The New York Times - November 5, 1985
Erik Eckholm

Other scientists believe that consorting with prostitutes has already caused some cases of AIDS in men, and that if current trends continue prostitutes could transmit the virus to many men, who in turn will infect their unsuspecting wives and lovers.

None of the experts see the AIDS virus coursing through the heterosexual community the way it has among homosexuals and intravenous drug addicts over the last six years. But the outcome of the debate will influence whether authorities single out prostitutes for AIDS-related testing, pursue special campaigns to educate the women and their potential customers about the dangers or contemplate new curbs on prostitution.

By all accounts, the number of AIDS cases spread by prostitutes in the United States has been minuscule. The number of men whose AIDS is attributed to sexual relations with any woman, in fact, remains small: only 16 cases out of the more than 14,000 reported to date. However, heterosexual contacts, including visits to prostitutes, are the prime suspects in scores of other unexplained cases of AIDS, an incurable disease that destroys the body's immune defenses.

Federal authorities say more than one million Americans, only some of whom will become ill as a result, may now be carrying the AIDS virus and can potentially spread it to others.

The controversy over prostitutes turns in large part on a related debate over the ease with which the AIDS virus can spread sexually from women to men. "Prostitutes pose a theoretical risk of AIDS transmission, but not a practical one," said Dr. Stephen Schultz, Deputy Health Commissioner for Epidemiological Services of New York City. "If it has occurred at all it has been very, very infrequent." City officials do not attribute a single one of the city's 4,821 AIDS cases to sexual relations with a prostitute, although some private physicians believe this is true of several cases.

Other scientists point to areas of central Africa where, many researchers contend, the virus is being spread sexually from women to men with some regularity, especially by prostitutes. These scientists worry that through prostitution and other routes the AIDS virus may become widely embedded in the American heterosexual community years before the resulting surge in AIDS cases makes this known.

"We still don't know how efficient the transmission of the AIDS virus is" from women to men, admitted Dr. Michael Marmor of the New York University Medical Center. "But waiting for AIDS to break out is waiting too long."

Dr. Marmor said he had urged the city to survey prostitutes for AIDS virus infection more than a year ago and that "things haven't moved as quickly as they could have." In his view, better information about the prevalence of infection among prostitutes could then form the basis for strong warnings about the danger to potential customers of prostitutes, including out-of-town visitors.

"I wouldn't fool around," Dr. Marmor said. "I'd say caution in this case means protecting people too much rather than too little."

Children Born With AIDS

Dr. Schultz, on the other hand, argued that, in view of the lack of evidence that prostitutes are spreading AIDS, sharper focus on them would only deflect resources from far worse threats. "The real up-and-coming story," he said, "is the sexual partners of drug addicts, and their babies. We have 85 children born with AIDS in New York and the number is increasing rapidly."

All the experts agree that men consorting with prostitutes should use condoms, both for their own safety and that of the women.

But AIDS experts warn that condoms cannot provide foolproof protection. "Obviously it's much better to use them than not," said Dr. Robert C. Gallo of the National Cancer Institute, a leading researcher on the AIDS virus. "But we don't know what aspects of intimate contact might spread the virus. Maybe its heavy salivary exchange, or being bit in the mouth. We just don't know yet."

Considerable debate about prostitutes and AIDS was provoked by a report in the Oct. 18 issue of The Journal of the American Medical Association. Written by Dr. Robert R. Redfield of the Walter Reed Army Institute of Research and other researchers, the study described nine military men with AIDS or related disease whose only apparent exposure to the virus had been multiple heterosexual contacts, including visits to prostitutes in the United States or abroad. "Prostitutes could serve as a reservoir for HTLV-III infection for heterosexually active individuals," the scientists concluded. HTLV-III is a name for the AIDS virus.

Critics argue that military men are not apt to admit past homosexual encounters or drug use since that can lead to a dishonorable discharge. Because of this, said Dr. Joyce I. Wallace, a New York physician, "the Army data are highly suspect."

"I think it's inaccurate epidemiology," said Dr. Schultz.

"The skepticism is, I believe, wishful thinking," responded Dr. Gallo, who was a co-author of the disputed report. He said the investigations of the patients' histories had been "careful and thoughtful." Pentagon officials would not allow Dr. Redfield, who directed the study, to comment.

"Why should there be any shock that men have been infected by prostitutes when this has been abundantly shown in Africa?" Dr. Gallo asked.

Dr. Gallo said that while the sexual spread of the AIDS virus from women to men is far less frequent than the reverse, he is nonetheless "positive" it can occur. "I'm certainly concerned that prostitutes may spread AIDS," he said.

Preliminary studies show that some prostitutes in several American cities are infected with the AIDS virus. In Miami, 10 of 25 prostitutes who visited a clinic for testing had antibodies to the AIDS virus in their blood; 8 of the 10 admitted to intravenous drug use. In Seattle, 5 of 92 prostitutes tested showed the antibody, a sign of probable viral infection.

New York Study Is Under Way

In New York, a state-financed survey of AIDS infection among prostitutes is under way. Right now, the prevalence of the virus among prostitutes here can only be imputed indirectly from estimates of drug addiction, believed to be their major source of AIDS infection.

According to Don Des Jarlais of the state's Division of Substance Abuse Services, drug addiction among prostitutes exists mainly among the subgroup called streetwalkers. "On the basis of interviews with arrested street prostitutes," he said, "it's clear that a substantial minority, perhaps one-third, inject drugs." Surveys indicate that from 50 to 60 percent of New York City's 200,000 intravenous drug addicts, most of them black or of Hispanic descent, now carry the AIDS virus, which is spread by shared needles.

Dr. Des Jarlais said the evidence suggested that since the late 1970's some New York streetwalkers have harbored the AIDS virus. However, he added, "we haven't seen the cases of AIDS among their customers that we should have seen by now if they were transmitting the virus on a significant scale."

He said this was apparently because most New York prostitutes use condoms and avoid exchanges of body fluids. "This is something prostitutes began promoting among themselves even before AIDS, for which we can be thankful."

Arleen Carmen, director of a Judson Memorial Church social program for prostitutes and co-author of "Working Women," a book about New York streetwalkers, confirmed that the city's prostitutes routinely require their customers to use condoms in both vaginal and oral sex. She said there is no evidence that prostitutes are spreading AIDS, and she said she feared that "they are becoming scapegoats."

Miss Carmen, who said she has talked with hundreds of New York streetwalkers over the last eight years, also challenged what she called the "myth" that large numbers of them are drug addicts. "I know what the attitude among these women is," she said. "A woman who is a junkie is scorned by the rest. And no self-respecting pimp would want to keep a woman who is shooting up all the money she makes."

Role of Male Prostitutes Cited

Most experts believe that male homosexual prostitutes are likely to be spreading AIDS on a far larger scale than female prostitutes, and note that the patrons include bisexual men who can in turn infect women.

"We've seen a few male prostitutes in the hospital with AIDS," said Dr. Fred Valentine of the New York University Medical Center. "By now, it's virtually certain that all of them are infected."

Thousands of juvenile males, many of whom were rejected by their families or foster homes for being homosexual, are homeless in New York and subsist by selling their bodies, said A. Damien Martin, director of the Institute for the Protection of Lesbian and Gay Youth. "A high percentage of their customers" are married men, according to Mr. Martin.

A recent case in Houston, where a male prostitute known to have AIDS persisted in his trade until finally persuaded by health officials to enter a hospital, has led Texas officials to request authority to quarantine individuals with AIDS.

"We have no intention of quarantining the average AIDS case," said Robert Bernstein, the Texas state health commissioner. "But if we encounter an incorrigible individual, this would give us the means to deal with it legally. I wouldn't think this would happen very often."

Mr. Martin, whose institute provides assistance to homosexual youths, argued that the way to get young prostitutes off the streets is "to give them homes, jobs, and education."

Officials in San Francisco have mounted an unusually comprehensive education campaign against AIDS. "Since last year we've told everybody, male or female, gay or straight, not to have unprotected sex with anyone who has had multiple sex partners since 1978," said Dr. Dean F. Echenberg of the San Francisco health department.

But Dr. Echenberg said he saw no role for the quarantine of AIDS-infected prostitutes or other sexually active individuals. "It's not like TB or typhoid," he said. "With AIDS, it takes a consensual act to get infected. Public education is the most important thing." Viral Infection And Disease HAMPERING all predictions about the future course of AIDS is ignorance about how many of those carrying the AIDS virus will eventually develop acquired immune deficiency syndrome or other disorders. And, because most AIDS cases appear years after infection, today's pattern of viral spread in the population will only become evident in the years to come.

A few people have been diagnosed with AIDS within a few months of their infection, according to Dr. Dean F. Echenberg of the San Francisco Department of Health, but most have taken years and new cases are still appearing among people infected five years ago.

Current estimates are mainly drawn from a group of homosexual men in San Francisco whose blood had been sampled in a different study in 1979 and 1980, just after the AIDS virus is believed to have appeared there. Of those who have been infected for five years, 8 percent have developed AIDS and another 30 percent the lesser, though sometimes fatal, symptoms of AIDS-related complex. Scientists cannot predict how many more will develop AIDS or other ailments that might be caused by the virus. Nor can they say whether the disease pattern of this sexually active group of homosexuals accurately foretells that of others.

Based on these and other limited data, Federal experts simply estimate that between 5 and 10 percent of individuals develop AIDS within five years of infection. "It's clear that the majority of people infected so far have had no consequences for their health at all," said Dr. Peter Drotman, an epidemiologist at the Centers for Disease Control. "But whether they'll stay that way for the rest of their natural lives we truly don't know."

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