The Social Impact of AIDS in the United States (1993) / Chapter Skim
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9 The HIV/AIDS Epidemic in New York City
9 The HIV/AIDS Epidemic in New York City
Pages 243-302
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From page 243... ...
Still, the panel believes that the New York City study, as it stands, offers a vivid portrait of the epidemic in a particular place and illustrates with particular force the principal conclusions of this report: namely, the epidemic is not spreading uniformly throughout the population but is highly localized, and the epidemic is now progressing in 243
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From page 244... ...
For example, many cities have few intravenous drug users who are infected and hence few women and infants who are HIV positive, while others have many intravenous drug users and so many infected women and infants. New York has always been described as "special," meaning that it is unlike any other city in the United States.
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From page 245... ...
the five boroughs of New York City and the immediate suburban counties of Putnam, Rockland, and Westchester (Centers for Disease Control, 1992~; the five boroughs account for more than 95 percent of the cases. Those cases comprised 37,062 adults and 890 children less than 13 years old: 17.6 percent of all adult and 24.7 percent of all child cases of AIDS reported to the CDC by health departments in the United States.
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From page 246... ...
The final source of underestimation is the occurrence of either new opportunistic infections that are the result of HIV infection or infections specific to particular populations that do not conform to the CDC case definitions. These are viewed by some as indications of the changing natural history of the disease or as symptoms of HIV/AIDS among less studied populations.
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From page 247... ...
for testing for inherited metabolic disorders. Such surveys are indirect measures of the rate of HIV infection among newborns, since only a fraction of babies born to HIV-infected mothers are themselves infected and since an infant may carry antibodies from its mother but not in fact be infected.
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From page 248... ...
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From page 249... ...
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From page 251... ...
However, the rates vary substantially for both African American and Hispanic women by borough of the city; again, the highest rates are found in Manhattan and the Bronx. Since there is evidence of higher rates of sexually transmitted diseases among African American women than other women, there may be some consequent reduction in
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From page 252... ...
252 THE SOCIAL IMPACT OF AIDS IN THE U.S. TABLE 9-2 Seroprevalence Among Mothers of Newborns in New York City, November 1987-September 1990, by Borough and Neighborhood Borough and Number Number Percent Neighborhood Tested Positive Positive Manhattan Total 44,141 697 1.58 Washington Heights/Inwood 8,808 57 0.65 Central Harlem/Morningside Heights 7,907 213 2.69 East Harlem 5,057 163 3.22 Upper West Side 5,239 39 0.74 Upper East Side 4,352 16 0.37 ChelsealClinton 2,894 61 2.11 Gramercy Park/Murray Hill 2,461 36 1.46 Greenwich Village/Soho 1,500 4 0.27 Union Square/Lower East Side 5,071 95 1.87 Lower Manhattan 852 13 1.53 Bronx Total 50,512 853 1.69 Kingsbridge/Riverside Dr.
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From page 253... ...
HIV seropositivity for women of childbearing age follows the general geographical pattern of AIDS cases for women and intravenous drug users in the city. The rates of highest seropositivity can be seen in the band extending from the northern edge of Manhattan into the central Bronx, across Manhattan below midtown, and in a solid band across the northern edge of Brooklyn.
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From page 254... ...
Number of New Yorkers seriously ill due to HIV infection but not yet diagnosed with AIDS Number of New Yorkers infected with HIV but not yet experiencing serious symptoms FIGURE 9-2 Estimate of numbers of New York City residents in various stages of HIV-related illness and infection. NOTE: Total estimated number of HIV-infected people in New York City, 126,000-235,000.
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From page 255... ...
Of particular interest are the differences in the estimates of the future course of the epidemic among women. Modifications in the program used to estimate the logistic growth curve, which assumed very high rates of sexual partnering of intravenous drug users with nonuser partners, resulted in estimates of women infected through sexual contacts with men that are about three times higher by 1996 than are estimates produced by other methods.
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From page 256... ...
during this period and by other studies of rectal gonorrhea reported by CDC for other cities (Centers for Disease Control, 1990:16~. Similar changes in risk behaviors may have also occurred among intravenous drug users, although these changes are less well substantiated.
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From page 257... ...
(1991) modeled the number of women in New York City infected with HIV as the result of sexual contact with intravenous drug users.
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From page 258... ...
In recent years, the ratio of AIDS cases between men who have sex with men and male intravenous drug users has reached parity, and there has been a significant increase in HIV/AIDS among women and children. For the period from 1982 to 1985, the proportion of women diagnosed with AIDS in New York City hovered around 10 percent.
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From page 259... ...
Individual trauma refers to the emotional responses to death or devastation, which are shock, numbness, disorientation, guilt, and emotional depletion. The HIV/AIDS epidemic has had many of these consequences for the gay community and the individuals who are part of it.
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From page 260... ...
Most of these men and women were white, only a handful were black or Puerto Rican. Working-class lesbians and gay men, who were predominantly white except for a sizable Puerto Rican contingent on the West Side, lived in tenements and rooming houses of Times Square, the seedy parts of Greenwich Village, and the Upper West Side.
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From page 261... ...
with large numbers of partners. The increased visibility, size, and density of the gay community and the public emergence of institutions that were designed to promote easy congregation (baths, bars, discos)
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From page 262... ...
Many treated sexually transmitted diseases as a price that had to be paid for a life style of erotic liberation. Initial Response to the Epidemic The response of the gay community to the beginning intimations of an epidemic were complex.
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From page 263... ...
As late as 1987 the major institutions of the African American and Hispanic communities had made only minimal formal responses and there was little evidence of AIDS-related Organizations. Substantial behavioral changes in sexual practices were documented in the gay community the reduction of unsafe sex, particularly anal intercourse, and numbers of sexual partners.
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From page 264... ...
The Gay Men's Health Crisis (GMHC) is probably the largest central volunteer agency in New York providing supportive care to the gay community in New York City.
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From page 265... ...
What has been learned about African American men and Hispanic men has largely emerged from research concerning the rates of HIV infection in these groups and ways of preventing further infection. Of all African American men who have been reported with AIDS in New York State, 33 percent are reported to be men who had sex with men; 49 percent are intravenous drug users; and 5 percent have both risk factors.
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From page 266... ...
A number of social networks in the African American community of men who have sex with men are epidemiologically separate from the gay community and show markedly different patterns of infection. A study of 57 African American gay men (who did not self-identify with the predominantly white gay community)
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From page 267... ...
The impact on other infected communities is not well documented, and when their histories are better understood they may differ in important respects from the New York gay community. Nonetheless, many features of the experience are common.
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From page 268... ...
Some have described the gay community as an economic colony of the health-care professions, the hospitals, and the pharmaceutical houses (Oppenheimer and Padgug, 1991~. Epidemic #2: Drug Users In the opening stages of the epidemic it became apparent that sharing of drug injection paraphernalia among heroin addicts was a critical element in HIV transmission (Drucker, 1986~.
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From page 269... ...
Indeed, early studies of HIV seropositivity among intravenous drug users showed a rapidly increasing rate. By 1985 it was estimated that intravenous drug users had a seropositivity rate that exceeded 50 percent (Des Jarlais, 1985; Drucker, 1986~.
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From page 270... ...
In the most extreme cases, women were reported to be staying in crack houses and exchanging sex for drugs on an indiscriminate basis with many sexual partners, at least some of whom were infected with HIV (Williams et al., 19884. Exchanges of sex for drugs also involved an increased risk of sexually transmitted diseases that might act as cofactors for HIV transmission.
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From page 271... ...
PUBLIC HEALTH AND HEALTH CARE The concentration of the epidemic, both socially and geographically, has differentially affected the component agencies and services of the health care and social welfare systems of New York City. For example, municipal hospitals serving areas with large numbers of people with HIV/AIDS who do not have health care insurance usually have a very large number of patients in various stages of HIV disease.
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From page 272... ...
This population's sexual partners are also relatively immobile, and often they and their children share common households with the drug users. Such factors increase the concentration of persons with HIV/AIDS within narrow boundaries and focus the impact of the epidemic .
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From page 273... ...
In addition, African Americans and Hispanics with HIV/AIDS (as well as those white gay men who are impoverished by HIV/AIDS) are more likely to be treated in municipal rather than private hospitals.
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From page 274... ...
Given the concentration of HIV/AIDS in specific neighborhoods and social communities, a substantial proportion of that number are professionals working in public-sector hospitals and physicians in private practice in gay areas of the city. Despite the recommendations of various AIDS commissions and task forces that the burden of HIV/AIDS be dealt with on a citywide basis (New York City Department of Health, 1989a,b; Rothman et al., 1990)
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From page 275... ...
The annual incidence of tuberculosis in the New York State correctional system increased from 15.4 cases per 100,000 in 1976-1978 to 132.2 cases in 1988. African Americans and Hispanics aged 30 to 39 who had used intravenous drugs were those usually infected, as one might expect.
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From page 276... ...
By 1989, 69 percent of men living in the streets were African American, 17 percent were white, and 12 percent were Hispanic; of those regularly using city shelters, 72 percent were African American, 7 percent white, and 16 percent Hispanic (Hopper, 1990)
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From page 277... ...
The absence of data on income, education, or occupation invites the fallacy of attributing to skin color effects that are in fact the result of poverty and racism and of further stigmatizing disadvantaged communities. Puerto Ricans are the ethnic group most severely affected by the HIV/ AIDS epidemic in New York City.
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From page 278... ...
In addition, needlesharing networks among intravenous drug users are often racially or ethnically homogeneous (Schoenbaum et al., 1989) , which further concentrates the virus.
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From page 279... ...
had nearly 70 percent of all births paid for by Medicaid, 40 percent with late or no prenatal care, and 20 percent of all births to teenage mothers. The districts with a high prevalence of low birthweight infants have a familiar ring when compared with the neighborhoods that have been the sites for the highest rates of reported AIDS cases among poor adults and children.
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From page 280... ...
Thus, between 10,000 and 15,000 people with HIV disease were in the city's correctional system during 1988 alone (Association of the Bar of the City of New York, 1989~. Approximately 54,000 people are held in state prisons, 60 to 70 percent of whom have histories of drug use (although not all are intravenous drug users)
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From page 281... ...
The city is itself residentially segregated along ethnic lines, and although data do not exist on the residential distribution of those who enter the criminal justice system, it is not unreasonable to argue, given their ethnic distribution, that they are drawn from the areas that house the poor of the city. Currently, on any given day, 23 percent of all African American men in New York State aged 20 to 29 are in some form of control by criminal justice authorities prison, jail, probation, or parole (see Table 9-3~.
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From page 283... ...
and Murphy, 1990~. The focus on law enforcement solutions to drug problems, particularly in the visible communities of drug users in minority populations where the epidemic of HIV disease has centered, has created a major crisis in the criminal justice system, especially in prisons and jails (Association of the Bar of the City of New York, 1989~.
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From page 284... ...
, and acute care takes place in a number of municipal hospitals with secure units when beds are available; in 1989 there were a total of 66 such beds in two hospitals, Bellevue and Kings County. When beds are not available or specialized care is needed, prisoners, including those with HIV disease, are placed in wards meant for the general population.
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From page 285... ...
According to various external reports, the department's health-care facilities are currently inadequate for the needs of the inmates with HIV/AIDS (see New York State Department of Health, 19881. Furthermore, although the department has "mainstreamed" many of its prisoners with HIV/AIDS, it has also attempted to create specialized segregated facilities, which was halted by court order (Association of the Bar of the City of New York, 1989:219~.~ There is evidence that the survival rate for prisoners in state custody who have histories of intravenous drug use and who have HIV/AIDS is far shorter than for people with similar characteristics in New York City who are not incarcerated: the latter survive 318 days from diagnosis to death; the former survive 159 days.
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From page 286... ...
In addition, such a distinction between guilty and innocent affects interactions between women with HIV/AIDS and the traditional systems of care and caretakers. Ethnographic studies document numerous negative experiences on the part of poor African American and Hispanic women in their interactions with the health care system.
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From page 287... ...
As rates of HIV infection among women have increased, a number of medical investigators have begun to question earlier findings about the effects of HIV infection on the outcome of pregnancies. Asymptomatic HIVinfected female intravenous drug users in a New York City methadone program were not found to have decreased pregnancy rates or increased risk of adverse pregnancy outcomes.
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From page 288... ...
Further evidence of the high rates of HIV infection in childbearing women in New York is provided by the New York State Department of Health's newborn seroprevalence study. On the basis of the testing of blood specimens obtained from all infants born in the state between November 30, 1987, and March 31, 1990, the study found an overall seropositivity rate of 0.66 percent for childbearing women.
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From page 289... ...
Caring for Infected Children: Examples in Harlem Pediatric HIV infection is a family disease: more than 80 percent of pediatric AIDS cases reported to the CDC identify perinatal exposure as the mode of transmission. Thus, a child with HIV disease is often the index case that leads to the identification of infected parents and siblings previously considered healthy.
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From page 290... ...
Resources have been made available to recruit foster care families willing to care for children at risk for HIV infection. New York City established the Incarnation Children's Center (ICC)
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From page 291... ...
At home, for complex reasons that include fear of community reaction or the desire to protect the child from full knowledge about the illness, parents or caretakers may also avoid discussing the full dimensions of the disease. However, with earlier diagnosis and treatment that can now prolong life, there are stronger incentives to deal with the fear and prejudice that HIV infection arouses.
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From page 292... ...
The logical consequence of this position is the provision of age-appropriate sex education that includes information about same-gender sex, modes of HIV transmission and methods of prevention, as well as the provision of condoms without either mandatory counseling or parental consent. The opponents of safer sex education and the provision of condoms stress the long term, the role of the parent and church versus the school and the state, and issues of morality.
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From page 293... ...
. Proponents of the program wished to dissociate it from pregnancy prevention the issues were simply those of HIV disease and health.
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From page 294... ...
The disagreements among African Americans mirrored the larger debate, with distortions born of racial discrimination: Did the provision of condoms to African American youths signal a racist lack of faith in their ability to be sexually abstinent? (This same subtext framed the needle-exchange debate: the conflict between health promotion and the danger that needle provision would simply support or expand the use of drugs in already afflicted communities.)
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From page 295... ...
HIV disease in New York City
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From page 296... ...
New York Times December 8:A1. Andrews, R., B
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From page 297... ...
New York Times December 5:B3. Berger, J
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From page 298... ...
Stoneburner (1991) A method for estimating HIV transmission rates among female sex partners of male intravenous drug users.
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From page 299... ...
(199Oa) AIDS travels New York-Puerto Rico "air bridge." New York Times June l5:B 1.
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From page 300... ...
New York State Department of Health, New York AIDS Institute (1989) Management of HIV Infection in New York State Prisons.
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From page 301... ...
(1989) Risk factors for human immunodeficiency virus infection in intravenous drug users.
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From page 302... ...
New York Times December 16:A1,A23. Trafford, A
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