Condom Safe prevent HIV AIDS?

Whenever I talk to young people in Africa, India or Europe about AIDS I find the same thing: they think that using a condom will prevent them from getting HIV. The truth is that it may greatly reduce the risk, but I wouldn’t trust my life to a condom.

As every doctor knows, condoms are unreliable. If a hundred couples use condoms for contraception, up to fifteen of them could be in clinics each year asking for abortions. If you are about to take a risk, you should use one, it could save your life, but don’t kid yourself it’s totally safe. For a start they vary in quality. A survey of 50,000 condoms from 110 brands on sale in Europe, Brazil, Indonesia and Thailand showed only 3% to be `very good’ (strength, aging, no holes), 48% `poor’ or `very poor’. No condoms on sale in Italy, Portugal or Spain were `very good’.

In one UK survey, holes were found in up to thirty-two out of a hundred condoms of the least reliable makes. These holes were gross defects, not microscopic holes seen in some latex (5 micron, HIV is 0.1 micron), which are worrying but probably far less significant. The British Standards Institute permits up to three out of a hundred to have holes in them when they leave the factory. In the US, government standards allow only four condoms out of every thousand to have leaks. But users still experience a failure rate of between 3% and 15%, which is the percentage of women who have an unwanted pregnancy using this method of birth control over a year.

A spokesman from the London Rubber Company (Durex) admitted that if incorrectly used, the failure rate of condoms could be anything from 25% up to 100%, and there are real problems with teaching people how to use them—not least because of illiteracy.

The condom is the least reliable contraceptive in wide use—it’s as bad as the diaphragm or cap with spermicide. Many violently disagree. They say it is a superb contraceptive, it is people who are unreliable: they put it on too late or inside out, tear it, forget it, let it fall off. They say people are unreliable but the condom is reliable, if properly used. It is easy to have an accident with a condom. Condoms are unreliable compared to, for example, the pill. That is why the pill is so popular—not just because it is a more convenient method.

Things are worse than they appear from the pregnancy rates. Out of 100 couples, ten will have great difficulty in conceiving anyway. Five will probably never be able to conceive for various reasons, including previous infections with sexually-transmitted diseases.

After four months of trying to conceive, only about half of an average group of women will succeed in becoming pregnant. If they used a perfectly safe method two out of three times that they had intercourse, it would take a year for half to become pregnant. If they used the method for ten out of twelve months of the year, then twenty-five out of a hundred could be expected to get pregnant in a year. If they had unprotected sex for one month a year and used the method for eleven months, then it could be expected that over twelve would become pregnant in a year.

What this means is that if condoms produce a failure rate of around twelve in a hundred per year, then they must be leaking often. It is about the same thing as having intercourse for a whole month without any protection at all but taking the pill the rest of the year. Somehow or other secretions from a man and a woman are very frequently meeting each other.

This conclusion is confirmed by a study of 2,000 acts of intercourse by eighty heterosexual and seven homosexual couples, with fourteen types of condoms. The overall failure rate from slippage or rupture was 11.3%, even higher than the one in twelve (8.3%) theoretical rate predicted above.

Think about it: a woman can only become pregnant on three days a month—while ovulating and shortly afterwards. After a single accident with a condom there is only a one in ten or so chance of it being a fertile day anyway. Even if it were, pregnancy may not follow. However, it is possible to catch HIV infection every day of the month. The overall risk of pregnancy after one episode of unprotected sex is 2–4%; the risk of HIV from an infected partner after unprotected vaginal sex is probably 0.5%, or 1 in 200 in the absence of other sexually-transmitted diseases. An increasing number of people have become pregnant because they switched from a more reliable contraceptive to the condom because of AIDS.

If up to fifteen out of a hundred couples each year are actually managing to conceive despite condom use, there must be frequent accidents—probably one time out of twelve, from the figures above. If you are having sex regularly with an infected person, it is like throwing dice. Every time you throw a twelve is how often the condom has let you down. Would you trust your life to a condom? Remember that one episode of unprotected sex can be enough to infect you. Over the next few years there will be a growing number of angry men and women who have become infected, despite their using a condom, having thought they were safe.

Various reports have been published on couples using condoms where only one partner is positive. In one study, up to a quarter of the partners became infected with HIV in only one to three years, despite use of the condom. Others may say these people were careless. All I am saying is that if correctly used, the condom can be a reliable contraceptive and will almost certainly reduce enormously your risk of getting AIDS, but the reports show that it is hard to use safely.

Another study of partners using condoms suggests that the risk of catching HIV is reduced by 85%. That sounds excellent, but it is not. If you persist in sleeping regularly with someone who is positive or with numbers of unknown people who are possibly positive, then eventually, condom or no condom, you may get AIDS. Vaginal or anal sex using a condom is not a low-risk or no-risk activity. It carries a medium risk at best.

World Health Organisation: `The most effective way to prevent sexual transmission of HIV is to abstain, or for two people who are not infected to be faithful to one another. Alternatively, the correct use of a condom will reduce the risk significantly.’

World AIDS Day 1991 and 1992.

A calculation can be as follows. Let us assume the estimate many use is correct that the risk of transmission is roughly one in 200 per episode of unprotected sex with an infected partner. Let us assume 95% protection from the condom for the sake of argument, or a twenty-fold risk reduction. This would give a total risk of one in 4,000 per episode of protected sex. Let us assume a couple has sex just under three times a week, or 150 times a year. The risk of the partner becoming infected in one year despite using a condom then becomes 3.7% or almost 20% in five years. If we only rate the condom protection as 90% instead of 95%, then the five-year infection rate could rise to 40% or 7.4% per year.

How do these theoretical estimates fit with experience? An Italian study of almost 400 women with infected partners found the following:

1.2% always using condoms were infected per year overall.
7.3% not using condoms regularly infected per year overall.
12.3% not using condoms regularly with highly-infectious partners became infected per year.
2.6% not using condoms regularly with partners of low infectiousness became infected per year.

Partners were considered highly infectious if their white cell (CD4) counts were low or if they were becoming unwell. Inconsistent condom use increased risk around six times. Anal sex doubled the risk. AIDS in the partner trebled the risk.

In another study, almost 200 women with HIV-infected haemophiliac partners were studied. Between 1985 and 1992, one in ten became infected. The risk of infection increased with time as the men deteriorated. It is very difficult to obtain meaningful figures for these risks because there are a number of variables: stage of infection, sexual practice, presence of other sex diseases, frequency of intercourse, frequency of condom use. For this reason different studies can give varying results.

A combined European study of 563 heterosexuals with infected partners in stable relationships from nine countries was carried out between 1987 and 1991. People were enrolled in the study month by month so some were part of it for only a short time. Altogether, 12% of the men and 20% of the women became infected. Risk increased to men with stage of illness, and intercourse during menstruation. For women the risk increased with her age, stage of the man’s infection and anal intercourse. None of twenty-four couples always using condoms became infected.

We do not know what the risk is from a single sexual contact with someone who is positive. It certainly depends on many other factors such as whether either partner also has gonorrhoea or syphilis. Any sores will be full of white cells and virus. Circumcision reduces risk. It seems people are most infectious for the first twelve to fifteen weeks after infection with HIV, and then years later when beginning to feel unwell again. Some individuals may be more susceptible than others genetically. In conclusion, it seems the risk from a single accident with a condom or a single unprotected contact is small, but some have become infected this way.

Condom manufacturers’ literature states that condoms are designed for vaginal sex only and are not suitable for protection from HIV transmission by the anal route. Particularly hazardous is the use of oil-based lubricants as these rot the rubber in minutes. Recently, some new `extra strong’ condoms have been marketed with lower failure rates for anal intercourse.

What is safe sex? (return to index)

So what is the correct health message? It is that condoms do not make sex safe, they simply make it safer. Safe sex is sex between two partners who are not infected. This means a partnership between two people who are uninfected—perhaps they were virgins—and who now remain faithful to each other for life and do not inject drugs. If you are going to have sex in an unsafe situation you are foolish indeed not to use a condom, and you must use it very carefully every single time. But don’t kid yourself that you will never get AIDS. (See previous chapter for further background on risks.)

Because condom use also provides a measure of protection against other sexually-transmitted diseases, and because genital ulceration caused by them makes the body so vulnerable to HIV, it may be that a key part of condom protection is reducing the incidence of ulceration. This is so particularly in developing countries.

How to use a condom more safely (return to index)

A condom is tightly rolled up. Make sure it is the right way around. It will only unroll one way. If you have sex in the dark you may need to turn the light on. The teat at the end is there to collect all semen and fluids from the man. This needs to be squeezed empty of air or the condom may leak. With one hand holding the teat, the other is used to roll the condom gently over the entire length of the erect penis. This needs to happen soon after the man is aroused for two reasons: first a small amount of fluid emerges from the end of the penis during arousal as part of the body’s natural lubrication before the man enters the woman. This can be full of virus. Secondly, a woman produces a lot of secretions during arousal for lubrication. These may also contain virus if a woman is infected. The early use of the condom is to keep any genital contact separate from the start.

Wear and tear (return to index)

A woman usually takes longer than a man to become fully aroused and will usually find things more satisfying if there is continuing caressing before her partner enters her. During this period a condom may unroll partly or fall off altogether. It may also suffer general wear and tear. It can snag on a woman’s jewellery or on her fingernails. This can happen if, as advocates of condoms suggest, the woman helps the man put on the condom as part of lovemaking. Damage is usually obvious early on. The real danger time can be when a woman helps her partner come inside her. Fingernails and jewellery can cause a minute tear in the condom which enlarges during intercourse. The result is discovered on withdrawal.

Rapid exit (return to index)

Withdrawal must be prompt for two reasons: first there is a small risk of semen leakage along the shaft of the penis, especially if the teat was full of air. Secondly, as soon as a man has reached climax, the penis starts to soften and what was a tight fit becomes a very loose fit. Condoms can easily leak or slip off inside a woman. The condom end must be held gently as the man withdraws.

Most people dislike using condoms (return to index)

A huge international campaign has been carried out to try and make the condom more acceptable. When used carefully as above there is no doubt in many couples’ minds that it is disruptive and they dislike it: it is a real turn-off. It is the same in countries like the US or African nations. What’s so romantic about a condom? After all, that is one reason why people stopped using condoms when the pill came along. The other was unreliability and constant fear of pregnancy. It was the pill, not the condom, that brought about the so-called sexual revolution of the 1960s.

1.´To put it on carefully takes precious seconds out of a continuing experience. Some men find that by the time they have got it on so they are happy it is comfortable (may need a couple of tries), their erection has disappeared. A woman is left hanging around and rapidly loses her momentum. Trying to find where you put one, opening the packet, and getting it on correctly can be a joke, but it is disruptive.

2.´Making sure it does not roll off can cause tension in the pre-intercourse stage of lovemaking.

3.´Checking it is still intact immediately before entry causes further delay.

4.´Many men say that the layer of rubber reduces what they can feel (although some who tend to ejaculate too early may find that an advantage). Some women dislike the thought of a piece of rubber in such a personal area.

5.´For many couples a central part of their celebration of oneness is to be lying together, with the man inside, immediately after both are satisfied. Many people enjoy being able to `cool off’ in each other’s arms like this. Correct condom use requires the man to withdraw immediately. Some see it as a rather abrupt and savage end to a marvellous experience.

6.´Some find disposing of the used condom rather revolting. The best method is to tie it up carefully, wrap it up in toilet paper, and flush it away.

In addition there is another vital factor: the very fact that a condom is being used, other than merely to provide some protection against pregnancy, implies slight anxiety about whether a partner is infected. This can cause tension.

Are people using condoms more? (return to index)

It is extremely difficult for a woman who has no boyfriend at the moment to buy a packet of condoms and keep one in her bag, because in doing so she is having to admit to herself and a prospective partner that she plans to have sex soon with someone perhaps she hardly knows. When she goes out for the evening it can be hard for her to take a condom. In doing so she is admitting that she might have sex with someone tonight. Many women feel carrying a condom makes them look promiscuous, when they feel they are not. A further major problem is when to produce it. A romantic evening is turning rapidly into something more. Are you going to show you don’t trust the other person by reaching for a condom? Will the other person take offence at you implying that he or she has been sleeping around? Insisting on a condom may take a lot of self-confidence and courage on the part of the woman. Female condoms may be easier, although pregnancy failure rates can be as high as 12%.

Because there are so many natural social barriers to condom use, a major part of some prevention campaigns has been the message: `Be confident in presenting your partner with a condom.’

How to minimise the disruption (return to index)

Be prepared. Talk it through with your partner. Practise! But there is another way: change your lifestyle. So many pamphlets tell us how wonderful `safe sex’ is. They say how fulfilling it is just to rub bodies together and have a cuddle. They describe a vast number of other things people can do to have sex safely together. That is not what most people call sex .

The choice is so obvious and clear. Find someone you love and trust—someone who is not infected at the moment and will remain faithful to you for life and to whom you will remain faithful. Then you can enjoy unlimited, anxiety-free sex.

Free love (return to index)

You may reject this. Your philosophy is that if people want to they can sleep together without any great relationship or strings attached. `We live in a free world and people should be free to do what they like.’ Maybe you feel that ultimately you want to be married but you want to have fun now. Friends of mine are afraid that their relationships will become tame and boring if they get married. `A piece of paper won’t make me love her any more.’

I am constantly seeing the casualties of this, and they are usually women. Life is unfair. Somehow it is usually the woman who comes off worse: she is the one who becomes pregnant and her risk of catching HIV is twice as great as the man’s risk from her. She suffers the chronic pain of pelvic inflammatory disease and cervical cancer. And the woman is often the one who is most devastated when a relationship breaks up.

Free love is fine until your lover leaves you at forty-three years of age, and you still have had no children because he would have walked out. A whole generation of people is growing older. Pensioners of tomorrow with no wives, no husbands, no children, no family—only a few casual relationships and old memories. No wonder many are deciding that enough is enough: the right person has not come along so they are staying single and celibate, yet forming long-lasting, warm, caring friendships.

Someone was saying in a newspaper article once how exciting it was to commit adultery. She was saying there was nothing wrong in it. There were some angry letters. One woman said that adultery was wrong for lots of reasons: for her it had meant an elaborate web of cheating, deceits, small lies and big lies. The total betrayal of the trust of another. No wonder it causes such terrible bitterness and hurt. Adultery wrecks marriages and damages children. Surely this is not the best plan for human relationships.

Women leading the way (return to index)

There are huge differences between the attitudes of boys and the girls in many countries. Some boys want to `score’ with as many girls as possible. Their reputations and image may depend on sleeping with every girl they go out with. Many girls are disgusted. They want commitment, friendship, companionship, security—and then they would give themselves in other ways. Romantic ideals live on even though there has been a trend in some Western nations for girls to take the lead a lot more in relationships, and in sexual conquests.

In most countries marriage remains very popular, with girls leading the way. I find similar differences expressed almost every time I go into a school to take an AIDS lesson. Girls are often more worried about consequences of sex than boys. Many boys could not care less. It is the girls who seem to worry most about getting pregnant or being let down. Part of the next education phase needs to be to teenage girls and young women, many of whom need little convincing about the desirability of being in a warm, loving, caring, exclusive relationship. This strategy should be designed to give them moral support when under pressure, not to `sell themselves cheap’.

It is strange that many men want easy women to have fun with, but deep down prefer by far the thought of marrying a virgin. We need to cultivate a new age where romance is in, self-respect is in, faithfulness is in, marriage is in. I don’t think it’s clever to sleep around or get divorced.

The people I admire are those who work at relationships, who are good at relationships, who have good happy marriages, who can handle things. What’s so smart about walking out on every problem? I respect and admire, too, those people who have made a positive decision—for whatever reason—to remain single and celibate.

Advice to someone married to a `positive’ spouse
(return to index)

You may be afraid you or your spouse are already positive. For many women with partners infected through medical treatments it has been a terrible shock to discover that their partner may have been HIV-infected several years before, without either of them realising.

This is an agonising situation, in addition to many others where one or other partner is known to be infected through other routes.

Such knowledge can place a severe strain on even the strongest relationships. One big question is over the future of the sexual relationship. Will it continue? What adjustments need to be made? To what degree does the uninfected person wish to `take a chance’? There are no right or wrong answers, and each couple will need to find their own way forward, with the help of those experienced in HIV counselling.

The important thing is to realise that many people are still uninfected after several months, or even years. As we have seen, it seems that the risk of infection rises when the person becomes ill. Before then the risk may be much lower. You may want to be tested yourself. If you are positive, neither of you need to take as many precautions. If you are negative, then the following is sensible:

1.´Use a thick strong condom carefully—see earlier in the chapter.

2.´You may want to reduce the frequency of your lovemaking where the end result is penetrative sex, but be sensible. Stopping altogether may cause terrible tensions and actually result in a rushed mistake. Arousal may be much stronger after abstinence and then it is not as easy to be careful. Do not make love while a woman is menstruating, if she is positive, as the blood will probably contain virus. Explore many other ways to express love and affection through sensuous, arousing, intimate touch.

3.´Deep kissing, where saliva may pass from one mouth to another, is probably not a good idea. Dry kissing carries a much, much lower risk. Oral sex is not sensible.

4.´An infected woman should probably avoid pregnancy as there is a significant chance that any child born may also be infected. So use a second method of contraception as well, eg the pill, or consider sterilisation very seriously.

This is a very difficult and traumatic area.

In this chapter we have looked only at condom effectiveness and risk reduction using them. There are, however, major questions over their promotion in many developing countries. In African nations or in South East Asia, for example, condoms may be unaffordable, unacceptable and difficult to obtain. There are also many ethical questions linked to the promotion of condoms, especially in the minds of many church leaders. We look in more detail at these issues in Chapter 14.

We have looked at the whole issue of the spread of AIDS and some ways to reduce the risks of getting infected, but we have never been faced with a disease which confronts us with so many conflicting moral choices to do with rights and freedom. Some of these issues threaten to tear society apart. We consider the most important of these in the next chapter.

Courtesy: Global Change

History of Aids

What is AIDS?
It was 1981. In a Los Angeles doctor’s office the men sitting in white coats were worried: within a few weeks they had diagnosed their fourth case of a condition so incredibly rare they had hardly expected to see it in their collective professional lifetime. They were baffled by the series of strange pneumonias that got worse despite normal antibiotics. All of the patients were men. All were young. All of them had died.

Three and a half thousand miles to the east, at a hospital in New York, several doctors were faced with a similar problem: strange tumours and lethal pneumonias in young men. What was going on?

The cases were all reported to the infectious disease centre. Could this be some sort of epidemic? Were the pneumonias and cancers caused by the same thing? What did the men have in common? Every day new reports of deaths came flooding in. It was becoming clear that most, if not all, of the deceased were men who had had sex with other men. The disease quickly became labelled `the gay plague’. How wrong they would turn out to be.

Dozens of strange infections were seen—with all the classic signs of weakened natural defences. The disease was called AIDS—Acquired Immune Deficiency Syndrome. It took some time to discover that the culprit was a tiny virus, called the Human Immunodeficiency Virus or HIV. It is now known that someone can be infected with HIV for ten years or more before developing the illness called AIDS.

Just five years later, by November 1986, 15,345 people had already died, another 12,000 were dying, and a further 30,000 were feeling unwell.

People were concerned that maybe up to a million people in the United States were also infected but were not yet ill. At first the `experts’ predicted only one in ten of those infected would die, then two in ten, then three in ten, then nine out of ten. Now we know that almost everyone with the infection will die as a result.

Most estimates from the early 1980s were exceeded. By April 1990 in the United States there were over 126,000 cases reported. (There were estimates of possibly 200–300,000 feeling unwell and maybe 700,000 infected, representing up to one in sixty of all men in the United States between the ages of twenty and fifty. In New York, AIDS became the commonest cause of death for men and women aged twenty-five to fourty-four, with 100 AIDS deaths every week. One in every sixty-one babies carried HIV. By 1993 more people were dying of AIDS in the United States each year than died in the entire ten-year Vietnam War—compared to 6,000 deaths total in the UK. By 2002 over 45,000 American citizens were still being infected every year, despite 15 years of prevention campaign.

The number of people already doomed in the United States made the Vietnam tragedy look like a minor skirmish, with one new infection every thirteen minutes. The coffins, if placed end to end, would stretch for 1,000 miles.

Yet while all the attention at first was on America, another similar but far more catastrophic disaster was silently destroying another continent, and no one had noticed.

The African experience (return to index)

Some years after AIDS was first diagnosed in the United States, the first cases were recognised in Africa. We know today that for years thousands had been dying, but their deaths were blamed on tuberculosis and other diseases.

In many towns and cities across Central Africa, up to a third of all young adults are infected. A third of the truck drivers running the main north/south routes and half the prostitutes in many towns are carrying HIV. One relief agency in the early 1990s talked unofficially about pulling out of Central Africa. `What’s the point in drilling more wells when most of the people will be dead in a few years?

Over 45 million Africans were infected by 2002 of which more than 30 million were still alive. A further 12 million children had already lost one or both of their parents. The effects over the last 15 years have been a catastrophe. Seven countries, all in southern Africa, now have prevalence rates higher than 20%: Botswana (38.8%), Lesotho (31%), Namibia (22.5%), South Africa (20.1%), Swaziland (33.4%), Zambia (21.5%) and Zimbabwe (33.7%).

Uganda remains the only country to have subdued a major HIV/AIDS epidemic, with the adult HIV prevalence rate continuing to drop-from 8.3% at the end of 1999 to 5% at the end of 2001. Huge challenges persist, however, such as taking care of the 880 000 Ugandan children who have been orphaned by AIDS. 60% of all adults infected are women.

I have visited villages where grandmothers are looking after their grandchildren because so many young men and women, the parents, have been wiped out by AIDS. Armies of troops in Central Africa are being depleted—not by rockets and machine guns, but by AIDS. Breadwinners for families and providers of the countries’ wealth are missing. The educated elite living in the main towns and cities have often been worst hit.

In the country, fields are uncultivated and cattle wander aimlessly. One journalist visiting an African country described areas where whole families had been wiped out, plantations gone back to bush. I have met someone who claims to have satellite photographs of a country in Central Africa taken two years apart, showing not deforestation, but reforestation as the amount of farming falls. It is an effect attributed to AIDS—the country is not at war.

As early as 1991 I found it hard in a city like Kampala to find a family that was not attending an AIDS funeral on average once a month. Deaths continued to soar over the next decade among young adults. In Africa they called it the `slim’ disease. Some Africans believe if you sleep with only fat women you are safe. `To be fat is to be healthy.’ Uganda has seen a dramatic response to prevention campaigns but for those already infected it is all too late.

In the early days of the pandemic, officials stood at the doors of some hospitals selecting the fit ones for treatment. Anyone who looked thin and weak was sent back into the bush—`Probably got AIDS; nothing we can do for him.’ Many were sent away with perfectly treatable diseases such as tuberculosis. You cannot tell the difference at the door.

Years and years of careful preventive medicine has been undermined. How do you start educating about a disease which produces no illness for years, when nurses are still battling against ingrained habits just to get mothers to give their children a healthy diet?

The children’s wards are full of dying children. Many are babies under one or two years old. Many are not dying of famine, but of AIDS. A terrible tragedy is that a significant number in the 1980s and early 1990s caught the virus not while in their mothers’ wombs, or from their mother’s milk, but from the use of unsterilised needles.

AIDS is not a gay plague; there are millions more women and children infected with HIV throughout the world than there are gay men. It gained this reputation in the United States because gay men were first to be diagnosed, yet 98% of all new infections worldwide are heterosexually acquired – and in the poorest nations.

The global pandemic (return to index)

We are seeing very rapid spread of HIV in Russia and other former Easter bloc countries. In Romania, up to one in ten of all children in orphanages became infected before the revolution in 1990, and a similar percentage shortly after. The route was mainly infected needles rather than the widely reported micro-transfusions used as a tonic.

In Thailand, many experts predicted a serious AIDS epidemic because of the sex industry and international sex tourism. However, by the time the Thai government was prepared to acknowledge the situation, the epidemic was well underway. In three years, half a million were infected—the great majority heterosexually. But as with Uganda, a prompt and aggressive health campaign has saved the lives of millions of Thai people.

In South East Asia, HIV is spreading so fast that it threatens to dwarf the African problem by the year 2010. However, there is hope that if denial is replaced by openness, and if openness leads to intensive prevention, then the eventual size of the tragedy may be significantly reduced. South East Asia has the advantage of advanced warning—something Africa never had.

In India alone there are more sexually-active people alive than adults in the whole of sub-Saharan Africa, and India by 2001 had more HIV cases than any other nation. What happens in the East is likely to have a massive impact on the world situation. In Bombay (Mumbai) alone there are an estimated 1000 new infections every night, just in the huge red light district which attracts over 100,000 young men daily. Some parts of India have HIV infection rates of more than 1%. If that rises as it has done in parts of Africa to more than 15% then we could see four times as many AIDS deaths in India than there had been in the entire world up until 2001.

China, with a fifth of the world’s population, registered a rise of more than 67% in reported HIV infections in the first six months of 2001. Although surveillance data are sketchy, an estimated 850 000 Chinese were living with HIV/AIDS as of the end of 2001.Since the early 1990s, tens of thousands of rural villagers (and possibly many more) have become infected in China through unsafe blood-donation procedures. Untreated sexually transmitted diseases doubled from 1997 to 2001 and huge population movements within the country are also accelerating spread.

In Indonesia – the fourth largest population of all countries – infection rates have jumped in a year from 15% to 40% among drug users attending treatment centres in Jakarta.

Denial of heterosexual risk (return to index)

Many have tried to play down the heterosexual problem as a non-issue for white men and women, especially in wealthy nations. This is remarkably short-sighted and inaccurate. Heterosexual acts are now the commonest cause of new infections in countries like the UK – mainly infected in other nations. You can’t place a ring of steel around a country and hope. What happens in one nations affects others. What hits Burundi also affects Rwanda. Infections travel. You can have a great health campaign but if the epidemic is out of control elsewhere, watch out.

It is clear that heterosexual spread in the US or Europe is far slower than in many developing countries. While viral variation could be the reason, with more virulent strains in some places (see Chapter 2) or some genetic susceptibility (see Chapter 5), the overwhelming evidence is that untreated sex diseases such as gonorrhoea and chancroid facilitate spread by damaging the protective surface of the genitalia. Differences in the numbers of sexual partners between wealthy and poorer nations are not enough to explain the much slower rates of HIV spread.

The AIDS epidemic world-wide is still in its very earliest stages. And with no vaccine or cure on the horizon, this is an epidemic that threatens our future. But even if a drug was found tomorrow that is as effective against HIV as antibiotics against TB and syphilis, we have to remember that despite these effective treatments, available for fifty years, we have the largest global epidemics of both illnesses today. In other words, even a cheap and widely available cure will not mean the end of AIDS. And effective vaccines are a long way off, despite media hype.

Many churches are experiencing phenomenal growth in different parts of the world. Millions of young people are becoming Christians each year. Often there are spectacular conversions resulting in radical changes in lifestyle. Heroin addicts throw away their needles. Marriages are rebuilt. The results are often permanent—but so is the previous infection. AIDS will damage churches physically, emotionally, psychologically and spiritually—unless they are prepared.

At a conference for church leaders, I met a man who had been a heroin addict before his conversion four or five years ago. He is now leading a church. This kind of success story is happening in many different nations. Some of these people will develop AIDS.

So what do we do? How can we prevent the disease? How can we cure it? How can we cope with it? The rest of this book addresses these four questions. But is AIDS really so different from any other disease, or is it just the mass hysteria and panic associated with it?

AIDS is certainly unusual or unique in two respects. First, I do not know of any other illness today where people are beaten up, killed or denied basic medical care just because they happen to have a particular diagnosis.

Secondly, I do not know of any other illness which has so generated political debates, pressures, campaigning and aggressive activism. Some companies are now saying it is hard to conduct normal medical research in the area of HIV or AIDS because the political pressures are so great that they threaten to overwhelm and interfere at every level. They are certainly under huge pressures to give away their ownership of any AIDS therapies they create, and that means investors get worried and less money is available for AIDS research, especially into vaccines. One day I hope we will have a vaccine that works, but whoever makes it will face irresistible demands to give it all away “to save the world”.

Discrimination, prejudice and fear are seen every day in many countries. It is true that some activism has been driven by members of the gay community in developed countries, rather than by drug users, heterosexuals or those with haemophilia, or by those in the poorest nations—a fact which becomes very obvious at the larger international AIDS conferences.

Indeed global AIDS events are often split by two conflicting interests: first by gay HIV activists who have a particular agenda, and second by far less well organised and less well resourced representatives of the vast majority of people with HIV who live in the poorest nations.

AIDS has also attracted the eccentric and the bizarre. I was recently sent literature from an organisation claiming that the US government made HIV as part of a deliberate plot to reduce the world population by 75%. The Mafia and the CIA are said to be deeply involved. Equally bizarre are some of the `cures’, including eating earth and drinking vinegar, or high-cost preparations with no proven value. Other minorities try to persuade people that HIV is harmless and does not even cause AIDS (see Chapter 5 Questions People Ask).

Yet in another sense there is nothing special about AIDS. It is just the latest in a long series of epidemics spread by sex. Sleeping around has always carried risks to health. Now it can be lethal.

Sex diseases are common (STDs). Over 30 million in the US are estimated to have genital herpes. Some 56 million, or 20% of all US adults, are estimated to be carrying an STD at any time. 50% of all adults in Mumbai India are carrying an STD. Worldwide there are an estimated 250 million new STD infections each year. With ordinary STDs the damage is usually more obvious, immediate and less serious than with HIV.

More than 300 years ago a plague broke out in Europe and spread across the Western world. Vast numbers died. Early symptoms were mild, the second stage made people very ill, and half of those who developed the third stage died, many with brain damage. It was a terrible disease, and it was spread by sex. It was named `syphilis’.

Syphilis only stopped being a major threat with the discovery of penicillin at the end of World War II. During the war, United States army recruits were warned that, after Hitler, syphilis was Public Enemy Number One. A famous US Army war poster was of a prostitute walking with Hitler on one arm and the Japanese Emperor on the other. The caption read: `VD (venereal disease) worst of the three.’ Syphilis has not gone away; we are in the middle of a major heterosexual explosion of cases which often produce few or no symptoms and are untreated for a long period.

Gonorrhoea also became a curable sexual disease with penicillin—until the recent advent of penicillin-resistant strains which are now spreading rapidly across the globe and becoming harder and harder to treat. There is an unprecedented epidemic of genital herpes. Highly infectious, appallingly painful blisters prevent sex. There is no cure and it can cause problems throughout a person’s life. There is also a big increase in cancer of the neck of the womb (cervix), some of which is associated with a virus infection and is due to sleeping with multiple partners.

There is also the heart-rending problem of infertility. Have you ever wondered about the huge test-tube baby programme in many wealthy nations? The major part of the workload is people with badly damaged and scarred fallopian tubes—the thin delicate tubes which guide the egg from the ovary to the womb. The cause is an infection called pelvic inflammatory disease (PID), which can be caused by a tiny organism called chlamydia. There is no treatment that can undo the damage of pelvic inflammatory disease. One in ten women develop it after being infected with chlamydia, gonorrhoea, or some other infections. It causes aches and pains that are chronically disabling, and it gradually causes the reproductive organs to stick together.

Then came a new disease—AIDS—that many people think has been around in Africa, the US and Europe for decades before recognition in the late 1980s Wherever it started, it spread slowly at first, undetected, and then explosively among men, women and young children. It was only detected as it hit the medical technology of the United States, was misdiagnosed as an American gay curiosity, and only traced to its probable roots some two or three years later.

The difference between HIV-related diseases and other sexual epidemics is that HIV can infect you for years before you know it, and by the time you do it has spread to infect possibly hundreds of others. The long “silent” delay between infection and death is why HIV is so dangerous – not the fact that it kills.

The other difference is that once you develop full-blown AIDS—which can take many years—you face almost certain death, unless you die of something else in the meantime. As I say, there is no cure and no vaccine, nor is either anywhere in sight. There are many misleading reports but no good results, many very expensive and toxic treatments that help prolong life but no way to rid the body of infection. However, some of these treatments can protect those who have recently been exposed, particularly the unborn or small babies.

A rapidly-spreading, silent killer which is difficult to detect, infectious and lethal causes panic. Radiation disasters are similar: you cannot hear, see, feel, or touch the enemy, nor feel the damage it is doing until too late—sometimes not for years. No wonder the Chernobyl nuclear reactor disaster in Russia caused such terrible pandemonium: false rumours, false scares, false cures, false hopes abounded. AIDS is the same today.

If a man had sex with a work colleague and three weeks later was dead, and that was repeated across the country, the impact would be dramatic. You would not need any health campaign because the coffins would be the campaign. But with HIV and AIDS the enormous time lag produces a credibility problem: the only people who really understand what is likely to hit us are the mathematicians. An invisible terror can be ignored.

If we have to wait tanother en years to see exactly what is happening, we will be too late.

The great cover-up (return to index)

Why are so few people being honest about the extent of the problem and the risks? AIDS is a hard illness to talk about, especially in Africa and Asia. In Africa there is an added sensitivity: confronted with a tragedy affecting their whole continent—and for once not related to war or famine—in an international atmosphere which they see as racist, many have been extremely unwilling to be honest. They are afraid of anti-black backlash if it is said that the problem started there. They are also afraid of economic ruin due to decisions of multinational companies to pull out, and the collapse of their tourist industries. Many of these countries desperately need foreign currency to prevent total bankruptcy. In addition it has often been difficult for doctors to be sure of the diagnosis. Testing is expensive, kits are hard to obtain, and sometimes hard to use. Indirect methods have to be used such as a negative skin reaction to the standard tuberculosis (TB) test. Most AIDS-related deaths seem to be happening out in the bush, unnoticed and unregistered. The wards and clinics see mainly early cases.

So we have a bizarre situation where doctors in these countries may be reeling under an impossible workload, and where even government members or relations of the country’s leaders may be dying, but the problem is denied, or blamed on other causes, or impossible to assess. Scientists studying the epidemic in Central and Southern Africa are often there under tolerance. Intensive research is going on all over Africa to understand the disease, but the results are sometimes censored. A scientist may have to sign an agreement not to disclose publicly what he sees happening.

Information is leaking out all the time, but if it is traced back to a particular person or team the workers may be thrown out of the country or into prison. Fortunately, the situation is changing. It has to. The cover-up has had one appalling consequence which prevents an educational campaign. How can a country embark on mass prevention for a disease it says it does not really have? Once again we see denial for emotional reasons too, not just economic ones. How can you accept from a mathematician that maybe a third of your entire nation could die?

South Africa has had its own reasons to cover up. It has an enormous problem, especially in the black townships where huge numbers of migrant workers come from countries further north in which AIDS is taking a terrible toll.

In places like Soweto, the town providing labour for the deep mines in Johannesburg, there have been up to 50,000 men living without their wives (officially). In the days of apartheid their wives and children were all meant to stay in homelands like the Transkei. They didn’t, of course, and drifted out in search of their husbands to build illegal residences made from corrugated iron, wood and plastic. Every now and then these `shanty towns’ were bulldozed to the ground and the women trucked back, sometimes more than 1,000 miles away.

Fifty thousand men on their own with a few prostitutes spelt trouble—yet this situation has been common in South Africa. The historic white government had no political will to change anything. For them, a major disease that selectively hit black Africans and offset the birthrate may have been convenient. But the new post-apartheid regime has also found it hard to talk about AIDS. Nelson Mandela fought for recognition of the disease, but when he handed over leadership of the nation the government mood changed to one of confusion and denial.

Life after AIDS (return to index)

Cover-up or no cover-up, honesty, secrecy, or confusion, one thing is clear: nothing will ever be quite the same again. AIDS is fundamentally altering fashions, behaviour, culture—in fact every fibre of our society. In some placs fat is back in fashion: `Who wants to look thin?—Perhaps he has AIDS.’ The Hollywood dinosaur of the movie industry is thrashing its tail and the ground is shaking. Television producers are stepping over each other in their zeal to include AIDS in soap operas, plays and comedies.

Magazines like Cosmopolitan say that smart girls carry condoms. They hope that smart girls will not feel like loose girls when they produce the packet. They hope too for a new courage and honesty so that people will always tell of their unfaithfulness and promiscuity or drug addiction. They hope for new security in relationships so that when a girl or boy suggests using a condom, the other will not treat it as a terrible insult or lack of trust.

Whether such hopes will remain hopes or get built into a strange harsh reality of rubber-separated sex is unclear. But one thing is almost inevitable: out of the ashes of the crematorium will rise a new sub-culture which will affect a whole generation in many parts of the world: a culture of stable relationships and marriages. A culture where a man and a woman find mutual sexual fulfilment for life.

The reality is that even an AIDS cure in 2008 or a remarkable vaccine in 2010 will not erase the traumas of a generation, nor eradicate the problem. As we have seen with the resurgence of TB and syphilis, low-cost treatment does not mean the end of the story. The message is burning home: sleeping around has always been unhealthy. Now it can be suicidal. Taking AIDS out still leaves the other epidemics untouched. The mid-twenty-first century will look at the 1980s, 1990s, and the early years of the next century as the `era of AIDS’. The reasons for its spread, its origins, the apathy of governments, and the mistakes of scientists will be debated by historians for generations.

AIDS is likely to dominate the rest of our adult lives—especially the lives of doctors and nurses, and of young people becoming sexually active today. The question is this: will you be able to hold your head high? Will you be proud of the way you responded when you look back on it all?

Apart from a radical change of lifestyle in our society—which will not help those already infected anyway—our only hope remains in understanding this strange virus so we can fight it. But what exactly is a virus?

Courtesy:GLOBAL CHANGE

History of Aids

What is AIDS?
It was 1981. In a Los Angeles doctor’s office the men sitting in white coats were worried: within a few weeks they had diagnosed their fourth case of a condition so incredibly rare they had hardly expected to see it in their collective professional lifetime. They were baffled by the series of strange pneumonias that got worse despite normal antibiotics. All of the patients were men. All were young. All of them had died.

Three and a half thousand miles to the east, at a hospital in New York, several doctors were faced with a similar problem: strange tumours and lethal pneumonias in young men. What was going on?

The cases were all reported to the infectious disease centre. Could this be some sort of epidemic? Were the pneumonias and cancers caused by the same thing? What did the men have in common? Every day new reports of deaths came flooding in. It was becoming clear that most, if not all, of the deceased were men who had had sex with other men. The disease quickly became labelled `the gay plague’. How wrong they would turn out to be.

Dozens of strange infections were seen—with all the classic signs of weakened natural defences. The disease was called AIDS—Acquired Immune Deficiency Syndrome. It took some time to discover that the culprit was a tiny virus, called the Human Immunodeficiency Virus or HIV. It is now known that someone can be infected with HIV for ten years or more before developing the illness called AIDS.

Just five years later, by November 1986, 15,345 people had already died, another 12,000 were dying, and a further 30,000 were feeling unwell.

People were concerned that maybe up to a million people in the United States were also infected but were not yet ill. At first the `experts’ predicted only one in ten of those infected would die, then two in ten, then three in ten, then nine out of ten. Now we know that almost everyone with the infection will die as a result.

Most estimates from the early 1980s were exceeded. By April 1990 in the United States there were over 126,000 cases reported. (There were estimates of possibly 200–300,000 feeling unwell and maybe 700,000 infected, representing up to one in sixty of all men in the United States between the ages of twenty and fifty. In New York, AIDS became the commonest cause of death for men and women aged twenty-five to fourty-four, with 100 AIDS deaths every week. One in every sixty-one babies carried HIV. By 1993 more people were dying of AIDS in the United States each year than died in the entire ten-year Vietnam War—compared to 6,000 deaths total in the UK. By 2002 over 45,000 American citizens were still being infected every year, despite 15 years of prevention campaign.

The number of people already doomed in the United States made the Vietnam tragedy look like a minor skirmish, with one new infection every thirteen minutes. The coffins, if placed end to end, would stretch for 1,000 miles.

Yet while all the attention at first was on America, another similar but far more catastrophic disaster was silently destroying another continent, and no one had noticed.

The African experience (return to index)

Some years after AIDS was first diagnosed in the United States, the first cases were recognised in Africa. We know today that for years thousands had been dying, but their deaths were blamed on tuberculosis and other diseases.

In many towns and cities across Central Africa, up to a third of all young adults are infected. A third of the truck drivers running the main north/south routes and half the prostitutes in many towns are carrying HIV. One relief agency in the early 1990s talked unofficially about pulling out of Central Africa. `What’s the point in drilling more wells when most of the people will be dead in a few years?

Over 45 million Africans were infected by 2002 of which more than 30 million were still alive. A further 12 million children had already lost one or both of their parents. The effects over the last 15 years have been a catastrophe. Seven countries, all in southern Africa, now have prevalence rates higher than 20%: Botswana (38.8%), Lesotho (31%), Namibia (22.5%), South Africa (20.1%), Swaziland (33.4%), Zambia (21.5%) and Zimbabwe (33.7%).

Uganda remains the only country to have subdued a major HIV/AIDS epidemic, with the adult HIV prevalence rate continuing to drop-from 8.3% at the end of 1999 to 5% at the end of 2001. Huge challenges persist, however, such as taking care of the 880 000 Ugandan children who have been orphaned by AIDS. 60% of all adults infected are women.

I have visited villages where grandmothers are looking after their grandchildren because so many young men and women, the parents, have been wiped out by AIDS. Armies of troops in Central Africa are being depleted—not by rockets and machine guns, but by AIDS. Breadwinners for families and providers of the countries’ wealth are missing. The educated elite living in the main towns and cities have often been worst hit.

In the country, fields are uncultivated and cattle wander aimlessly. One journalist visiting an African country described areas where whole families had been wiped out, plantations gone back to bush. I have met someone who claims to have satellite photographs of a country in Central Africa taken two years apart, showing not deforestation, but reforestation as the amount of farming falls. It is an effect attributed to AIDS—the country is not at war.

As early as 1991 I found it hard in a city like Kampala to find a family that was not attending an AIDS funeral on average once a month. Deaths continued to soar over the next decade among young adults. In Africa they called it the `slim’ disease. Some Africans believe if you sleep with only fat women you are safe. `To be fat is to be healthy.’ Uganda has seen a dramatic response to prevention campaigns but for those already infected it is all too late.

In the early days of the pandemic, officials stood at the doors of some hospitals selecting the fit ones for treatment. Anyone who looked thin and weak was sent back into the bush—`Probably got AIDS; nothing we can do for him.’ Many were sent away with perfectly treatable diseases such as tuberculosis. You cannot tell the difference at the door.

Years and years of careful preventive medicine has been undermined. How do you start educating about a disease which produces no illness for years, when nurses are still battling against ingrained habits just to get mothers to give their children a healthy diet?

The children’s wards are full of dying children. Many are babies under one or two years old. Many are not dying of famine, but of AIDS. A terrible tragedy is that a significant number in the 1980s and early 1990s caught the virus not while in their mothers’ wombs, or from their mother’s milk, but from the use of unsterilised needles.

AIDS is not a gay plague; there are millions more women and children infected with HIV throughout the world than there are gay men. It gained this reputation in the United States because gay men were first to be diagnosed, yet 98% of all new infections worldwide are heterosexually acquired – and in the poorest nations.

The global pandemic (return to index)

We are seeing very rapid spread of HIV in Russia and other former Easter bloc countries. In Romania, up to one in ten of all children in orphanages became infected before the revolution in 1990, and a similar percentage shortly after. The route was mainly infected needles rather than the widely reported micro-transfusions used as a tonic.

In Thailand, many experts predicted a serious AIDS epidemic because of the sex industry and international sex tourism. However, by the time the Thai government was prepared to acknowledge the situation, the epidemic was well underway. In three years, half a million were infected—the great majority heterosexually. But as with Uganda, a prompt and aggressive health campaign has saved the lives of millions of Thai people.

In South East Asia, HIV is spreading so fast that it threatens to dwarf the African problem by the year 2010. However, there is hope that if denial is replaced by openness, and if openness leads to intensive prevention, then the eventual size of the tragedy may be significantly reduced. South East Asia has the advantage of advanced warning—something Africa never had.

In India alone there are more sexually-active people alive than adults in the whole of sub-Saharan Africa, and India by 2001 had more HIV cases than any other nation. What happens in the East is likely to have a massive impact on the world situation. In Bombay (Mumbai) alone there are an estimated 1000 new infections every night, just in the huge red light district which attracts over 100,000 young men daily. Some parts of India have HIV infection rates of more than 1%. If that rises as it has done in parts of Africa to more than 15% then we could see four times as many AIDS deaths in India than there had been in the entire world up until 2001.

China, with a fifth of the world’s population, registered a rise of more than 67% in reported HIV infections in the first six months of 2001. Although surveillance data are sketchy, an estimated 850 000 Chinese were living with HIV/AIDS as of the end of 2001.Since the early 1990s, tens of thousands of rural villagers (and possibly many more) have become infected in China through unsafe blood-donation procedures. Untreated sexually transmitted diseases doubled from 1997 to 2001 and huge population movements within the country are also accelerating spread.

In Indonesia – the fourth largest population of all countries – infection rates have jumped in a year from 15% to 40% among drug users attending treatment centres in Jakarta.

Denial of heterosexual risk (return to index)

Many have tried to play down the heterosexual problem as a non-issue for white men and women, especially in wealthy nations. This is remarkably short-sighted and inaccurate. Heterosexual acts are now the commonest cause of new infections in countries like the UK – mainly infected in other nations. You can’t place a ring of steel around a country and hope. What happens in one nations affects others. What hits Burundi also affects Rwanda. Infections travel. You can have a great health campaign but if the epidemic is out of control elsewhere, watch out.

It is clear that heterosexual spread in the US or Europe is far slower than in many developing countries. While viral variation could be the reason, with more virulent strains in some places (see Chapter 2) or some genetic susceptibility (see Chapter 5), the overwhelming evidence is that untreated sex diseases such as gonorrhoea and chancroid facilitate spread by damaging the protective surface of the genitalia. Differences in the numbers of sexual partners between wealthy and poorer nations are not enough to explain the much slower rates of HIV spread.

The AIDS epidemic world-wide is still in its very earliest stages. And with no vaccine or cure on the horizon, this is an epidemic that threatens our future. But even if a drug was found tomorrow that is as effective against HIV as antibiotics against TB and syphilis, we have to remember that despite these effective treatments, available for fifty years, we have the largest global epidemics of both illnesses today. In other words, even a cheap and widely available cure will not mean the end of AIDS. And effective vaccines are a long way off, despite media hype.

Many churches are experiencing phenomenal growth in different parts of the world. Millions of young people are becoming Christians each year. Often there are spectacular conversions resulting in radical changes in lifestyle. Heroin addicts throw away their needles. Marriages are rebuilt. The results are often permanent—but so is the previous infection. AIDS will damage churches physically, emotionally, psychologically and spiritually—unless they are prepared.

At a conference for church leaders, I met a man who had been a heroin addict before his conversion four or five years ago. He is now leading a church. This kind of success story is happening in many different nations. Some of these people will develop AIDS.

So what do we do? How can we prevent the disease? How can we cure it? How can we cope with it? The rest of this book addresses these four questions. But is AIDS really so different from any other disease, or is it just the mass hysteria and panic associated with it?

AIDS is certainly unusual or unique in two respects. First, I do not know of any other illness today where people are beaten up, killed or denied basic medical care just because they happen to have a particular diagnosis.

Secondly, I do not know of any other illness which has so generated political debates, pressures, campaigning and aggressive activism. Some companies are now saying it is hard to conduct normal medical research in the area of HIV or AIDS because the political pressures are so great that they threaten to overwhelm and interfere at every level. They are certainly under huge pressures to give away their ownership of any AIDS therapies they create, and that means investors get worried and less money is available for AIDS research, especially into vaccines. One day I hope we will have a vaccine that works, but whoever makes it will face irresistible demands to give it all away “to save the world”.

Discrimination, prejudice and fear are seen every day in many countries. It is true that some activism has been driven by members of the gay community in developed countries, rather than by drug users, heterosexuals or those with haemophilia, or by those in the poorest nations—a fact which becomes very obvious at the larger international AIDS conferences.

Indeed global AIDS events are often split by two conflicting interests: first by gay HIV activists who have a particular agenda, and second by far less well organised and less well resourced representatives of the vast majority of people with HIV who live in the poorest nations.

AIDS has also attracted the eccentric and the bizarre. I was recently sent literature from an organisation claiming that the US government made HIV as part of a deliberate plot to reduce the world population by 75%. The Mafia and the CIA are said to be deeply involved. Equally bizarre are some of the `cures’, including eating earth and drinking vinegar, or high-cost preparations with no proven value. Other minorities try to persuade people that HIV is harmless and does not even cause AIDS (see Chapter 5 Questions People Ask).

Yet in another sense there is nothing special about AIDS. It is just the latest in a long series of epidemics spread by sex. Sleeping around has always carried risks to health. Now it can be lethal.

Sex diseases are common (STDs). Over 30 million in the US are estimated to have genital herpes. Some 56 million, or 20% of all US adults, are estimated to be carrying an STD at any time. 50% of all adults in Mumbai India are carrying an STD. Worldwide there are an estimated 250 million new STD infections each year. With ordinary STDs the damage is usually more obvious, immediate and less serious than with HIV.

More than 300 years ago a plague broke out in Europe and spread across the Western world. Vast numbers died. Early symptoms were mild, the second stage made people very ill, and half of those who developed the third stage died, many with brain damage. It was a terrible disease, and it was spread by sex. It was named `syphilis’.

Syphilis only stopped being a major threat with the discovery of penicillin at the end of World War II. During the war, United States army recruits were warned that, after Hitler, syphilis was Public Enemy Number One. A famous US Army war poster was of a prostitute walking with Hitler on one arm and the Japanese Emperor on the other. The caption read: `VD (venereal disease) worst of the three.’ Syphilis has not gone away; we are in the middle of a major heterosexual explosion of cases which often produce few or no symptoms and are untreated for a long period.

Gonorrhoea also became a curable sexual disease with penicillin—until the recent advent of penicillin-resistant strains which are now spreading rapidly across the globe and becoming harder and harder to treat. There is an unprecedented epidemic of genital herpes. Highly infectious, appallingly painful blisters prevent sex. There is no cure and it can cause problems throughout a person’s life. There is also a big increase in cancer of the neck of the womb (cervix), some of which is associated with a virus infection and is due to sleeping with multiple partners.

There is also the heart-rending problem of infertility. Have you ever wondered about the huge test-tube baby programme in many wealthy nations? The major part of the workload is people with badly damaged and scarred fallopian tubes—the thin delicate tubes which guide the egg from the ovary to the womb. The cause is an infection called pelvic inflammatory disease (PID), which can be caused by a tiny organism called chlamydia. There is no treatment that can undo the damage of pelvic inflammatory disease. One in ten women develop it after being infected with chlamydia, gonorrhoea, or some other infections. It causes aches and pains that are chronically disabling, and it gradually causes the reproductive organs to stick together.

Then came a new disease—AIDS—that many people think has been around in Africa, the US and Europe for decades before recognition in the late 1980s Wherever it started, it spread slowly at first, undetected, and then explosively among men, women and young children. It was only detected as it hit the medical technology of the United States, was misdiagnosed as an American gay curiosity, and only traced to its probable roots some two or three years later.

The difference between HIV-related diseases and other sexual epidemics is that HIV can infect you for years before you know it, and by the time you do it has spread to infect possibly hundreds of others. The long “silent” delay between infection and death is why HIV is so dangerous – not the fact that it kills.

The other difference is that once you develop full-blown AIDS—which can take many years—you face almost certain death, unless you die of something else in the meantime. As I say, there is no cure and no vaccine, nor is either anywhere in sight. There are many misleading reports but no good results, many very expensive and toxic treatments that help prolong life but no way to rid the body of infection. However, some of these treatments can protect those who have recently been exposed, particularly the unborn or small babies.

A rapidly-spreading, silent killer which is difficult to detect, infectious and lethal causes panic. Radiation disasters are similar: you cannot hear, see, feel, or touch the enemy, nor feel the damage it is doing until too late—sometimes not for years. No wonder the Chernobyl nuclear reactor disaster in Russia caused such terrible pandemonium: false rumours, false scares, false cures, false hopes abounded. AIDS is the same today.

If a man had sex with a work colleague and three weeks later was dead, and that was repeated across the country, the impact would be dramatic. You would not need any health campaign because the coffins would be the campaign. But with HIV and AIDS the enormous time lag produces a credibility problem: the only people who really understand what is likely to hit us are the mathematicians. An invisible terror can be ignored.

If we have to wait tanother en years to see exactly what is happening, we will be too late.

The great cover-up (return to index)

Why are so few people being honest about the extent of the problem and the risks? AIDS is a hard illness to talk about, especially in Africa and Asia. In Africa there is an added sensitivity: confronted with a tragedy affecting their whole continent—and for once not related to war or famine—in an international atmosphere which they see as racist, many have been extremely unwilling to be honest. They are afraid of anti-black backlash if it is said that the problem started there. They are also afraid of economic ruin due to decisions of multinational companies to pull out, and the collapse of their tourist industries. Many of these countries desperately need foreign currency to prevent total bankruptcy. In addition it has often been difficult for doctors to be sure of the diagnosis. Testing is expensive, kits are hard to obtain, and sometimes hard to use. Indirect methods have to be used such as a negative skin reaction to the standard tuberculosis (TB) test. Most AIDS-related deaths seem to be happening out in the bush, unnoticed and unregistered. The wards and clinics see mainly early cases.

So we have a bizarre situation where doctors in these countries may be reeling under an impossible workload, and where even government members or relations of the country’s leaders may be dying, but the problem is denied, or blamed on other causes, or impossible to assess. Scientists studying the epidemic in Central and Southern Africa are often there under tolerance. Intensive research is going on all over Africa to understand the disease, but the results are sometimes censored. A scientist may have to sign an agreement not to disclose publicly what he sees happening.

Information is leaking out all the time, but if it is traced back to a particular person or team the workers may be thrown out of the country or into prison. Fortunately, the situation is changing. It has to. The cover-up has had one appalling consequence which prevents an educational campaign. How can a country embark on mass prevention for a disease it says it does not really have? Once again we see denial for emotional reasons too, not just economic ones. How can you accept from a mathematician that maybe a third of your entire nation could die?

South Africa has had its own reasons to cover up. It has an enormous problem, especially in the black townships where huge numbers of migrant workers come from countries further north in which AIDS is taking a terrible toll.

In places like Soweto, the town providing labour for the deep mines in Johannesburg, there have been up to 50,000 men living without their wives (officially). In the days of apartheid their wives and children were all meant to stay in homelands like the Transkei. They didn’t, of course, and drifted out in search of their husbands to build illegal residences made from corrugated iron, wood and plastic. Every now and then these `shanty towns’ were bulldozed to the ground and the women trucked back, sometimes more than 1,000 miles away.

Fifty thousand men on their own with a few prostitutes spelt trouble—yet this situation has been common in South Africa. The historic white government had no political will to change anything. For them, a major disease that selectively hit black Africans and offset the birthrate may have been convenient. But the new post-apartheid regime has also found it hard to talk about AIDS. Nelson Mandela fought for recognition of the disease, but when he handed over leadership of the nation the government mood changed to one of confusion and denial.

Life after AIDS (return to index)

Cover-up or no cover-up, honesty, secrecy, or confusion, one thing is clear: nothing will ever be quite the same again. AIDS is fundamentally altering fashions, behaviour, culture—in fact every fibre of our society. In some placs fat is back in fashion: `Who wants to look thin?—Perhaps he has AIDS.’ The Hollywood dinosaur of the movie industry is thrashing its tail and the ground is shaking. Television producers are stepping over each other in their zeal to include AIDS in soap operas, plays and comedies.

Magazines like Cosmopolitan say that smart girls carry condoms. They hope that smart girls will not feel like loose girls when they produce the packet. They hope too for a new courage and honesty so that people will always tell of their unfaithfulness and promiscuity or drug addiction. They hope for new security in relationships so that when a girl or boy suggests using a condom, the other will not treat it as a terrible insult or lack of trust.

Whether such hopes will remain hopes or get built into a strange harsh reality of rubber-separated sex is unclear. But one thing is almost inevitable: out of the ashes of the crematorium will rise a new sub-culture which will affect a whole generation in many parts of the world: a culture of stable relationships and marriages. A culture where a man and a woman find mutual sexual fulfilment for life.

The reality is that even an AIDS cure in 2008 or a remarkable vaccine in 2010 will not erase the traumas of a generation, nor eradicate the problem. As we have seen with the resurgence of TB and syphilis, low-cost treatment does not mean the end of the story. The message is burning home: sleeping around has always been unhealthy. Now it can be suicidal. Taking AIDS out still leaves the other epidemics untouched. The mid-twenty-first century will look at the 1980s, 1990s, and the early years of the next century as the `era of AIDS’. The reasons for its spread, its origins, the apathy of governments, and the mistakes of scientists will be debated by historians for generations.

AIDS is likely to dominate the rest of our adult lives—especially the lives of doctors and nurses, and of young people becoming sexually active today. The question is this: will you be able to hold your head high? Will you be proud of the way you responded when you look back on it all?

Apart from a radical change of lifestyle in our society—which will not help those already infected anyway—our only hope remains in understanding this strange virus so we can fight it. But what exactly is a virus?

Courtesy:GLOBAL CHANGE