HOW AIDS THREATENS ALL OF US

Aids is no longer the disease of a homosexual how it spreads and who is most in danger

THE time when the average Spectator reader could think of the Aids epidemic as being somebody else's problem is past. The disease has spread beyond the high risk groups in which it started and is no longer confined to homosexuals, drug addicts, prostitutes and the victims of contaminated blood transfusions. No better evidence that it concerns all classes regardless of their income group or sexual preferences can be found than in the appointment of Lord Whitelaw as chairman of the Cabinet committee.

Lord Whitelaw has an almost impossible task. It is little wonder that Mrs Thatcher is reputed to have thought the whole subject as politically dangerous as it is personally revolting. The committee has to tread the narrow path between allowing the general public to remain complacent, and the fear that if they become too alarmed there will be a backlash against the high-risk groups who will be further alienated and isolated. As Aids is a problem which has sexual and racial overtones, and where death is the cost of infection, it is not surprising that it will remain headline news. The campaign against it is one in which it will be easier to lose votes than gain mass support, but the cause is one on which the Government will be judged and success would be as great an achievement as several of its other battles.

Britain should not have been taken by surprise by the spread of Aids; we have had the example of America where the epidemic is three years ahead of ours. It should have given us time to take the necessary public health steps to avoid the problems that they are now experiencing. We haven't learnt by their mistakes. Some of the delay in public awareness has been due to the confusion about the number of people affected. This has been caused by the imprecise use of the terms, Aids, Aids virus, HTLV III virus and HIV. Aids is not a single disease, but a syndrome, a collec- tion of pathological conditions which have occurred as a result of opportunist infec- tion or malignant disease taking advantage of weaknesses in the body's defence mechanism following attack by a virus, HIV, previously known as HTLV III and colloquially referred to as the Aids virus. As there is a long period of latency between infection with HIV and the de- velopment of the final and invariably fatal syndrome, Aids, the figures for Aids are only a very small fraction of the number of people in the community who are HIV sero-positive (30-50,000) and therefore in- fectious.

Initially it was supposed that only one in ten of HIV positive people would later develop the full syndrome; this forecast is now known to be wildly inaccurate. In- formed British opinion is that 30 per cent of patients who are found to be HIV sero-positive will have developed Aids within five years, but recent work from Frankfurt suggests that even this figure is too encouraging. In a report based on a study since 1982 of 543 people who are the sexual partners of Aids victims 50 per cent of those who were carriers developed Aids within five years and the team estimate that 75 per cent will have done so within seven. Although this is the gloomiest report yet published, some British specialists are saying privately that it must now be assumed that the great majority, but never all, HIV carriers will become victims of Aids in the fulness of time.

HIV infections run a variable course. A few weeks after infection the patient has a glandular fever-type illness often so trivial that it is not even noticed. There then starts a period of latency which varies from some months to years. There is evidence that a patient's habits during this time can be a factor in the time this remission lasts. Certain events are known to compromise the beleaguered immune system and pre- cipitate its breakdown, thereby hastening the advent of Aids. Intravenous drug users who do not renounce the needle have a notoriously short latent period. Ano-oral contact, perhaps because of intestinal in- fections caught through it, together with other sexually transmitted diseases, as well as tiredness, depression and malnutrition all shorten the time between infection and the development of the syndrome. In the past it was generally believed that the disease would sometimes arrest at stages other than full Aids and doctors spoke of persistent generalised lymphadenopathy (enlarged lymph glands without destruc- tion of the immune system) and ARC, the Aids-related complex which has many of the signs and symptoms of the syndrome but without evidence of opportunistic in- fection or tumour. Unfortunately these conditions are now usually visualised as part of a continuum, milestones on a rough downhill path leading finally to the com- plete syndrome.

Joanna's case is a fairly typical presenta- tion. When Joanna went to her university she was confident that a stable home background and a high school education would ensure a stimulating social life and a reasonable degree. She sat her finals re- laxed and happy, only slightly irritated that a long affair had not survived the summer term revision. She teamed up with a fellow student for the end of term parties although she knew that he had the reputa- tion of being a loner and having ex- perimented with drugs; they slept together on two or three occasions not from any commitment to each other, but merely as part of the final year joie de vivre. Three years later, established in a career and having had another serious boyfriend, she developed a cough, night sweats and weight loss. An astute house physician suspected from tell-tale signs on the X-ray that she might have Pneumocystis carinii pneumonia, the most common way in which Aids presents. He referred her to the sexually transmitted diseases clinic where the diagnosis was confirmed. When she realised that so little of life was now left to her, for survival for two years after the first attack of Pneumocystis carinii is, to put it at its best, very rare, and that she would never experience either marriage or children, she attempted suicide. Cases like that of Joanna are still a rarity. If the disease is allowed to spread, they will become commonplace. Aids will manifest itself in a variety of ways, but whichever system of the body is attacked by opportunistic infection or tumour there is likely to be excessive weight loss and fever. Fifty per cent of patients will present with Pneumocystis carinii pneumonia which gives rise to a persistent dry, unproductive cough, chest pain and a low-grade temperature during the day rising to peaks at night. Other organisms too give rise to chest infection.

Kaposi's sarcoma is the most common tumour to take advantage of the body's weakened defences. It usually appears initially as a skin disease with raised hard, purple patches, but later the tumour can affect any organ of the body. Intractable diarrhoea, widespread thrush and persis- tent herpes are among other signs and symptoms which draw the patient's atten- tion to the disease. Some estimates suggest 60 per cent of HIV positive patients, whatever their Aids state, develop marked cerebral changes akin to pre-senile demen- tia.

Aids can be spread by blood, either used medically or as contamination of addicts' needles, accidentally, from mother to child, or by any sexual intercourse.

Now that Factor 8, made from pooled blood plasma and used in the treatment of haemophilia, is heat-treated, and blood for transfusion is checked for HIV, there should be little danger in the medical use of blood. Needles for ear-piercing, or tat- tooing, and barber's razors must be well sterilised.

Accidental infection is uncommon. A nurse is known to have become HIV positive after pricking her finger with a needle, and there is anecdotal evidence that a person with severe eczema who cared for an Aids patient became sero positive, but otherwise the risks of accidental infection seem low, for HIV, the Aids virus, is, as viruses go, not particu- larly infectious. There is no risk in shaking hands, nobody has been shown to catch it from sharing a washbasin, bath or lavatory and there is no evidence that it has ever been caught from any cup, cutlery or crockery.

Drug addiction remains an important source of infection, and addicts and bisex- ual people remain the main bridges over which infection spreads from the homosex- ual to the heterosexual community. Unfor- tunately the more effective the police are in tightening their hold on drug-based communities the more the addicts share needles and the higher the cost of heroin, so that they are less likely to inhale heroin and more likely to mainline it. Needles should be made available to known addicts.

Sexual intercourse whether heterosexual or homosexual is the predominant way in which the disease is spread. As it becomes established, the proportion of women to men who are infected increases. In Amer- ica the proportion in some centres is now two men to each woman. In Africa it is about one to one. In Britain, official estimates put it (optimistically) at 30 to one. Aids is essentially a venereal disease, but unlike other venereal diseases it cannot be cured and is fatal. The virus can enter the recipient's body through either the urethral, genital or rectal mucosa and probably also enters through the intact mucosa of the mouth. The relative thinness of the rectal mucosa was never designed to withstand the trauma of copulation, which partly explains why anal intercourse is so potentially infectious. Minor trauma in intercourse which causes trivial bleeding heightens the chance of infection. The cervix in women, particularly if they are on the pill, will often bleed on touch, and anal, unlike vaginal penetration, is rarely achieved without some slight bleeding and fissuring of the perianal skin. The gums are notoriously apt to bleed which adds danger to oral sex. Saliva contains the virus, but probably not in large enough quantities to be infectious, but blood, semen, vaginal and cervical secretions are all perfect media to carry the virus. Kissing on the cheek is therefore safe, but deep French kissing has a theoretical risk, oral sex an obvious hazard. Anal or vaginal inter- course are the usual ways in which the infection is spread with ano-oral or oro- genital sex as other high-risk activities. If sexual intercourse is to take place outside an established relationship, the wearing of a condom will greatly reduce the risk in both homo- and heterosexual intercourse, but in the former case it is essential that the extra strong pattern should be used.

Treatment at the moment is directed at treating the infections and tumours as they arise; the various antiviral agents and AZT inhibit rather than cure the disease. It is thought that it will be 15 years before a vaccine is produced.

Lord Whitelaw's campaign must be particularly addressed to those sections of the community which have customarily been sexually rather promiscuous; the leader in last week's Spectator was the first to mention the two groups which are thought to be most at risk, students and the West Indian community — which has traditionally had a very different domestic background from the indigenous popula- tion. It is unlikely that the West Indians will readily change their approach to sex and marriage. As a venereologist, I have chatted to many hundreds of them over the past 15 years, and they always make it clear that they consider their way of life which, for the young male, includes multipart- nership, is in no way inferior to the standard British approach. Widespread in- fection in either group would produce the most appalling social, racial and medical problems. Although there is overwhelming public demand (more even than for capital punishment) for compulsory testing for Aids, this would, as well as being highly impractical, have other disadvantages, one of the troubles being that it may take several months after an unwise sexual contact for the blood test to become positive and a false negative result can still be obtained even after the patient has become infectious. However, it would seem essential that there should be a vigorous campaign for testing to be made generally available and that certain public figures can lead the way. Who can forget the effect of Michael Parkinson in the vasectomy campaign, or the Royal Fami- ly's example over whooping cough vaccina- tion?

Failure of patients in high-risk groups to determine whether they have been infected may preserve their peace of mind for some additional years, but only at cost to the community. Consider the case of George, whose behaviour placed his wife, his youngest child and medical staff in hazard. George is a parson; his stipend was sup- plemented with private means so that he was able to enjoy a reasonable standard of living and when he needed routine abdo- minal surgery had it done privately. The operation was straightforward, but his convalescence was made stormy by chest complications and a wound which would not heal. The physician to the surprise of the surgeons suggested Aids as a reason for the post-operation infection. George, it transpired, had always been bisexual, although he had never admitted these tendencies to anybody. Surgery even if uncomplicated would represent a hazard to the medical staff; as it was, his wound oozed a bloody discharge for several weeks before the cause was discovered.

Aids, like indeed many other venereal diseaes, is now rife in sub-Saharan Africa. Over a million people are expected to die from the disease in an area whch is already so plagued with other sexually transmitted diseases that they form between 20 and 40 per cent of all gynaecological out-patient attendances in this. community. Fifty per cent of the women are infertile and 80 per cent of this is due to sexually transmitted disease; between five and eight per cent of all children who survive their third month later die from syphilis; and cervical cancer is the .commonest malignant disease. There is therefore a case for testing immigrants from this area, but only at great diplomatic cost as it would inevitably be seen as a decision taken on grounds of race rather than health. However, in order to avoid introducing one high-risk group to another, students from Africa and Amer- ica could be required to be tested before they take up a university place.

Evidence from a study of other sexually transmitted diseases among homosexuals shows that some changes can be made in the pattern of sexual behaviour as a result of advertising. A few million spent now on television to drive home the point that the permissive era is over, that monogamy alone is totally safe, and that sexual inter- course with a stranger without a condom is dangerous, may yet save Britain from medical and social problems, the like of which have not been seen for centuries.

Dr Thomas Stuttaford is medical corres- pondent of the Times.