How Safe Is Sex?

By Philip Elmer-DeWitt

As long as the epidemic didn't touch anyone close to them, many Americans found it easy to put AIDS out of mind. For all the suffering and pain and lives cut short, it just seemed like someone else's problem. AIDS was something that happened to ghetto dwellers, drug addicts or gays, not to middle- and upper-class folks who limited themselves to straight sex.

Now it's harder to ignore AIDS. When Magic Johnson stepped forward to announce that he had tested HIV positive, his plight suddenly seemed like everybody's nightmare. Johnson's claim that he picked up the AIDS virus heterosexually, rather than through intravenous-drug use or homosexual contact, dramatically raised some of the most crucial health questions of the 1990s: How easy is it to get AIDS from straight sex? How fast can it spread? Could an AIDS epidemic like the ones sweeping through Third World nations take root in the general U.S. population as well?

According to the latest figures from the Centers for Disease Control, the risk to most American heterosexuals is still small, but it is real and growing. About 11,000 reported AIDS cases -- or less than 6% of the 200,000 Americans afflicted over the past decade -- have arisen from heterosexual contact. But while the number of heterosexual cases is relatively tiny, it jumped 40% last year, faster than any other category. As many as 1 million Americans may be infected with the virus that causes AIDS but not yet suffering from the disease. And no one knows how many of those people were exposed heterosexually.

The epidemic has hit the U.S. in three waves. The first occurred among homosexual men and is now leveling off. The second swept through pockets of IV-drug users, especially in certain East Coast cities, and has yet to reach its peak. The third wave is just taking off among heterosexual men and women who have had sexual contact with one or more of the high-risk groups. The question now is how far -- and how fast -- it will travel into the rest of the population.

One cause for concern is that heterosexual transmission is the rule, not the exception, in most countries affected by the disease. Figures released by the World Health Organization last week show that 75% of the people who have the AIDS virus worldwide were infected heterosexually. In Africa, where one-tenth of the world's population accounts for half the estimated 10 million AIDS infections around the globe, heterosexual transmission is responsible for more than 8 out of 10 cases. In Southern and Southeast Asia, where the epidemic is growing more rapidly than anywhere else, heterosexual contact is also the dominant mode of transmission. Among the prostitutes in Bombay's red-light district, 25% to 30% are HIV positive. In the poorer sections of Nairobi, Kenya, infection rates among prostitutes run higher than 90%.

Most experts attribute the prevalence of heterosexual AIDS transmission in Africa to widespread venereal diseases such as syphilis and chancroid. These diseases cause sores and infections that make it easier for the virus to pass from one person to another -- a problem exacerbated by a medical system that is shockingly inadequate. Gonorrhea rates in Africa are as much as 20 times those of the industrialized West, and yet there are one-sixtieth as many doctors per capita as there are in the U.S. A case that would be treated promptly in a young American is likely to become chronic in his African counterpart. "After a couple of weeks, the person gets used to it and resumes having sex," says Dr. Myron Essex, chairman of the Harvard AIDS Institute. In crowded African urban centers, the virus has become ubiquitous, threatening to kill off almost an entire generation of young adults.

Few experts believe anything like that is going to happen in the U.S. Most Americans do not have the venereal diseases that make it so much easier for the virus to be transmitted through heterosexual intercourse. The general level of hygiene, the relative isolation of the pockets of infection from the rest of the population and the widespread availability of treatment for sexually transmitted diseases, even among the poor, make it unlikely that an African-style epidemic could sweep across America.

But the U.S. does have trouble spots: the largely African-American and Hispanic ghettos in the East. Widespread needle sharing among drug addicts allowed the AIDS virus to get a solid foothold in major U.S. cities in the 1980s, and now practices such as trading sex for drugs threaten to broaden the problem. AIDS is already epidemic in the poorest neighborhoods of New York City, Newark, Baltimore, Washington and Miami, places where social problems and the lack of good medical care mimic Third World conditions. "The fact that we see sexually transmitted diseases rising in our inner cities is an ominous sign," says Helene Gayle, an international AIDS expert at the Centers for Disease Control.

There are already indications that AIDS fostered in the inner cities may be beginning to creep into outlying areas. In parts of Georgia and Texas, mini- epidemics are appearing. "The fastest growth is in rural areas and small cities," says Sten Vermund, chief of AIDS epidemiology at the National Institutes of Health. Investigators suspect that drug users who contracted AIDS in the city have started to move back to their hometowns, either to be cared for by family members or to try to straighten out their lives. Once there, they may start a chain reaction of local AIDS infections.

But while health officials caution against complacency, they emphasize that < there is no need for most people to panic. The fact is that unless a person has a chronic venereal disease -- or engages in a high-risk activity such as needle swapping or anal sex -- the AIDS virus is not that easy to get. Medical literature is filled with cases in which husbands and wives had sex hundreds of times over several years without passing the virus from one to the other.

It is especially difficult for the virus to move from an infected woman to an uninfected man, as a study published last September in the Journal of the American Medical Association makes clear. A team of scientists, led by Nancy Padian of the University of California at San Francisco, studied AIDS-virus transmission among 379 heterosexual couples. While the scientists found 61 cases in which an HIV-infected man gave the virus to a woman, they saw only one case of an infected woman's giving it to a man. And in that case, the couple engaged in some particularly unsafe practices, including unprotected anal sex and swapping sex partners with members of a "swinging" club.

The initial skepticism that greeted Magic Johnson's explanation of how he had contracted the AIDS virus stemmed from such studies -- and from his reluctance to speak directly to the rumors of bisexual activities in the past. Johnson finally addressed those rumors last week. "I have never had a homosexual encounter," he wrote in SPORTS ILLUSTRATED. "Never."

Such denials are sometimes questioned by medical professionals. Doctors and nurses who minister to AIDS patients say that a heterosexual man who has contracted HIV will often tell his wife and children he got it from a prostitute. But close to death, these same men will sometimes confide that they did have a homosexual experience. Or that they flirted, many years ago, with intravenous drugs. At Sherman Oaks Hospital in California, which has been caring for AIDS patients since 1980, the nurses are no longer surprised. "When a guy says he got it from a woman, we just nod," says a nurse. "It's probably not true, but that's the way most of them want to handle it. And that's fine."

In the end, it doesn't matter whether Magic Johnson got the AIDS virus through heterosexual or homosexual sex. The fact remains that people can get infected through heterosexual contact and that a few simple precautions can sharply reduce -- or eliminate -- those risks. If Johnson can get that message across to those who need it most -- sexually active teens and young adults -- then his outspokenness will have done an immeasurable public service.

There were signs last week that Johnson has already started to make a difference. In schools across the country, teachers hastily organized classes and assemblies to answer the flood of student questions. At Inglewood High School near Los Angeles, where the Lakers frequently practice and Magic's name is magical, Jesse Jackson spoke to the students about AIDS, and the school passed out free condoms. "I hope everyone got one," says Rashieda Lane, 16. "I don't want my friends to catch it."

Americans are likely to hear a lot more about condoms in the coming months. Fox Broadcasting, the fourth largest TV network, reversed a long-standing policy and became the first national broadcaster willing to accept paid condom advertising -- provided the ads stress the health benefits and not birth control. CBS is also reviewing its condom-ad policies.

Government policymakers could be coming around as well. In New York City, where a program that provided drug addicts with clean needles had been canceled, Mayor David Dinkins announced that he had changed his mind and endorsed a new needle-exchange scheme. Even President Bush, who has done little of substance to support prevention campaigns, made the symbolic gesture of inviting Magic Johnson to fill a vacancy on his National Commission on AIDS. Johnson quickly accepted.

Efforts are also being accelerated on the research front. The World Health Organization, which had held up field trials of several experimental AIDS vaccines pending tests on animals, announced last week that it would skip the time-consuming lab trials and test the vaccines on humans in Brazil, Rwanda, Thailand and Uganda, perhaps within two years. In the U.S. the Centers for Disease Control is considering doing the same thing in the country's AIDS hot spots.

Until there is a vaccine or a cure, responsibility for AIDS in America will have to remain where it is now: with the people in danger of getting and spreading it. For the individual considering a casual sexual encounter, wearing a condom -- or abstaining altogether -- can mean the difference between acquiring a deadly virus and avoiding one. For the country as a whole, it can spell the difference between a contained health problem and one that is out of control.

With reporting by Elaine Lafferty/Los Angeles, Andrew Purvis/New York and Dick Thompson/Washington