And the Band Played On

by Randy Shilts

  There was, of course, no question of what Silvana would do tonight. Tony couldn’t work. He certainly didn’t want her to stop working either; that would mean the end of his heroin.

  “It’s the drugs,” she concluded. “It’s like what they say on TV. You get in and you can’t get out.”

  That was why Silvana was going back to the streets that night. Yes, she was worried about spreading AIDS. In fact, her lymph nodes were swollen, her sleep was disturbed by chronic nightsweats, and she felt dog-tired all the time. But she had to work. She didn’t know any other way to make money.

  The next morning’s front-page story about a prostitute raised all the profound public policy questions implicit in the case of a working hooker who almost certainly was an AIDS carrier. Dr. Paul Volberding talked about how the prostitute posed a “monster of a public health issue,” with its classical conflict between public health and individual rights. Other news coverage of Silvana Strangis, however, was less delicate.

  “A human time bomb is walking the streets of San Francisco,” announced the grim anchor at the top of the local evening news that night. Another newscast likened her to “Typhoid Mary.”

  All weekend, television crews trolled the Tenderloin in their Instant Eye vans, trying to interview anxious streetwalkers. Frightened callers to talk shows almost unanimously opined that the police should lock the woman up and quickly discard the key.

  Silvana became such an instant persona non grata in her neighborhood that she was literally chased off the streets and into her residential hotel lobby by four angry prostitutes who threatened to have her stabbed to death if she left her hotel again. The news stories, it turned out, hadn’t done much for business. It seemed every John looking for action that weekend started negotiations by asking, “Are you the one with AIDS?”

  The uproar illuminated the profoundly heterosexual male bias that dominates the news business. After all, thousands of gay men had been infecting each other for years, but attempts to interest news organizations to pressure the city for an aggressive AIDS education campaign had yielded minimal interest. A single female heterosexual prostitute, however, was a different matter. She might infect a heterosexual man. That was someone who mattered; that was news.

  Although evidence of heterosexual AIDS transmission could be dated back to the first epidemiological studies by the Centers for Disease Control in the summer of 1981, it was not until early 1985 that the straight links of the disease garnered much attention. The most disconcerting stories came from Central Africa, where AIDS was simply called “the horror sex disease.” Although image-conscious African governments swore to silence the researchers working within their borders, leaks confirmed that thousands of immune-suppressed people were dying in black Africa, usually from gastrointestinal parasites, the most common opportunistic infections of that region. Unaware of foreign acronyms, Ugandans had dubbed AIDS “slim disease” because of the wasting away that marked the virulent parasitic diseases.

  In scientific forums, European researchers working closely with teams in Central Africa were the most outspoken about the heterosexual dimension of the epidemic. These doctors, largely in Belgium and France, had always considered the preoccupation with the gay angle of AIDS to be a strange American idiosyncrasy. Given the experiences of such nations as Zajre and Rwanda, these doctors warned that the Western world should not be complacent about the threat that this new sexually transmitted disease posed to all people.

  In the United States, the most aggressive research on heterosexual AIDS transmission came from a most unlikely source, the U.S. Army. From his work at the Walter Reed Army Institute in Washington, D.C., Dr. Robert Redfield had documented the ease of male-to-female sexual transmission of AIDS. Of seven married male sufferers of AIDS and ARC, for example, Redfield found that five had wives who were infected with HTLV-III. Of these five wives, three were already showing clinical symptoms of ARC. The fact that one-third of military AIDS and ARC cases claimed that prostitute contact was their only risk behavior also made Redfield a passionate proponent of the threat posed by female-to-male AIDS transmission. His case, however, was problematical because the military was by now routinely dismissing gay servicemen suffering from the syndrome. That provided powerful motivation for military personnel to blame prostitutes rather than homosexual contacts for their infection.

  The question of female-to-male AIDS transmission had exploded in San Francisco not long before, when Dr. Paul Volberding at the AIDS Clinic held a press conference to announce the first two local AIDS cases among heterosexual men who claimed no other high-risk activity than sexual relations with intravenous drug-using prostitutes. In San Francisco, the new cases were something of a revelation because AIDS had remained an almost purely gay phenomenon in that city. More than 98 percent of the city’s caseload were gay or bisexual men; the transfusion AIDS cases and five drug addicts were the exception proving the rule that, in San Francisco, AIDS was a gay disease.

  “We don’t usually call a press conference to announce every new AIDS case,” Volberding admitted when he announced that two straight men had contracted the disease from women. “But we shouldn’t lose track that this might be our last chance to halt an epidemic among heterosexuals.”

  Days later, Volberding’s concern was underscored with the diagnosis of the first local woman to contract AIDS through a heterosexual liaison. Within days, she was in Ward 5B, the first woman on the AIDS Ward, staring at the stark landscape outside her window and wondering how a tryst with a bisexual man several years before had brought her here.

  Dr. Mervyn Silverman, in his last weeks as health director, announced that the health department would start updating brochures to include risks to heterosexuals. A new task force was organized to start laying groundwork for more elaborate educational plans in the future. Volberding took things a step further when he suggested that city epidemiologists begin sexual contact tracing on every heterosexual AIDS case. Dr. Dean Echenberg, who had replaced Selma Dritz in the Bureau of Communicable Disease Control, took what became the standard public health argument against such tracing, saying that even if the tracing turned up infected people, there was no medical treatment to offer them. “You might cause a tremendous amount of damage without doing any good,” Echenberg said. Volberding countered that the people who might later get infected from such contacts, however, would not see it that way.

  This medical point of view did not prevail. AIDSpeak still dominated public health decision making, and those rules decreed that, even in a deadly epidemic, you weren’t supposed to do anything that might hurt somebody’s feelings.

  For all the concern about heterosexual transmission—and the role prostitutes might play in spreading the disease—there was probably no aspect of the epidemic in which the facts were more arguable. At this point, only 50 AIDS cases nationally were linked to heterosexual transmission. Of these, 45 were women and only 5 were men who appeared to have no other risk except sexual contact with infected women. Five out of nearly 8,000 AIDS cases reported nationally did not constitute an epidemic. And there could be no certainty that those 5 men, 2 of whom lived in San Francisco, were not gay men who were too ashamed to admit it.

  The mechanics of female-to-male transmission also were problematical. Which female body fluids are as invasive to men as semen is during vaginal or anal intercourse? In Africa, transmission appeared possible when vaginal fluids connected with blood through open sores stemming from untreated venereal disease. In the United States, venereal disease was almost always treated, and female-to-male transmission was rare. To be sure it did exist, and numbers would probably increase as more women became infected with the virus. However, heterosexuals had no amplification system comparable to the gay bathhouses to speed the virus throughtout the country. In the future, heterosexual AIDS would remain a problem for the people it had already struck; sexual partners of intravenous drug users, concentrated largely among poor and minorities in eastern urban cities. It seemed unlikely that
the epidemic would suddenly become a heterosexual blight in the way it had swept the gay community.

  Perhaps no single aspect of the epidemic was as instructive in this point than the AIDS-carrying prostitutes. Even while the Silvana Strangis story raged on the front pages, UCSF researchers were completing their journal article on the first person in the United States known to have been infected with the AIDS virus. The first documented carrier was not a gay man, they said, but a San Francisco prostitute. This woman, like Strangis, had a long rap sheet of Tenderloin arrests related to prostitution and intravenous drugs. In 1977, the woman, who was then twenty-five years old, gave birth to a baby girl who began showing signs of immune deficiency eleven months later. While the infant’s condition deteriorated, the mother gave birth to a second girl in 1979. This child also showed signs of immune abnormalities, including chronic diarrhea and swollen lymph glands. A third daughter was born in April 1982. Within two months, she had candidiasis in both her mouth and vagina. Three months later, doctors blamed her breathing problems on Pneumocystis. By 1984, two of the three children were dead. Any mystery about the source of their immune problems was resolved when UCSF researchers tested their stored blood samples for HTLV-III antibodies. All three children were infected. The mother, who suffered from swollen lymph nodes in 1982, clearly was infected with the virus as early as 1977 and possibly 1976, shortly after the virus arrived in the United States.

  During all these years of infection, the woman had been an active prostitute in the Tenderloin, as she would continue to be until her death in May 1987. If she was easily spreading the virus to her clients, there had been plenty of time for the stricken men to surface. Yet, San Francisco counted only two male heterosexual cases. Similarly, New York City was not teeming with straight men blaming prostitutes, even though that city’s legion of drug-shooting hookers dwarfed the number of such women on the West Coast. Taken together, it appeared there was more smoke than fire in the prostitution-AIDS debate.

  Nevertheless, the outpouring of official attention to the handful of heterosexual AIDS cases in early 1985 proved a crucial event in determining the direction of AIDS debate in the next two years. It instructed health officials and AIDS researchers, who had had such a difficult time seizing government and media interest in the epidemic, that nothing captured the attention of editors and news directors like the talk of widespread heterosexual transmission of AIDS. Such talk could be guaranteed air time and news space, which, in the AIDS business, quickly translated into funds and resources. Thus, even though epidemiological support for fears of a pandemic spread of AIDS among heterosexuals was scant, few researchers would say so aloud. There was no gain in taking such a position, even if it did ultimately prove to be honest and truthful. Five years of bitter experience had schooled just about everyone involved in this epidemic that truth did not count for much in AIDS policy.

  January 10

  Cathy Borchelt was at work in the San Francisco Police Department’s record room when a co-worker handed her the morning Chronicle and asked about the story on page eight. It was an announcement by the Irwin Memorial Blood Bank that an ailing, unnamed woman at Seton Medical Center had contracted AIDS through blood provided by Irwin in August 1983.

  “Is that your mom?”

  It was the first time anybody in the Borchelt family was informed that Frances was indeed suffering from transfusion AIDS.

  “I’ve been suspecting this because the doctors said she had Pneumocystis,” Cathy said as she scanned the story.

  “There’s a lot of Pneumocystis going around,” her colleague agreed.

  Cathy knew her mother was an intensely private woman and would not want to see anything about herself in the newspaper, even if it did not carry her name. She called the hospital to make sure nobody put a copy of the Chronicle in her room.

  That evening at the hospital, Cathy was watching television with Frances when the newscaster began talking about the new transfusion case in Seton Medical Center. Frances Borchelt shook her head sadly at the news.

  “That poor lady,” she said. “If it were me, I’d sue.”

  Cathy was shocked. Obviously, nobody had told her mother yet that she had AIDS. That night, Bob Borchelt insisted that the doctors tell Frances what had happened.

  The next day, Frances didn’t say anything about the conversation she had had with her doctor, although the family noted that she seemed depressed.

  The woman in Seton Medical Center was the 100th American known to have contracted AIDS through a blood transfusion, Irwin president Brian McDonough said the next day. As part of a new policy of openness, Irwin was now publicly announcing each new case of transfusion AIDS. The intent was to allay any suspicion that the blood bank was whitewashing the transfusion-AIDS problem. In revealing Frances’s diagnosis, McDonough added that thirty-two AIDS patients had donated blood to Irwin in recent years and that at least seventy-two local people had received blood products from these donors. The blood bank expected another two dozen AIDS cases from recipients of its products in the next year.

  The Irwin policy of candor infuriated other blood bankers who were still clinging to their one-in-a-million rhetoric, if not declining comment on the problem of transfusion AIDS altogether. Blood bankers were anxious to get the entire AIDS problem behind them. That would happen with the release of the HTLV-III antibody test, when at last they could pronounce the blood supply safe from AIDS.

  The Food and Drug Administration had announced a February 15 release date for the screening test. Local public health officials and gay organizations, however, continued to be concerned about its vast policy implications. In few issues had social, political, psychological, and medical variables converged to create such a policy morass.

  Surveys of gay men indicated that as many as 75 percent planned to take the antibody test once it was available. Concern soared that, once blood banks started screening, the men would go to a blood bank and donate blood in an effort to learn their antibody status.

  Meanwhile, scientists were uncertain as to the accuracy of the test. Dr. Robert Gallo said in early January that the test might not detect between 5 and 30 percent of AIDS virus carriers. The problem stemmed both from the test’s accuracy and the fact that it did not appear that people developed detectable HTLV-III antibodies until six weeks after infection. Thus, somebody recently infected with the AIDS virus would not test positive on the antibody test. This left health officials worried that if gay men donated blood to learn their antibody status, some infected blood might slip through the AIDS screening, further contaminating the blood supply.

  Added to these fears was the growing anxiety about the civil liberties implications of blood testing among gay men. With as many as one-half of gay men testing positive for HTLV-III in some studies, it appeared that the test could well become a de facto test for sexual orientation. Access to test results could possibly result in widespread discrimination against gays by employers, insurers, or a government that might turn repressive toward gays in future years.

  All this could happen even while the medical value of the test remained in some doubt. Official estimates still put the number of antibody-positive people who would develop AIDS at between 5 and 10 percent, although it was still not possible to predict which group that might be. Because the test had little predictive value, therefore, the newest axiom of AIDSpeak became “the test doesn’t mean anything.”

  Translating all these concerns to policy became the task of Dr. Mervyn Silverman, who was president of the U.S. Conference of Local Health Officers. Silverman put together a proposal that seemed to meet everyone’s needs, seeking money for alternative test sites in which gay men and other concerned people could be tested outside the blood banks. Silverman also wanted the government to issue regulations assuring the confidentiality of blood bank test results, so employers or government agencies could not subpoena them for purposes unrelated to protecting the blood supply.

  The proposals were greeted with enthusiasm at t
he Centers for Disease Control, which had long grappled with the complexities of AIDS policy. In meetings with federal officials, however, Silverman ran into a brick wall of resistance. The alternative test sites would cost money, he was told, and the federal government had no plans to expend more money on AIDS. As it was, the Reagan administration still had not released the more than $8 million that Congress had appropriated the October before to speed the antibody test to blood banks. Moreover, the government would do nothing to assure confidentiality for blood bank test results. That should be handled on the local level, officials said.

  In a January 15 meeting with representatives from the Food and Drug Administration, Silverman got tough. If the government did not release funds for the alternative test sites, he would publicly announce that federal officials were fashioning a new threat to the blood supply. He gave the FDA a two-week deadline. Angry at being handed ultimatums, administration officials told Silverman he was just looking for a way to line the pockets of his health department. The charge amused Silverman, coming as it did on his last day as public health director of San Francisco.

  The efficient social services department at the San Francisco AIDS Foundation easily found Silvana Strangis a slot in a methadone program and quickly obtained food stamps and general assistance funds, so she would not have to turn tricks to pay rent. Silvana seemed repentant and ready for a new life. “Nobody should have to see the kind of life I’ve lived in the Tenderloin,” she said tearfully. “At least now I’m beginning to see an end to all this.”