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Initial Concentration in the Gay Community

Three factors were responsible for the original concentration of AIDS in the male homosexual population in the United States. First, it appears that AIDS originated in Africa as a mutation of an endemic virus and was carried from there to Haiti. Haiti was a popular vacation spot for homosexuals, and male prostitution was widespread among the impoverished Haitians. Irrespective of how the initial introduction of the disease occurred, the second factor was the existence of the bathhouses. These provided large numbers of sexual contacts and a high incidence of other sexually transmitted diseases. It is likely that genital lesions secondary to these other venereal diseases made the spread of HIV easier.

Most important, the rate of spread of diseases is proportional to the frequency of contact with potentially infected individuals and the effectiveness of those contacts in spreading the disease. This becomes critical for diseases such as HIV with a low probability of transmission in a given sexual encounter. Some bathhouse patrons had more than 1000 sexual contacts a year. A very sexually active heterosexual man might have 100 contacts a year. Although HIV was probably introduced into the heterosexual population simultaneously as in the homosexual population, the spread would be less than one-tenth as fast. (While female prostitutes do have large numbers of sexual contracts, women are less effective at infecting their sexual contacts than are men.)

It is important to note that AIDS in Africa is primarily a disease of heterosexuals. It may be spread by nonsexual rituals and the reuse of needles in medical practice. The number of people infected, evidence about modes of transmission, and other vital information have been hard to obtain on these populations. It is clear, however, that the spread follows traditional prostitution patterns. There is also evidence that HIV is primarily transmitted heterosexually in Central and South America.

Currently the percentage of AIDS cases attributable to heterosexual spread is much lower than the number of cases secondary to homosexual contact or drug abuse. The rate of increase of heterosexual cases parallels the rate among homosexual men early in the epidemic. Given that an AIDS case diagnosed in 1990 may represent an infection acquired in 1983 and given the lower rate of spread among heterosexuals, the number of heterosexual cases should continue to increase for many years.

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