He, She and HIV
The following week Johnson accepted President Bush's invitation to join the National Commission on AIDS, a 15-member group headed by Dr. June Osborn. "Magic Johnson's courage was extraordinary," says Osborn, 54. "He is turning his experience into something that can benefit everyone, including people with HIV."
Osborn says, however, that a massive job of public information remains to be done. "We are moving closer to an epidemic that affects everybody," she warns, citing an inexorable trend toward heterosexual transmission. Dean of the University of Michigan School of Public Health and a professor of pediatrics and communicable diseases at the university's medical school, Osborn has been an adviser on AIDS science and public policy since 1983. She is a member of the World Health Organization's Global Commission on AIDS.
In a talk with correspondent Giovanna Breu, Osborn detailed what is currently known—and not known—about heterosexual transmission of the AIDS virus.
Magic Johnson says he tested HIV positive but that he does not have AIDS. What is the difference?
HIV, or human immunodeficiency virus, is necessary for AIDS to develop. It sets the stage by infecting key cells in the immune system and then over time depleting the body of those cells so that ultimately the infected person ends up defenseless. The defenseless-ness sets the stage for the infections and tumors that make up Acquired Immune Deficiency Syndrome.
If you are my positive, does it mean you will get AIDS?
After sexual transmission, the interval between infection and symptoms of AIDS usually ranges from 5 to 10 years. It can be shorter, and we do know of individuals who have been infected as long as 13 years and are still well. Given the long, silent interval before disease strikes, the virus is a real microbiological time bomb.
Magic got a lot of people's attention when he announced he had been infected through heterosexual sex. What percentage of people with the virus have been infected in this way?
That's a hard question to answer. I can give you the lower limit, which is about six percent of the total of 200,000 people in the U.S. who have had AIDS. This, however, is an out-of-date snapshot. Most of those who are now sick with AIDS were infected in the early '80s, when the so-called risk groups were predominantly gays and intravenous-drug users. Last year the number of heterosexual AIDS cases increased 40 percent.
How transmittable is the virus from male to female during vaginal intercourse—and vice versa?
We do not know enough about the nature of transmission to quantify the risk exactly, but we do know of numerous cases in which a female has been infected after a single instance of vaginal intercourse with an HIV-positive male.
Some studies have shown that the risk can be substantially greater to a woman than to a man, which makes sense considering that the whole vaginal area in a woman is exposed to the infected semen, which can remain there for some time.
What role, if any, do genital lesions—the open sores that often result from venereal diseases—play in heterosexual transmission?
Viruses do poorly in getting through intact skin. Whenever the skin is broken down, there is a wider area of cells that can be infected.
How many cases have been discovered of female-to-male transmission of the virus, through vaginal sex, in the absence of genital lesions?
We don't have official statistics on this, but one recent study of 379 heterosexual couples showed that while 20 percent of the women contracted HIV from their partners, only 1.4 percent of the men were infected by theirs. Another study, however, has indicated a more equal transmission in both directions. In general, heterosexual contact accounts for 75 percent of the world's AIDS cases. We believe that the epidemic in the U.S. will one day have a very similar pattern unless heterosexuals take dramatic steps toward safer sex.
Is oral sex any more or less dangerous than vaginal sex?
Oral sex might occasionally be dangerous, particularly if there are lesions in the mouth. However vaginal sex presents a much greater risk.
What about anal sex?
Anal-receptive intercourse is especially risky—the virus seems to enter the system more efficiently through anal tissue than vaginal. Heterosexual anal sex is often used as a poor man's contraceptive in many parts of the world, including ours; it is also a way to preserve the physical evidence of virginity, which is often much prized. We need to know more about heterosexual anal sex, but we aren't allowed to ask: In recent months two major proposals for a systematic study of American sexual behavior have been canceled by the government.
How about deep kissing?
No, this doesn't appear to be risky. You can occasionally catch tiny traces of HIV in saliva, but transmission through deep kissing alone has never been proved.
Are there different stages of infection when the HIV virus is more likely to be transmitted?
Yes, in the very earliest stages—before antibodies begin fighting off the virus—and in the very last stages, when the virus has overwhelmed the immune system.
What can people do to protect themselves?
The best defense is abstinence, but if that's not feasible, then proper condom use.
Not everyone knows how to use a condom. First of all, even pre-ejaculate fluid can carry the virus. Exchanging bodily fluids during intercourse just shouldn't happen. It is terribly important that a condom be worn at the beginning of things, and it should be kept on until disengagement.
Are all condoms effective?
No, only those that are made of latex should be used. The so-called natural condoms—lambskin, for example—are not effective in stopping the virus. Furthermore, oil-based lubricants, such as Vaseline, should be avoided because they destroy the integrity of the latex, and the condom can start leaking like a sieve.
What do you say to men who think condoms are unromantic?
I think they ought to go volunteer to work with people living with HIV and AIDS and rethink it. Go find out what we're talking about, and then see if they can't redefine "romantic." Some people are advocating teaching women to put on the condom in an erotic way and build it into the sexual foreplay.
Is there any other way to effectively block the virus?
No. Remarkably, you'll find a lot of adolescents who think that birth control pills protect them. They don't. There are some studies that suggest that nonoxynol-9, the most common of the spermicides, used with a condom, probably adds a measure of protection because it has a virus-killing effect. But, I repeat, none of this works without a condom.
Should women provide their own condoms?
Absolutely. It's really quite important for young women to carry their own condoms and, if necessary, have a little empowerment training about insisting on the use of condoms. Probably a lot of young women could be helped by learning in peer-group counseling how to say no. As a society we need to get past the point in which discussing condom use immediately raises issues of trust.
Are there any other risk activities?
Yes, substance use. Sharing injection equipment is always very dangerous. The combination of sex with alcohol and other kinds of mood-and awareness-altering drugs is risky behavior. Alcohol diminishes judgment and makes your memory rather hazy too. Did I put the condom on before anything else happened? All that stuff gets fuzzy if you're fuzzy.
Witt an AIDS test tell you if you are HIV negative?
Yes, as long as you weren't infected within the past three to six months. It can take that long for the virus to show up in an AIDS test. Even if you have asked your partner, "Are you HIV positive," and he or she says, "No, I just tested negative," that is not enough of a guarantee. You can infect your partner, even while testing negative, if you have been freshly infected yourself.
You call this disease a diabolical nightmare. Why?
It's striking people down in the prime of their lives, oftentimes years after they've rethought lifestyles. We are losing the Prousts and Tchaikovskys of our generation before their talent has had time to bloom. It's a deadly disease. It's a horrible disease. It can be a terribly painful disease. And it's just leaching a generation of talent from this country.