Notes
This chapter is a considerably revised version of a paper first presented at the annual meeting of the American Historical Association in December 1986. It has been much improved by the generous comments of Ronald Bayer, Benjamin Brody, Don C. Des Jarlais, Elizabeth Fee, Daniel M. Fox, Robert Padgug, Zena Stein, Anne Stone, and Mervyn Susser.
1. Robert C. Gallo, "The AIDS Virus," Scientific American 256 (1987): 47. The descriptive term "acquired immunodeficiency syndrome," or AIDS, became synonymous with the new disorder; it has recently been replaced by "human immunodeficiency virus" (HIV) infection, named after the putatively causal virus. Though, in general, this essay uses the new acronym, in discussing specific studies it will employ whatever term was used by the investigators reporting. [BACK]
2. This essay was completed before the publication of Randy Shilts's And the Band Played On : Politics , People and the AIDS Epidemic (New York: St.
Martin's Press, 1987), a broad account of the HIV epidemic based almost entirely on interviews and written in a diary-like format. Where Shilts writes of the work of epidemiologists (the CDC in particular), his narrative complements this essay, providing political information and descriptions of personalities that could not be inferred from the scientific literature, the primary source for this chapter. Consequently, where appropriate, reference will be made to Shilts's book in the notes. [BACK]
3. Neither inductive nor deductive logic can account for the origins of explanatory hypotheses in science. These hypotheses may have their sources in intuition, based on experience. See Douglas L. Weed, "On the Logic of Causal Inference," American Journal of Epidemiology 123 (1986): 965-979. [BACK]
4. Jennifer L. Kelsey, W. Douglas Thompson, and Alfred S. Evans, Methods in Observational Epidemiology (New York: Oxford University Press, 1986), 3. [BACK]
5. Brian MacMahon and Thomas F. Pugh, Epidemiology (Boston: Little, Brown, 1970), 25.
6. Ibid. Also, John M. Last, ed., A Dictionary of Epidemiology (New York: Oxford University Press, 1983), s.v. "multiple causation." [BACK]
5. Brian MacMahon and Thomas F. Pugh, Epidemiology (Boston: Little, Brown, 1970), 25.
6. Ibid. Also, John M. Last, ed., A Dictionary of Epidemiology (New York: Oxford University Press, 1983), s.v. "multiple causation." [BACK]
7. U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, Reports on AIDS Published in the Morbidity and Mortality Weekly Report , June 1981 through February 1986 (Springfield, Va.: National Technical Information Service, 1986), 1-2 (hereafter cited as MMWR ). For Shilts's account of the background to the MMWR report, see Band Played On , 63, 66-69. [BACK]
8. MMWR , 2-4.
9. Ibid., 2. [BACK]
8. MMWR , 2-4.
9. Ibid., 2. [BACK]
10. David G. Ostrow, "Homosexuality and Sexually Transmitted Diseases," in Sexually Transmitted Diseases , ed. Yehudi M. Felman (New York: Churchill Livingston, 1986), 210. See, too, M. T. Schreeder et al., "Hepatitis B in Homosexual Men: Prevalence of Infection and Factors Related to Transmission," Journal of Infectious Diseases 146 (1982): 7-15. [BACK]
11. William W. Darrow, "Sexual Behavior in America," in Sexually Transmitted Diseases , ed. Felman, 269-271. [BACK]
12. Terry Alan Sandholzer, "Factors Affecting the Incidence and Management of Sexually Transmitted Diseases in Homosexual Men," in Sexually Transmitted Diseases in Homosexual Men , ed. David G. Ostrow, Terry Alan Sandholzer, and Yehudi M. Felman (New York: Plenum Medical Book, 1983), 5. [BACK]
13. For "pathetic promiscuity" see "No Need for Panic About AIDS," Nature 302 (1983): 749. It is worth noting that the CDC never used the words "promiscuous" or "promiscuity" to describe homosexual life-styles. [BACK]
14. See House Subcommittee on Consumer Protection and Finance, Committee on Interstate and Foreign Commerce, Hearings on Legionnaires ' Disease , 23-24 November 1976, 94th Cong. For a defense of the CDC, see Barbara J. Culliton, "Legion Fever: Postmortem on an Investigation that Failed," Science 194 (1976): 1025-1027. [BACK]
15. Stephen Schultz, M.D., deputy commissioner, New York City Department of Health, former EIS officer, personal communication with the author, 22 July 1987. [BACK]
16. House Subcommittee on Health and the Environment, Committee on Energy and Commerce, Hearings on Kaposi ' s Sarcoma and Related Opportunistic Infections , 13 April 1982, 8 (hereafter, Hearings ). [BACK]
20. Centers for Disease Control Task Force on Kaposi's Sarcoma and Opportunistic Infections, "Epidemiologic Aspects of the Current Outbreak of Kaposi's Sarcoma and Opportunistic Infections," New England Journal of Medicine 302 (1982): 248 (hereafter, "Task Force Report"). [BACK]
21. Hearings , 9-10. Also, Shilts, Band Played On , 80-81. [BACK]
22. Hearings , 10; "Task Force Report," 252; see, too, Gerald Astor, The Disease Detectives (New York: New American Library, 1983), 56. [BACK]
23. "Task Force Report," 252. [BACK]
24. Astor, Disease Detectives , 56. [BACK]
25. MMWR , 4-5. [BACK]
26. Kenneth B. Hymes et al., "Kaposi's Sarcoma in Homosexual Men—A Report on Eight Cases," Lancet 2 (1981): 508-600. [BACK]
27. Michael S. Gottlieb et al., " Pneumocystis Carinii Pneumonia and Mucosal Candidiasis in Previously Healthy Homosexual Men," New England Journal of Medicine 305 (1981): 1430. [BACK]
28. "Task Force Report." In the early, or descriptive, stages of epidemiological investigations, studies are made of the frequency of the disease in various places, among different groups of people, and, if possible, during different periods of time. Knowledge of the relative frequency of a disease in specific groups gives rise to hypotheses and analytic case-control or cohort studies. See Judith Mausner and Shira Kramer, Epidemiology—An Introductory Text , 2d ed. (Philadelphia: W. B. Saunders, 1974), 119-153. [BACK]
29. Henry Masur et al., "An Outbreak of Community-Acquired Pneumocystis Carinii Pneumonia," New England Journal of Medicine 305 (1981): 1431-1438. The CDC published its first report of a heterosexual case, a woman, in August 1981; see MMWR , 4-5. [BACK]
30. David T. Durack, "Opportunistic Infections and Kaposi's Sarcoma in Homosexual Men," New England Journal of Medicine 305 (1981): 1466. [BACK]
31. A model can be defined as "a description, a collection of statistical data, or an analogy used to help visualize often in a simplified way something that cannot be directly observed"; see Webster ' s Third New International Dictionary , unabr. (1986), s.v. "model." According to Susser, a model is a system reduced to a set of related variables for the purpose of prediction or representation; see Mervyn Susser, Causal Thinking in the Health Sciences (New York: Oxford University Press, 1973), 32. In the present essay, the models discussed perform a representational function in that they "represent existing or postulated relationships in simplified form" (ibid., 33). [BACK]
32. James J. Goedert et al., "Amyl Nitrite May Alter T Lymphocytes in Homosexual Men," Lancet 1 (1982): 412-416. [BACK]
33. The authors found that seven of the eight volunteers who were frequent amyl nitrite users, but only one nonuser, had a reduced number of T4 cells and
an inverted ratio of T4 to T8 cells, indicating immunosuppression. CMV antibodies were at a similar (high) level in the user and nonuser groups, and were not correlated with the low T4/T8 ratios, suggesting that repeated CMV infection does not uniformly cause immunosuppression. Unwilling to jettison the CMV hypothesis, the investigators postulated instead a joint effect: "These data provide preliminary evidence that [amyl nitrite]-induced immunosuppression, together with repeated CMV exposure, predisposes homosexual men to P . carinii pneumonia and to KS. . . . Further study is needed to disentangle the roles of [amyl nitrite], viruses, and other factors in the development of immunodeficiency, opportunistic infections, and KS" (ibid., 415). [BACK]
34. As a causal factor, nitrite continues to attract research attention. A CDC study found that nitrite inhalants were not a cause of immunosuppression in AIDS, but would not rule out nitrite as a cofactor for some AIDS-associated illnesses; see MMWR , 44. Other studies that could not find a significant association between nitrite and illnesses associated with HIV infection include: Michael Marmor et al., "Kaposi's Sarcoma in Homosexual Men," Annals of Internal Medicine 100 (1984): 809-815; Harold W. Jaffe et al., "National Case-Control Study of Kaposi's Sarcoma and Pneumocystis Carinii Pneumonia in Homosexual Men: Part 1, Epidemiologic Results," Annals of Internal Medicine 99 (1983): 145-151; James J. Goedert et al., "Effect of T4 Count and Cofactors on the Incidence of AIDS in Homosexual Men," New England Journal of Medicine 316 (1987): 61-66.
Those who do find an association include Michael Marmor et al., "Risk Factors for Kaposi's Sarcoma in Homosexual Men," Lancet 1 (1982): 1083-1087; Mads Melbeye et al., "Seroepidemiology of HTLV-III Antibody in Danish Homosexual Men: Prevalence, Transmission and Disease Outcome," British Medical Journal 289 (1984): 573-575; Usha Mathur-Wagh, Donna Mildvan, and Ruby T. Senie, "Follow-up at Four and a Half Years on Homosexual Men with Generalized Lymphadenopathy" [letter], New England Journal of Medicine 313 (1985): 1542-1543; and Harry W. Haverkos et al., "Disease Manifestation among Homosexual Men with Acquired Immunodeficiency Syndrome: A Possible Role of Nitrites in Kaposi's Sarcoma," Sexually Transmitted Diseases 12 (1985): 203-208. [BACK]
35. Marmor et al., "Risk Factors," 1083-1087. With great care, the researchers assessed the different pathways by which nitrites might be linked to the new disorder. Amyl nitrite could itself be an immunosuppressor, leaving the body susceptible to a cancer-causing sexually transmitted disease. Alternatively, multiple and repetitive infections of sexually transmitted diseases might result in immunosuppression, thereby allowing a carcinogenic agent (possibly amyl nitrite) to act on the body. A third possibility was that amyl nitrite inhalation was not a cause so much as a marker for a true or "confounding" causal variable, perhaps an oncogenic virus, transmitted sexually.
In a follow-up study (Michael Marmor et al., "Kaposi's Sarcoma in Homosexual Men," 809-815) that integrated questionnaire and laboratory data, investigators found, using stepwise logistic regression analysis, that nitrite use was no longer statistically significant after CMV or the number of partners per month with whom one had anal-receptive intercourse or "fisting" were entered
into the model. To explain immunodeficiency and KS in the cases, Marmor and his colleagues posited an unknown infectious agent transmitted through anal-genital intercourse and "fisting." In this hypothesis, CMV either jointly caused immunosuppression with the unknown agent or bore a responsibility for the development of KS in the compromised host. The authors suggest that if further studies confirmed the hypothesis of disease transmission through anal-genital intercourse, then preventive methods might follow which could decelerate the spread of the new disorder within the gay community. [BACK]
36. Harold W. Jaffe et al., "National Case-Control Study," 145-151. For background to the study, see Shilts, Band Played On , 96-97, 106-107, 125. [BACK]
37. Martha F. Rogers et al., "National Case-Control Study of Kaposi's Sarcoma and Pneumocystis Carinii Pneumonia in Homosexual Men: Part 2, Laboratory Results," Annals of Internal Medicine 99 (1983): 151. [BACK]
38. Michael Marmor et al., "Risk Factors for Kaposi's Sarcoma in Homosexual Men," Lancet 1 (1982): 1083-1087. [BACK]
39. Webster ' s Third New International Dictionary , unabr., s.v. "promiscuity," s.v. "irregular." [BACK]
40. Allan M. Brandt, No Magic Bullet (New York: Oxford University Press, 1985), 157. Also Gerald M. Oppenheimer, "Historical Models and the Social Definition of AIDS" (Paper presented at the 101st Annual Meeting of the American Historical Association, Chicago, 27-30 December 1986); and Cindy Patton, Sex and Germs (Boston: South End Press, 1985), 11-12. [BACK]
41. Wolf Szmuness et al., "On the Role of Sexual Behavior in the Spread of Hepatitis B Infection," Annals of Internal Medicine 83 (1975): 491. [BACK]
42. R. N. Thin and D. M. Smith, "Some Characteristics of Homosexual Men," British Journal of Venereal Diseases 52 (1976): 164. [BACK]
43. R. R. Willcox, "The Rectum as Viewed by a Venereologist," British Journal of Venereal Diseases 57 (1981): 1. [BACK]
44. Phyllis Shaw, "Medical Sequelae of a Lifestyle," Journal of the American Medical Women ' s Association 37 (1982): 199-200.
45. Ibid., 200.
46. Ibid. [BACK]
44. Phyllis Shaw, "Medical Sequelae of a Lifestyle," Journal of the American Medical Women ' s Association 37 (1982): 199-200.
45. Ibid., 200.
46. Ibid. [BACK]
44. Phyllis Shaw, "Medical Sequelae of a Lifestyle," Journal of the American Medical Women ' s Association 37 (1982): 199-200.
45. Ibid., 200.
46. Ibid. [BACK]
47. Dennis J. McShane and Neil R. Schram, letter to the editor, JAMA 251 (1984): 341. [BACK]
48. MMWR , 5. [BACK]
49. Masur, "An Outbreak of Community-Acquired Pneumocystis Carinii Pneumonia." [BACK]
50. MMWR , 10. [BACK]
51. Harold M. Ginzburg, "The Human T-Cell Lymphotropic Virus, Type III (HTLV-III) and Drug Abusers" (Paper prepared for the Committee on a National Strategy for AIDS, Institute of Medicine, National Academy of Sciences), 14. See, too, Don C. Des Jarlais and Samuel R. Friedman, "AIDS Among Intravenous Drug Users: Current Research in Epidemiology, Natural History and Prevention Strategies," also prepared for the Committee on a National Strategy for AIDS, as well as Don C. Des Jarlais et al., "Kaposi's Sarcoma among Four Different AIDS Risk Groups," [letter] New England Journal of Medicine 310 (1984): 119, and Don C. Des Jarlais et al., "Heterosexual Partners: A Large
Risk Group for AIDS," Lancet 2 (1984): 1346-1347. For articles on women and AIDS published prior to 1984 (when the virus model superseded that of the "life-style" model in importance), see Henry Masur et al., "Opportunistic Infection in Previously Healthy Women," Annals of Internal Medicine 97 (1982): 533-539, and Carol Harris et al., "Immunodeficiency in Female Sexual Partners of Men with Acquired Immunodeficiency Syndrome," New England Journal of Medicine 308 (1983): 1181-1184. [BACK]
52. Don C. Des Jarlais, Ph.D., coordinator for AIDS Research, New York State Division of Substance Abuse Services, personal communication with the author, 15 January 1988. As exceptions to that decision, NIDA funded some internal biomedical work in 1983, the same year it made a single extramural award to New York State to study risk factors for AIDS in drug users. In 1985 NIDA reversed itself and began to fund AIDS research extensively. [BACK]
53. Stephen Schultz, M.D., personal communication with the author, 22 July 1987. [BACK]
54. Don C. Des Jarlais, personal communication with the author, 15 January 1988.
55. Ibid. [BACK]
54. Don C. Des Jarlais, personal communication with the author, 15 January 1988.
55. Ibid. [BACK]
56. Schultz, personal communication with the author, 22 July 1987.
57. Ibid. [BACK]
56. Schultz, personal communication with the author, 22 July 1987.
57. Ibid. [BACK]
58. Catherine Macek, "Acquired Immunodeficiency Syndrome Cause(s) Still Elusive," JAMA 248 (1982): 1426. [BACK]
59. MMWR , 32-34.
60. Ibid., 12-13.
61. Ibid., 14-15, 24-26.
62. Ibid., 47.
63. Ibid., 26-27. For an exploration of the events leading up to the MMWR report of 4 March 1983, see Shilts, Band Played On , 95, 116, 169-171, 177, 206-207, 226. [BACK]
59. MMWR , 32-34.
60. Ibid., 12-13.
61. Ibid., 14-15, 24-26.
62. Ibid., 47.
63. Ibid., 26-27. For an exploration of the events leading up to the MMWR report of 4 March 1983, see Shilts, Band Played On , 95, 116, 169-171, 177, 206-207, 226. [BACK]
59. MMWR , 32-34.
60. Ibid., 12-13.
61. Ibid., 14-15, 24-26.
62. Ibid., 47.
63. Ibid., 26-27. For an exploration of the events leading up to the MMWR report of 4 March 1983, see Shilts, Band Played On , 95, 116, 169-171, 177, 206-207, 226. [BACK]
59. MMWR , 32-34.
60. Ibid., 12-13.
61. Ibid., 14-15, 24-26.
62. Ibid., 47.
63. Ibid., 26-27. For an exploration of the events leading up to the MMWR report of 4 March 1983, see Shilts, Band Played On , 95, 116, 169-171, 177, 206-207, 226. [BACK]
59. MMWR , 32-34.
60. Ibid., 12-13.
61. Ibid., 14-15, 24-26.
62. Ibid., 47.
63. Ibid., 26-27. For an exploration of the events leading up to the MMWR report of 4 March 1983, see Shilts, Band Played On , 95, 116, 169-171, 177, 206-207, 226. [BACK]
64. W. Thomas London and Baruch S. Blumberg, "Comments on the Role of Epidemiology in the Investigation of Hepatitis B Virus," Epidemiologic Reviews 7 (1985): 59-79. [BACK]
65. MMWR , 33. [BACK]
66. Jaffe et al., "National Case-Control Study," 149. [BACK]
67. MMWR , 32.
68. Ibid., 45. Whatever the scientific basis for these "high-risk groups," their existence was also open to negotiation. For a short discussion of the successful pressure applied by the Haitian government to have Haitians dropped as a risk group, see Dennis Altman, AIDS in the Mind of America (Garden City, N.Y.: Anchor/Doubleday, 1986), 71-73. [BACK]
67. MMWR , 32.
68. Ibid., 45. Whatever the scientific basis for these "high-risk groups," their existence was also open to negotiation. For a short discussion of the successful pressure applied by the Haitian government to have Haitians dropped as a risk group, see Dennis Altman, AIDS in the Mind of America (Garden City, N.Y.: Anchor/Doubleday, 1986), 71-73. [BACK]
69. Abram S. Benenson, ed., Control of Communicable Diseases in Man , 12th ed. (Washington, D.C.: APHA, 1975). [BACK]
70. For the newly discovered and defined groups at greater risk, Haitians and hemophiliac patients, high-risk group designation marked them with a double shame. In addition to being associated with a fatal disease that threatened the blood supply, they were associated with a "promiscuous" population of gays and intravenous drug users. Though Haitians were eventually dropped
by the CDC as a high-risk group, they suffered the consequences of stigmatization, as do hemophiliac patients, who experience what one of them dubbed "hemophobia" (see Patton, Sex and Germs , 23). Ironically, the ones who may have gained something by risk-group designation were intravenous drug users who, for the first time, changed from being a parenthetical clause to becoming a segment of the explanatory model. [BACK]
71. Michael S. Gottlieb et al., "Gay-Related Immunodeficiency (GRID) Syndrome: Clinical and Autopsy Observations," Clinical Research 30 (1982): 349A. [BACK]
72. Arye Rubinstein et al., "Acquired Immunodeficiency with Reversed T4 / T8 Ratios in Infants Born to Promiscuous and Drug-Addicted Mothers," JAMA 249 (1983): 2345-2356.
73. Ibid., 2351. [BACK]
72. Arye Rubinstein et al., "Acquired Immunodeficiency with Reversed T4 / T8 Ratios in Infants Born to Promiscuous and Drug-Addicted Mothers," JAMA 249 (1983): 2345-2356.
73. Ibid., 2351. [BACK]
74. James Oleske et al., "Immune Deficiency Syndrome in Children," JAMA 249 (1983): 2347-2348. [BACK]
75. Anthony S. Fauci, "The Acquired Immune Deficiency Syndrome: The Ever-Broadening Clinical Spectrum," JAMA 249 (1983): 2375-2376. Also William A. Check, "Beyond the Political Model of Reporting: Non-Specific Symptoms in Media Communication About AIDS" (Paper prepared for the Committee on a National Strategy for AIDS, Institute of Medicine, National Academy of Sciences). [BACK]
76. Jean L. Marx, "A New Disease Baffles Medical Community," Science 217 (1982): 619; Gallo, "The AIDS Virus," 48. James W. Curran was showing slides demonstrating the plausibility of a viral etiology at scientific meetings as early as February 1982 (Pauline Thomas, M.D., director of AIDS surveillance, New York City Department of Health, personal communication with the author, 28 July 1987). [BACK]
77. Science 224 (1984): 497-508. [BACK]
78. That scientists concentrated on the microbe and its pathogenesis is not surprising, given the expectations raised by the new discovery and the complex scientific work required to exploit its potential. The extent to which the traditional germ theory's agent-host diad replaced the multifactorial model is noteworthy. [BACK]
79. Eve K. Nichols, Mobilizing Against AIDS : The Unfinished Story of a Virus (Cambridge: Harvard University Press, 1986). [BACK]
80. Catherine Macek, "Acquired Immunodeficiency Syndrome Cause(s) Still Elusive," 1425. [BACK]
81. James J. Goedert et al., "Effect of T4 Count and Cofactors on the Incidence of AIDS in Homosexual Men Infected with Human Immunodeficiency Virus," JAMA 257 (1987): 334. [BACK]
82. Institute of Medicine and National Academy of Sciences, Confronting AIDS (Washington, D.C.: National Academy Press, 1986), 45.
83. Ibid., 193, 201. [BACK]
82. Institute of Medicine and National Academy of Sciences, Confronting AIDS (Washington, D.C.: National Academy Press, 1986), 45.
83. Ibid., 193, 201. [BACK]
84. P. M. Feorino et al., "Lymphadenopathy-Associated Virus Infection of a Blood Donor-Recipient Pair with Acquired Immunodeficiency Syndrome," Science 225 (1984): 70-71.
85. Ibid.; Robert C. Gallo et al., "Frequent Detection and Isolation of Cytopathic Retroviruses (HTLV-III) from Patients with AIDS and at Risk for AIDS," Science 224 (1984): 500-502; M. G. Sarngadharan et al., "Antibodies
Reactive with Human T-Lymphotropic Retroviruses (HTLV-III) in the Serum of Patients with AIDS," Science 224 (1984): 506-508; see, too, Bijan Safai et al., "Seroepidemiological Studies of Human T-Lymphotropic Retrovirus Type III in Acquired Immunodeficiency Syndrome," The Lancet 1 (1984): 1438-1440. [BACK]
84. P. M. Feorino et al., "Lymphadenopathy-Associated Virus Infection of a Blood Donor-Recipient Pair with Acquired Immunodeficiency Syndrome," Science 225 (1984): 70-71.
85. Ibid.; Robert C. Gallo et al., "Frequent Detection and Isolation of Cytopathic Retroviruses (HTLV-III) from Patients with AIDS and at Risk for AIDS," Science 224 (1984): 500-502; M. G. Sarngadharan et al., "Antibodies
Reactive with Human T-Lymphotropic Retroviruses (HTLV-III) in the Serum of Patients with AIDS," Science 224 (1984): 506-508; see, too, Bijan Safai et al., "Seroepidemiological Studies of Human T-Lymphotropic Retrovirus Type III in Acquired Immunodeficiency Syndrome," The Lancet 1 (1984): 1438-1440. [BACK]
86. Feorino et al., "Lymphadenopathy," 69-72; Harold W. Jaffe et al., "Infection with HTLV-III/LAV and Transfusion-Associated Acquired Immunodeficiency Syndrome," JAMA 254 (1985): 770-773; Mads Melbye et al., "Seroepidemiology," 573-575. [BACK]
87. MMWR , 63.
88. Ibid. [BACK]
87. MMWR , 63.
88. Ibid. [BACK]
89. See, for example, Institute of Medicine and National Academy of Science, Confronting AIDS , viii-ix. [BACK]
90. Cladd E. Stevens et al., "Human T-Cell Lymphotropic Virus Type III Infection in a Cohort of Homosexual Men in New York City," JAMA 255 (1986): 2167-2172.
91. Ibid., 2170. [BACK]
90. Cladd E. Stevens et al., "Human T-Cell Lymphotropic Virus Type III Infection in a Cohort of Homosexual Men in New York City," JAMA 255 (1986): 2167-2172.
91. Ibid., 2170. [BACK]
92. Godfried J. P. van Griensven et al., "Risk Factors and Prevalence of HIV Antibodies in Homosexual Men in the Netherlands," American Journal of Epidemiology 125 (1987): 1048-1057. [BACK]
93. Warren Winkelstein, Jr., et al., "Sexual Practices and Risk of Infection by the Human Immunodeficiency Virus," JAMA 257 (1987): 321-325. [BACK]
94. The sample was of single men aged twenty-five to fifty-four years residing in the nineteen census tracts with the highest rates of AIDS in San Francisco. Unfortunately, 40 percent of those selected refused to participate, making those who agreed quasi volunteers. The total cohort obtained consisted of 1,034 individuals, of whom 809 were homosexual/bisexual men. [BACK]
95. For example, a study by Harold W. Jaffe et al., "The Acquired Immunodeficiency Syndrome in a Cohort of Homosexual Men," Annals of Internal Medicine 103 (1985): 210-214, which sampled a cohort of male homosexual STD patients attending San Francisco City Clinic, found that 67.4 percent tested positive for HIV antibodies in 1984. The Winkelstein study, which attempted to generate a random sample of the San Francisco gay male population in nineteen census tracts, found that a smaller proportion, 48.5 percent, had tested positive in 1984-1985.
The reported prevalence of HIV infection varies by place, time, and person. The Multicenter AIDS Cohort Study reported seropositivity for homosexual men in Los Angeles, Chicago, Baltimore/Washington, and Pittsburgh in 1984-1985 to be 51, 43, 31, and 21 percent respectively, with recruitment processes differing from center to center. See Richard A. Kaslow et al., "The Multicenter AIDS Cohort Study: Rationale, Organization and Selected Characteristics of Participants," American Journal of Epidemiology 126 (1987): 310-318. Among U.S. hemophiliacs, 70-85 percent were infected with HIV by the end of 1984. See Gene A. McGrady, Janine M. Mason, and Bruce L. Evatt, "The Course of the Epidemic of Acquired Immunodeficiency Syndrome in the United States Hemophilia Population," American Journal of Epidemiology 126 (1987): 25-30. [BACK]
96. Van Griensven et al., "Risk Factors," 1052-1056; Winkelstein et al., "Sexual Practices," 324-325.
97. Ibid., 325. [BACK]
96. Van Griensven et al., "Risk Factors," 1052-1056; Winkelstein et al., "Sexual Practices," 324-325.
97. Ibid., 325. [BACK]
98. Jaffe et al., ''Cohort," 210-211. [BACK]
99. Approximately a third of the sample refused to participate. [BACK]
100. Mads Melbye et al., "Long-Term Seropositivity for Human T-Lymphotropic Virus Type III in Homosexual Men without the Acquired Immunodeficiency Syndrome: Development of Immunologic and Clinical Abnormalities," Annals of Internal Medicine 104 (1986): 496-500. [BACK]
101. B. Frank Polk et al., "Predictors of the Acquired Immunodeficiency Syndrome Developing in a Cohort of Seropositive Homosexual Men," New England Journal of Medicine 316 (1987): 61-66.
102. Ibid., 65. [BACK]
101. B. Frank Polk et al., "Predictors of the Acquired Immunodeficiency Syndrome Developing in a Cohort of Seropositive Homosexual Men," New England Journal of Medicine 316 (1987): 61-66.
102. Ibid., 65. [BACK]
103. James J. Goedert et al., "Three-Year Incidence of AIDS in Five Cohorts of HTLV-III-Infected Risk Group Members," Science 231 (1986): 992-995.
104. Ibid., 994. [BACK]
103. James J. Goedert et al., "Three-Year Incidence of AIDS in Five Cohorts of HTLV-III-Infected Risk Group Members," Science 231 (1986): 992-995.
104. Ibid., 994. [BACK]
105. Confronting AIDS , 193. [BACK]
106. Thomas C. Quinn et al., "Serologic and Immunologic Studies in Patients with AIDS in North America and Africa," JAMA 257 (1987): 2617-2621. [BACK]
107. L.-J. Eales et al., "Association of Different Allelic Forms of Group Specific Component with Susceptibility to and Clinical Manifestation of Human Immunodeficiency Virus Infection," Lancet 1 (1987): 999-1002. [BACK]
108. Donald P. Francis and James Chin, "The Prevention of Acquired Immunodeficiency Syndrome in the United States," JAMA 257 (1987): 1359.
109. Ibid. [BACK]
108. Donald P. Francis and James Chin, "The Prevention of Acquired Immunodeficiency Syndrome in the United States," JAMA 257 (1987): 1359.
109. Ibid. [BACK]
110. Quinn et al., "Serologic," 2617, 2620. [BACK]
111. Francis and Chin, "Prevention," 1359-1361. [BACK]
112. See, for example, John L. Martin, "AIDS Risk-Reduction Recommendations and Sexual Behavior Patterns among Gay Men: A Multifactorial Categorical Approach to Assessing Change," Health Education Quarterly 13 (1986): 347-358. [BACK]
113. Warren Winkelstein, Jr., et al., "The San Francisco Men's Health Study: III, Reduction in Human Immunodeficiency Virus Transmission amon g Homosexual/Bisexual Men, 1982-1986," American Journal of Public Health 77 (1987): 686-689. [BACK]
114. John L. Martin, "The Impact of AIDS on Gay Male Sexual Behavior Patterns in New York City," American Journal of Public Health 77 (1987): 578-581. [BACK]
115. John B. McKinlay and Sonja M. McKinlay, "The Questionable Contribution of Medical Measures to the Decline of Mortality in the United States in the Twentieth Century," Milbank Memorial Fund Quarterly 55 (1977): 425. I want to thank Daniel M. Fox for bringing this article and its hypothesis to my attention. [BACK]
116. Thomas McKeown, R. G. Record, and R. D. Turner, "An Interpretation of the Decline of Mortality in England and Wales during the Twentieth Century," Population Studies 29 (1975): 391-422. [BACK]