It was within the epicenters of gay life - San Francisco, New York, and Los Angeles - that omens of an epidemic were first recognized. In 1980 and 1981, physicians in these cities began diagnosing rare conditions, Pneumocystis cari-nii pneumonia and Kaposi's Sarcoma (a skin cancer), in young homosexual men. The fact that these diseases were very rare, were being seen in an unexpected context, and were clustering in homosexual men hinted at the possibility of an emerging epidemic. The first published reports of the sudden outbreak of these conditions came from clinicians in these three cities who simultaneously noted that what they were observing might be related to a "homosexual lifestyle" (CDC, 1981a, 1981b). That several of the individuals represented in these reports had already died underscored the seriousness of this fledgling epidemic. Other unusual opportunistic infections were also showing up in gay men, prompting conjecture that a common underlying immune suppressing disease was involved (Shilts, 1987). The presence of Pneumocystis carinii pneumonia in intravenous drug users (IDUs) (Masur et al., 1981) and hemophiliacs (CDC, 1982a) suggested the likelihood of a blood-borne infectious agent that could also be transmitted sexually, like hepatitis B.
This newly recognized immune-suppressing disease was initially referred to as Gay-Related Immune Deficiency (GRID). By mid-1982, however, GRID had also been diagnosed in IDUs, hemophiliacs, and individuals from Haiti, and was renamed AIDS. That AIDS was an epidemic was clear by the end of 1982. By 15 September 1982, the Centers for Disease Control (CDC) had received reports of a total of 593 cases of AIDS and noted that the incidence of AIDS by date of diagnosis had essentially doubled every six months since the second half of 1979 (CDC, 1982b). In San Francisco, the number of AIDS cases diagnosed in the second half of 1982 equaled the number of cases that had been diagnosed since the epidemic was first recognized (Moss et al., 1983). While the rate at which cases of AIDS were emerging was causing alarm among public health officials and gay activists, governmental and public response to the epidemic was minimal, especially when compared with other recent public health scares including toxic shock syndrome and Legionnaire's disease (Shilts, 1987). Many, including Larry Kramer, co-founder of the Gay Men's Health Crisis, the first AIDS advocacy and fund-raising organization, argued that public neglect of the burgeoning epidemic stemmed from the fact that the majority of the first victims were gay men (Shilts, 1987). This reality may also have hampered early prevention efforts.
In March of 1983, the CDC shared the results of their epidemiologic investigations into AIDS, observing that among homosexual men those with multiple sexual partners appeared to be at greater risk of contracting the disease, and that the period between exposure and the manifestation of illness could be as long as two years (CDC, 1983). These findings led the CDC to recommend that individuals avoid sexual contact with "persons known or suspected to have AIDS." A New York Times article published in February explained that the only protection against AIDS that clinicians could offer their homosexual patients was behavior change. In particular, it was suggested that homosexual men practice monogamy and, ideally, abstain from anal intercourse altogether (Henig, 1983). Many gay men balked at these recommendations, feeling that they undermined a sexual freedom so recently gained (Shilts, 1987).
Concern about the transmission of AIDS led inevitably to concerns about gay bathhouses. As early as March 1983, the closing of gay bathhouses in San Francisco was proposed (Shilts, 1987). In deference to AIDS and the environment of fear it was creating, some gay bathhouses made changes. They distributed and displayed safe-sex posters, brochures, and condoms; boarded up orgy rooms; and introduced "jack-off" nights (Berube, 2003). Despite these innovations, activists and officials in San Francisco wrestled with the issue of gay bathhouses and sex clubs, debating whether or not they should be closed, regulated, or encouraged as the ideal setting in which to foster AIDS awareness (Disman,
2003). Ultimately, in October 1984, Dr Mervyn Silverman, San Francisco's Public Health Director, ordered that gay bathhouses be closed (Disman, 2003). While the legality of this move continued to be debated, the decision itself reflected disenchantment with the bathhouses and the risk they symbolized in the midst of a deadly epidemic.
Awareness of AIDS increased as the number of AIDS cases escalated and AIDS became the "leading cause of premature mortality" in never-married men aged 25 to 44 years in New York and San Francisco (Jaffe et al., 1985). By 1985, the effects of AIDS awareness and prevention campaigns were reflected in reductions of self-reported risk behaviors by homosexual men in San Francisco (CDC, 1985) and New York (Martin, 1987). Notable drops in rates of gonorrhea in homosexually active men New York City (CDC, 1984), Denver (Judson, 1983), and Seattle (Handsfield, 1985) provided further evidence of a reduction in sexual risk-taking behavior. Behavioral prevention efforts were strengthened by the formation of groups such as Stop AIDS, whose members pledged to eliminate AIDS by practicing safe sex (Andriote, 1999). By the beginning of 1986, the incidence of the virus which causes AIDS, Human Immunodeficiency Virus (HIV), among a sample of MSM in San Francisco had dropped to 4.2 percent from a high of 18.4 percent in mid-1982 (Winkelstein et al., 1987). "Voluntary activist organizations" within the homosexual community were credited with achievements in behavior change and reduction in infection rates (Institute of Medicine, 1986).
Success in curbing the spread of HIV/AIDS was accompanied by increasingly vocal AIDS activism on the part of homosexual men. One of the most successful AIDS activist organizations, the AIDS Coalition to Unleash Power (ACT UP), was formed in 1987 in response to concerns about the FDA drug approval process and its impact on the testing and approval of drugs for the treatment of HIV/ AIDS (Andriote, 1999). ACT UP chapters formed throughout the country and internationally (Andriote, 1999). Pressure from ACT UP improved the accessibility and pricing of AIDS drugs, and the speed with which AIDS drugs were developed and made available to HIV/AIDS infected individuals. This process undoubtedly altered the long-term impact of the AIDS epidemic for many, many individuals.
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