actions seemed more along the lines of hubris and entitlement, rather than any sort of prudent strategy. Other risky behaviors like blood transfusion and injections are handled with the utmost caution. Not so with sex. The gay community itself had the ability to wipe out aids for good soon after it was first discovered. All they had to do was put a community wide moratorium on sexual activity until all the infected died off. Then, the free love party could start over again.

  5. deti

    Ceer:

    One of the fascinating discussions I remember back in college was trying to deconstruct whether or how AIDS could get into the general population. Theoretically, one infected man could have sex with one woman, who could then have sex with another man, who then might have sex with two other women, and so on and so on.

    I recall one of the counterarguments involved — and I’ll get the name wrong — social movement theory, which involved the social circles people move in, sexual behavior, the types of men who women had sex with, etc. And it was essentially that, based on the then existing sexual behavioral models and what was then known about partner counts, there were not enough people having enough sex with enough HIV+ people to permit cross-pollination from HIV+ persons to HIV negative persons on a large enough scale to reach epidemic proportions into the general population. Put another way, there would never be a sufficient number of heteros having sex with enough infected persons to cause a large scale spread of HIV into the general population, of which the vast majority is hetero.

    That, and condom use absolutely skyrocketed. Rarely did anyone go completely naked. In spite of all that, I remember that the single biggest deterrent for a lot of men was fear of unwanted pregnancy. You worried a lot less about AIDS than you did knocking up a girl.

  6. Looking Glass

    @ Deti:

    Social groups tend to have sex with each other, as Sex has heavy location bias. Then you have to add in that Female to Male transmission of AIDS is very, very rare. This is what prevented it from moving over into the standard population at a high rate.

    Most of the Hetero population that ended up with it actually is from IV drugs or pre-1991 blood transfusions. One of the little said details is that gay men pretty much cannot donate blood these days. Those little things you really don’t hear, but it became really important for preventing HIV spread.

    I don’t think the outcry was Hubris. It was pure, unmitigated Fear. Without the anti-retroviral drugs, Gay men, as a group, would have been obliterated already. It’s the simple reality. So, the fear was very, very real. There was also a problem that, if it did bridge over into the normal sexual circles, it could obliterate society.

    Though, it should be noted, AIDS actually had more risk to destroying the post-1960s Open Sexuality movement. If going up to a 3rd sex partner suddenly put you at 50% odds of getting AIDS, the free-sex movement suddenly gets turned from a “Free Love” group to a “Single Biggest Pushers of Death” group. That simply wouldn’t be allowed to stand, as too many were bought into the issue by that point. If AIDS had hit in 1950, things would have been very different.

    @ Ceer:

    While I’m not gay or bi, I’ve spent enough time looking at the stats and interacting with a whole lot of gay men that I’m pretty comfortable saying this: the gay male lifestyle *is* about having sex with as many men as possible. These days, it includes lots of drug usage as well. While it’s not true to every single gay male, it’s a solid enough of a generality that there is no way they’d have “put a community wide moratorium on sexual activity” for any reason. Their approach, on the whole, is a denial of all inhibition, so any move to limit them would have been anathema. There only option was to find a way to treat or cure it. They were given the option of “Live” or “Give up promiscuity”, they chose the latter.

  7. Looking Glass

    Argh, last line should have been “they didn’t chose the latter”. (I can’t edit my comments, lol)

  8. Arch

    I actually had a class on AIDS at Emory University in 1994. It was incredibly surprising and interesting and as the CDC is right next door we got to meet Dr. Anthony Fauci.

    It’s been a long time since I’ve studied the subject and I don’t want to cause a flame war but I would like to say there were actually some smart people who have very good evidence that AIDS has been misrepresented. One is Dr. Peter Duesberg. His main argument is that recreational drug use or immuno-suppressive drugs such as used by hemophiliacs was what caused the explosion. (comment segment clipped)

    [Thanks for commenting. With all due respect, Duesberg is just non-credible; being a skeptical scientist is one thing, but he's virulently opposed reality on the AIDS issue. Duesberg denies that HIV causes AIDS, but the only statistically significant predictor for the development of AIDS is a positive HIV test. The reduction of viral load via drugs is correlated with delayed development of full-blown AIDS. Duesberg's bogus theory is partially responsible for South Africa's disastrous AIDS policy.]

    He was reviled by the “Fund AIDS research NOW!” crowd in the same way that global warmistas savage anyone who doesn’t tow the globalclimatewarmingchange line. Back then the same kind of scare tactics were used (“we must act now or the world will die!”) and I can remember a lot of propaganda predicting 30 million dead Americans by 2000. Obviously it didn’t happen.

    [I remember the alarmism of the time, it was quite disconcerting to say the least. Conant discusses the lack of a first-world heterosexual epidemic, and makes a good case for one overwhelming explanation: straight Americans and Europeans practice serial monogamy, while gay Westerners and straight central Africans are more keen on juggling multiple partners at the same time. Like Deti said, there just aren't enough infected straight people having enough sex with other straight people to make it catch fire. He interestingly argues one of the keys to solving the disease on a social level might be society normalizing monogamy among gays, i.e. legal gay marriage.]

    Among other interesting bits I learned was that the primary test used in Africa, Western Blot, is prone to false negatives caused by malaria antibodies. So prone, in fact, that the actual numbers of Africans with AIDS is probably about 1/3 of what is advertised. Unfortunately those numbers are used as emotional arguments for funding so any attempt to discredit them is met with cries of racism and hate-speech or whatever canard is on hand at the time.

    Another interesting bit was that there are documented mystery illnesses going back over 200 years that exactly match AIDS. Apparently its been around for quite a while but never turned into an epidemic until the 1980s. That epidemic was largely traced to gay men and bath houses in San Francisco with the American bicentennial celebration in 1976 as a major event drawing the men together. Some donated blood which would infect hemophiliacs. There was a lot of drug use in the bath houses, especially a drug known as “poppers” used to enhance pleasure.

    [I've read interesting theories that AIDS has existed in primates for one to two centuries, and possibly jumped to humans around 1900. and that the epidemic may have been spurred on by Western medical intervention in central Africa - medical missions and mass vaccination campaigns with shared needles that may have mutated the virus.]

    Whether you believe in the “Patient Zero” hypothesis or not, its interesting that one of the men credited most with spreading HIV claimed to have had over 2500 (that’s not a typ-o) sexual partners. (http://en.wikipedia.org/wiki/Ga%C3%ABtan_Dugas) That kind of behavior by just 10 individual gay men can affect tens of thousands of lives.

    [Without a doubt, the disease couldn't have exploded as fast as it did without the activities of the massively promiscuous cohort. That was a factor that disgusted even doctors, let alone Middle America.]

    I think the best thing about the AIDS situation was how it scared the West back into a sense of sexual responsibility, even if it is still less than some of us would like.

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