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The Community Education Argument

The third argument against intrusive disease control measures is that they are unneeded because community education programs can control spread of HIV infection. This is supported by reference to the reduced number of new AIDS cases in the San Francisco gay community. This low rate of new AIDS cases, however, represents saturation. Saturation occurs with HIV when the probability of a sexual contact between an infected and an uninfected person drops below the probability of transmitting the disease through a given contact. Most of the highly sexually active individuals were infected in the late 1970s and very early 1980s. This accounted for perhaps 50 percent of the gay men in San Francisco.

Saturation in this subgroup does not mean that the disease is under control. Sexual contact networks are relatively stable, with relatively little intermixing of the various social subgroups. If the subgroup contains few or no HIV-infected persons, there will be slow or no transmission of HIV in the group. The great majority of the most sexually active gay men have already died of the disease. While most of the remainder have reduced their unsafe sexual activity, many were never highly promiscuous.

The gay man with 1000 sexual contacts a year is an unfortunate stereotype that does not, and never did, describe most gay men. Sexual activity in the gay community has a multimodal that parallels the heterosexual community. This has the same implications for gay men as it does for the heterosexual community: the high rate of HIV transmission and the rapid saturation of the the most sexually active subgroup mask the lower but inexorable rise of HIV infection in the much less sexually active majority of gay men.

A greater threat to controlling the transmission of HIV is the influx of young gay men into San Francisco who are engaging in high-risk sexual activity at much higher rates than the existing community. It appears that it is not community education that reduces the incidence of unsafe sexual activity but the personal experience of witnessing the sickness and death of one's friends. While this personal experience may profoundly affect the behavior of older gay men in urban centers, it is largely irrelevant to younger gay men, intravenous drug users, and women.

Perhaps the most important factor that limits the usefulness of the experience of older, urban gay men is the special demographics of that community--a relatively affluent, well-educated group without dependent children. They bear little resemblance to the poor, minority, young, and increasingly female populations accounting for many new cases of HIV infection. These women are less able to protect themselves by safer sexual practices because these depend on the cooperation of their male partners. They are at the mercy of their partners both to take precautions and to inform them of their HIV status. These women can benefit from disease reporting and contact tracing to warn them when they and their children are at risk of HIV infection.

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