9
The HIV/AIDS Epidemic in New York City

The panel planned to study in some detail the impact of the HIV/AIDS epidemic in several locales as part of an effort to understand the localized dimensions of the epidemic. Our plan had been to focus on three cities, New York, Miami, and Sacramento, to determine the epidemic's impacts in places with quite different social, cultural, and demographic characteristics. Unfortunately, it proved logistically and financially difficult to carry out this plan. Fortunately, however, since several members of the panel lived or worked in New York and had convened for regular discussions over the several years of the panel's life a group of experienced observers of the epidemic, the panel was able to complete one of its planned empirical studies, that of New York City.

"Completed" is not quite accurate: many aspects of the epidemic in New York City are not included in this chapter and much more needs to be done before a picture that is in any way complete can be presented. We refrain from calling this chapter a case study in the proper sense, since such a study, being only one and thus lacking comparisons with similar studies, would require much more detail and depth before either causal connections between the complex phenomena can be discerned or even tentative generalizations can be suggested. 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



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The Social Impact of Aids in the United States 9 The HIV/AIDS Epidemic in New York City The panel planned to study in some detail the impact of the HIV/AIDS epidemic in several locales as part of an effort to understand the localized dimensions of the epidemic. Our plan had been to focus on three cities, New York, Miami, and Sacramento, to determine the epidemic's impacts in places with quite different social, cultural, and demographic characteristics. Unfortunately, it proved logistically and financially difficult to carry out this plan. Fortunately, however, since several members of the panel lived or worked in New York and had convened for regular discussions over the several years of the panel's life a group of experienced observers of the epidemic, the panel was able to complete one of its planned empirical studies, that of New York City. "Completed" is not quite accurate: many aspects of the epidemic in New York City are not included in this chapter and much more needs to be done before a picture that is in any way complete can be presented. We refrain from calling this chapter a case study in the proper sense, since such a study, being only one and thus lacking comparisons with similar studies, would require much more detail and depth before either causal connections between the complex phenomena can be discerned or even tentative generalizations can be suggested. 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

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The Social Impact of Aids in the United States such a way that a convergence of social ills creates a nidus in which it can flourish. It is our belief that New York City, special though it may be, exemplifies these conclusions. In New York City, as in the United States, the epidemic is highly localized and is flourishing in social settings where there is a ''synergism of plagues" (Wallace, 1988). Much of the attention given to the epidemic has focused on national estimates and national needs. Although these are perfectly appropriate concerns, it must be understood that ultimately the epidemic, its impacts, and the responses to the impacts are experienced in specific locales. The United States, unlike many European countries, is composed of states and other political subunits that can and do pursue quasi-independent policies in many aspects of social life. For instance, all states, counties, and most large cities have their own public health agencies, which have differing traditions and varying levels of quality. In addition, these subnational, geopolitical units often have different political, economic, welfare, and crime control practices, all of which are involved in dealing with HIV/AIDS. Although these subnational jurisdictions are smaller in size and population than the country, they are not homogeneous social and cultural units. Affluent people live in some parts of a city, and poor people live in others; individuals of European descent live in some communities, and African Americans and persons of Latin descent live in others. In some cities there are residential communities of gay men and lesbians, but in many there are not. Because HIV is not spread through casual contact, the structure of social networks in different localities and the geographical mobility of persons engaging in risky behavior shape the transmission of the virus. Sexual relationships and the sharing of drug injection paraphernalia are not random activities, but are embedded in other patterns of social interaction. HIV/AIDS is thus a disease of neighborhoods and communities, of high-prevalence localities and low-prevalence localities. Even a cursory look at the patterns of CDC-defined AIDS cases suggests distinct patterns in different cities. 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. This view has considerable truth in it: New York City is an unruly, chaotic urban place, which regularly seems to verge on being economically and politically unmanageable. Its residents are the children of old immigrants who came by boat and new arrivals just off an airliner. New York City is actually a large number of collaborating and competing communities with disparate levels of power and resources. Many of these communities have no direct contact with other communities and compete with each other over resources and entitlements

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The Social Impact of Aids in the United States in distant arenas, while others directly confront each other on the streets of the city over specific pieces of turf. This study only partly confronts the complexity of the city and its response to the HIV/AIDS epidemic. It does not, as it might, list all of the people who took leadership positions and made the limited institutional reforms that characterized the city's best efforts. It is therefore a somewhat gloomy and admittedly partial vision. There is little discussion about the local media and its responses and nonresponses to the epidemic. We have used articles in the local press to track various controversies. A number of commissions and committees have attempted to analyze the epidemic in New York and plan for the future. We have read and quoted from their studies, even though we do not describe their special efforts (e.g., Citizens Commission on AIDS for New York City and Northern New Jersey, 1991). Other local studies of the epidemic are needed (see Andrews et al., 1989). We hope there are researchers who will attempt to find out what happened in Los Angeles, San Francisco, Miami, Houston, Dallas, and Atlanta, as well as in Chicago, Detroit, and Denver. We believe the research community needs to discover the stories of the epidemic from the perspectives of the streets of the South Bronx and the apartments of Chelsea, the emergency rooms and pediatric units of Harlem, Bronx Lebanon, Woodhull, and St. Vincent's Hospitals, and the offices of the Gay Men's Health Crisis (GMHC), AIDS Coalition to Unleash Power (ACT-UP), Association for Drug Abuse Prevention and Treatment (ADAPT), and God's Love We Deliver, as well as providing the epidemiological models and health cost estimates that are the accounting frames that are only mere summaries of the realities of human action. COURSE OF THE EPIDEMIC Current Situation By March 1992, 37,952 cases of AIDS had been reported to the Centers for Disease Control (CDC) for the New York City metropolitan statistical area (MSA)—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. The proportion of the national epidemic represented by the New York City MSA has declined somewhat over the course of the epidemic. For cases reported from March 1990 to February 1991, the proportion from the New York City

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The Social Impact of Aids in the United States MAS was 15.6 percent; from March 1991 to February 1992, it was 14.8 percent All these figures, however, are an underestimation of the numbers of actual AIDS cases. There are four sources of this underestimation, which mirror the undercount problems on a national level. The first is the lag in the reporting of cases from the local site in which the disease is diagnosed to the local health department; the next lag is from then until the cases are reported to CDC and entered into the AIDS Case Registry. In New York City, one-third of AIDS cases are reported to the city health department within 1 month of diagnosis, about 85 percent are reported by 6 months, and the count is as nearly complete as it is likely to be after about 15 months (New York City Department of Health, 1989a). According to the U.S. General Accounting Office (1989), the lag time between diagnosis and reporting is growing longer rather than shorter. A second source of underestimation is the extent of undercounting, that is, the number of cases that, if diagnosed and reported, would meet the current CDC case definition. These are cases that are lost to the system by inadvertence and overwork, failures of paperwork, deliberate decision, or by death from other causes among individuals whose AIDS was not diagnosed because they were not in contact with the health care system. The proportion of undercounted cases varies by geographical location and by risk group (U.S. General Accounting Office, 1989; Buehler, Berkelman, and Stehr-Green, 1992). A third source of underestimation of the dimensions of the epidemic is HIV-infected people who die from complications of the disease prior to a diagnosis of AIDS. This may be a very significant factor in New York City. 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. Of the 26,336 cases of AIDS reported in the state by December 1989, 87 percent were from the five boroughs of New York City, and an additional 7.8 percent were from the four counties with the most intimate social and economic connections with the city (Nassau, Suffolk, Westchester, and Rockland)—in all, 95 percent of all cases reported in New York State (AIDS in New York State, 1989). Whatever the precise number of cases of AIDS, deaths from the opportunistic infections that are associated with end-stage HIV disease accounted for a very large proportion of the total mortality among young men and women in New York City in 1989. Among men aged 25 to 44, AIDS was the leading cause of death: 31.6 percent of deaths of men aged 25 to 34 and

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The Social Impact of Aids in the United States 35.2 percent of deaths of men aged 35 to 44. Among women aged 25 to 34, AIDS accounted for 26.1 percent of all deaths; in addition, 10 percent of the mortality among women aged 15 to 24 and 17 percent of the mortality among women aged 35 to 44 was also directly attributable to AIDS. Localization of the Epidemic One of the most striking features of the HIV/AIDS epidemic is its concentration in and within large urban centers. This is manifested across the United States, and New York is no exception. As noted above, 87 percent of all cases in New York State are concentrated in the five boroughs of the city. But that is only the first level of concentration of the epidemic. Within the city itself, AIDS cases are concentrated both in individual boroughs and in neighborhoods within the boroughs. Data on various characteristics of AIDS cases by 41 neighborhoods in the five boroughs have been published by the New York City Department of Health (1990a,b,c,d,e). Although there are other ways to define neighborhoods, these 41 areas—10 each in Manhattan, Queens, and Brooklyn, 7 in the Bronx, and 4 in Staten Island—have the virtue of being used for a wide variety of other epidemiologic, health care, and planning purposes. The incidence rates vary as much within New York City as they do across the counties of New York State. Table 9-1 presents data on the number of adult persons with AIDS by selected demographic characteristic or risk categories and ethnic groups, reflecting the intense concentration of the epidemic in certain city neighborhoods. The variation in Manhattan, which is the hardest hit of the boroughs, remains quite large (from 341 to 1,802 per 100,000 persons). A more precise pattern is evident when the cumulative AIDS case data for the city are plotted using zip codes; see Figure 9-1. Within the larger geographical units, as defined by the United Hospital Fund's community health areas, one can observe the zip code areas with the highest concentrations of cumulative AIDS cases. In vast areas of the city, cumulative AIDS cases are fewer than 175 per 100,000, but in a small set of zip code areas, the rates are more than 700 per 100,000. A similar geographical pattern can be found in the data on rates of HIV antibody seropositivity among women bearing children in New York City. Since 1987 all infants born in New York State have been tested for antibodies to HIV in anonymous serologic surveys of blood routinely taken (from the heel) 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. They are, however, accurate indicators of the serostatus of the mother. Of 359,470 babies tested in New York City between November 1987 and September 1990, 4,453 women were determined to be infected

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The Social Impact of Aids in the United States TABLE 9-1 AIDS Cases by Neighborhoods in New York City, Cumulative Incidence from 1981 to June 1990     Percentagea Borough and Neighborhood Number of Cases Rate per 100,000 Women Gay Menb IVDU African American Hispanic American Manhattan 10,523 — 9 67 29 25 21 Washington Heights/Inwood 487 348 10 59 32 39 36 Central Harlem/Morningside Heights 1,107 722 22 32 59 81 11 East Harlem 873 1,125 21 26 65 50 41 Upper West Side 1,807 925 6 78 20 18 21 Upper East Side 597 341 5 86 10 9 14 Chelsea/Clinton 1,986 1,802 3 84 14 11 15 Gramercy Park/Murray Hill 979 852 4 79 18 13 16 Greenwich Village/Soho 1,175 1,524 2 81 17 10 13 Union Square/Lower East Side 1,434 960 12 57 39 16 32 Lower Manhattan 96 748 16 58 36 23 25 Bronx 3,855 — 22 23 64 37 53 Kingsbridge/Riverside Dr. 114 163 14 44 39 26 36 Northeast Bronx 269 174 16 34 47 53 28 Fordham/Bronx Park 699 420 22 25 61 29 56 Pelham/Throgs Neck 611 268 22 22 62 32 50 Crotona/Tremont 748 730 24 21 64 41 55 Highbridge/Morrisania 866 795 24 21 68 48 49 Hunts Point/Mott Haven 548 1,047 22 16 73 27 70

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The Social Impact of Aids in the United States Brooklyn 5,297 — 20 31 51 50 26 Greenpoint/Williamsburg 700 450 22 19 67 32 56 Bensonhurst/Bay Ridge 207 128 14 39 50 9 16 Downtown, Heights, Park Slope 907 523 12 56 37 33 25 Bedford Stuyvesant/Crown Heights 1,516 523 24 24 57 78 14 East New York 406 361 22 20 65 57 33 Sunset Park 207 296 19 27 57 10 64 Borough Park 218 140 19 35 49 15 27 East Flatbush/Flatbush 716 293 23 28 34c 73 14 Canarsie/Flatlands 147 110 24 35 41 31 14 Coney Island/Sheepshead Bay 273 120 21 34 51 25 23 Queens 2,916 — 15 41 45 39 26 Long Island City/Astoria 279 158 12 51 41 25 24 West Queens 852 309 8 52 40 19 47 Flushing/Clearview 160 88 14 50 32 20 25 Bayside/Littleneck 42 65 14 29 33d 14 17 Bridgewood/Forest Hills 206 110 7 48 40 6 23 Fresh Meadows 65 82 13 46 42 22 18 Southwest Queens 257 147 14 45 44 25 25 Jamaica 665 334 21 26 58 81 10 Southeast Queens 252 172 22 36 41 62 12 Rockaway 138 177 30 20 65 63 16

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The Social Impact of Aids in the United States     Percentagea Borough and Neighborhood Number of Cases Rate per 100,000 Women Gay Menb IVDU African American Hispanic American Staten Island 357 — 17 33 52 22 16 Port Richmond 70 153 24 16 57 31 11 Stapleton/St. George 188 188 19 40 45 24 19 Willowbrook 38 47 8 39 45 3 13 South Beach/Tottenville 61 43 8 18 71 18 15 Total Borough 25,260e             Total Neighborhood 22,948f             a Does not equal 100 percent because a person can be counted in more than one category. b More broadly, men who have sex with men. c Thirty-two percent of cases defined as other. d Twenty-six percent of cases defined as other. e 186 unknown addresses. f 2,126 cases without zip code. SOURCE: Data from New York City Department of Health (1990a,b,c,d,e).

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The Social Impact of Aids in the United States FIGURE 9-1 AIDS case rates in New York City, by zip code, as of April 1989. SOURCE: Data from New York City Department of Health (1990a,b,c,d,e). with HIV—a citywide seropositivity rate of 1.24 percent (Novick et al., 1991); see Table 9-2. This proportion has not changed substantially since testing of infants began, indicating there have not been rapid increases in seropositivity among women who are having children. This seroprevalence measure does not estimate the rates of HIV infection among all women of childbearing age: it excludes women who are not having children because of contraceptive use, infertility, celibacy, or spontaneous or induced abortion. These data for childbearing women show a pattern similar to the AIDS data for women. Rates are high among African American (2.21 percent positive) and Hispanic women (1.41 percent positive) and particularly high for women aged 25 to 34. 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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The Social Impact of Aids in the United States TABLE 9-2 Seroprevalence Among Mothers of Newborns in New York City, November 1987-September 1990, by Borough and Neighborhood Borough and Neighborhood Number Tested Number Positive Percent 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 Chelsea/Clinton 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. 2,091 7 0.33 Northeast Bronx 5,165 63 1.22 Fordham/Bronx Park 10,128 125 1.23 Pelham/Throgs Neck 8,655 95 1.10 Crotona/Tremont 9,805 183 1.87 Highbridge/Morrisania 9,093 225 2.47 Hunts Point/Mott Haven 5,575 155 2.78 Brooklyn Total 89,240 1,169 1.31 Greenpoint/Williamsburg 10,782 148 1.37 Bensonhurst/Bay Ridge 4,343 16 0.37 Downtown, Heights, Park Slope 7,509 127 1.69 Bedford Stuyvesant/Crown Heights 21,134 452 2.14 East New York 7,838 119 1.52 Sunset Park 4,670 46 0.99 Borough Park 7,677 29 0.38 East Flatbush/Flatbush 13,710 155 1.13 Canarsie/Flatlands 4,367 24 0.55 Coney Island/Sheepshead Bay 7,210 53 0.74 Queens Total 59,550 376 0.63 Long Island City/Astoria 5,337 42 0.79 West Queens 13,010 70 0.54 Flushing/Clearview 6,441 15 0.23 Bayside/Littleneck 1,828 1 0.05 Bridgewood/Forest Hills 5,269 20 0.38 Fresh Meadows 2,239 4 0.18 Jamaica 9,468 113 1.19

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The Social Impact of Aids in the United States Borough and Neighborhood Number Tested Number Positive Percent Positive Southwest Queens 6,953 36 0.52 Southeast Queens 5,212 36 0.69 Rockaway 3,793 39 1.03 Staten Island Total 11,835 68 0.57 Port Richmond 1,881 25 1.33 Stapleton/St. George 3,200 27 0.84 Willowbrook 2,306 6 0.26 South Beach/Tottenville 4,448 10 0.22 New York City Total 255,278 3,163 1.24   SOURCE: Data from New York City Department of Health (1990a,b,c,d,e). childbearing capacity that would result in an underestimation of the seropositivity rate among this group (Aral and Holmes, 1990). 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. The scattered nature of the areas of high seropositivity suggests the decentralized and local nature of the epidemic in large portions of the city. Predicting the Future of the Epidemic As the AIDS epidemic evolves, the proportion of persons at various stages of the disease has also been changing. If a major surge in infections in New York City occurred in the late 1970s and early 1980s, the early to mid-1990s should be the period, in the absence of effective therapies, when a majority of those who were infected will begin to show the symptoms of "frank" AIDS. Although the distributions in Figure 9-2 reflect substantial errors of measurement, they offer some numerical guidance as to what the future has in store for the city. The number at the apex of each pyramid is an indicator of the impact on the acute-care components of the health care system. The numbers in the two lower strata of each pyramid indicate people in the early stages of disease who could benefit from prophylactic measures to prevent or delay the onset of opportunistic infections. Those in the middle strata of the pyramid will require increased levels of outpatient care.

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The Social Impact of Aids in the United States RELIGION: CONFLICT OVER CONDOMS AND AIDS EDUCATION FOR YOUNG PEOPLE From the beginning of the HIV/AIDS epidemic, there has been a continuous conflict over the role of education about safer sex and condoms in preventing the transmission of HIV. This debate has been particularly sharp when the targets of the educational and condom distribution programs have been young people of high school age, although there has been strong resistance in the national government to condom education for persons of all ages (Specter, 1989). The proponents of safer sex education and condom provision to youths point out that they do not necessarily approve of early sexual experimentation on the part of young people, but that large numbers of young persons are sexually active under conditions of relative ignorance about the consequences of their conduct. The decision not to provide safer sex education or condoms to young people places them in danger of the transmission of HIV and other STDs that increase the likelihood of HIV transmission. The arguments of the proponents are short term, pragmatic, and health oriented: young people are sexually active; it is unlikely that they will abstain regardless of how often they are exhorted, and they are in danger of contracting a fatal disease. 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. In their view, the control of the sexuality of young people properly resides with parents and the religious institutions to which parents and children belong, which emphasize chastity before marriage and fidelity afterward. The provision of safer sex education and condoms threaten these goals and appear to condone sexual experimentation. For some religious groups, such as the Roman Catholic church, condoms are a completely forbidden form of birth control. The antagonists in New York City have been locked in a debate largely directed not at each other, but at the relatively uncommitted wider community. The immediate targets of the arguments are such decision makers, such as school board members and school administrators or those who appoint them. When condom provision in the public senior high schools was proposed in 1986, an active coalition of religious groups, spearheaded by the Archdioceses of New York and Brooklyn, persuaded the school board to reject the proposal. In the fall of 1990 the new school chancellor asked that the

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The Social Impact of Aids in the United States members of the newly appointed school board support a plan for condom distribution (Berger, 1990b). He noted the many AIDS cases among young people and reported that 80 percent of New York City's 261,000 public high school students were having intercourse. Four of the five new members of the seven-member board reported that they favored such distribution. The plan was opposed by one board member, who said, "It sends a message to young people that we expect them to have sex" (Berger, 1990b:B4). The officials of the Roman Catholic church made their position clear by pointing out that condom provision "says that the universal value that places sexual activity as acceptable only within the context of marriage can neither be taught by our schools nor accepted by our students" (Berger, 1990b:B4). In December 1990 the Board of Education received the chancellor's plan to distribute condoms to all students who requested them. All public high schools were to be included, and counseling or parental consent was not required (Berger, 1990d). Opponents remained adamant, and some potential supporters wanted counseling to be provided, including information on condom use and how to persuade a partner to use one. In addition, they wanted all students to be told that sexual abstinence before marriage is the best method of prevention (Berger, 1990a). Proponents of the program wished to dissociate it from pregnancy prevention—the issues were simply those of HIV disease and health. They hoped to avoid further conflict with the Roman Catholic church over birth control. The role of the Roman Catholic church in AIDS education and prevention had already produced conflict regarding church obligations in AIDS prevention education when receiving state funds for health care services. The New York State Public Health Council voted to exempt Catholic-operated nursing homes and hospitals from the requirement that HIV/AIDS patients receive condoms, safer sex counseling, contraceptives, and abortion services. AIDS activists opposed receipt of public funds by Catholic-operated institutions unless they agreed to provide prevention information (e.g., the role of condoms in AIDS prevention), which they declined to do because it is contrary to church doctrine. The church stated that such information violates its "institutional conscience" and can be received elsewhere. In another dispute, the Archdiocese refused to lease to the Board of Education unused Catholic parochial school space for special education classes on AIDS prevention. The leases were barred unless the board waived its sex education curriculum, which includes information on forms of contraception not approved by the church. The decision was based on the evaluation of the 1984 sex education curriculum that, according to the evaluation "makes no mention of modesty, chastity, premarital sexual abstinence or even marital fidelity" (Goldman, 1991:30). The Board of Education itself was divided on the condom plan. The four African American and Hispanic members favored it (in varying degrees),

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The Social Impact of Aids in the United States and the three white members opposed it, again in varying degrees. One of the opponents objected to the board's citation in its curriculum of literature from a gay and lesbian organization that had published a booklet that one board member considered particularly offensive, although that booklet was not used in school education (Berger, 1990c). An open meeting conducted by the board in February 1991 attracted 277 speakers and ran from 10 a.m. until late in the evening. The division between the proponents and opponents was clear: on one side were religious groups and those whose allegiance was to traditional values; on the other side were health professionals, AIDS workers, persons with AIDS, and activist groups. 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.) Actual research about the utility of condoms, either in preventing HIV transmission or in influencing the sexual activity of young people, was rarely cited in the debate over condom use. The actual experiences of school districts across the country that had implemented condom programs were rarely discussed (Lewin, 1991). The complexity of the studies and the mixed results they presented seemed to limit their usefulness in public debate (Dreyfoos, 1991). A few weeks after the public meeting Mayor David Dinkins backed the condom plan without counseling or parental consent (Berger, 1991a). The board approved the plan for condom provision without parental consent by a vote of four to three, divided along racial and ethnic lines, with some discussion of a future provision for a parental option to exclude their children from the program (Berger, 1991b). The ideological structure of the conflict and the social composition of the opposing groups were predictable and similar to conflicts over HIV/AIDS and sexuality in other communities and at the national level. Although the specific outcome in any community is unpredictable, there are constants: the relative inadequacy of scientific evidence on those questions for which science is important (e.g., if the presence of a condom provision program increases or decreases sexual activity among the young) and the irrelevance of scientific findings in settling what are ultimately conflicts between different religious and secular perspectives on the solution of social problems.

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The Social Impact of Aids in the United States CONCLUSIONS The panel's findings on the HIV/AIDS epidemic among gay men, intravenous drug users, and women and children in New York City reflect a highly localized epidemic that is increasingly concentrated among poor people and racial and ethnic minorities. Responding to the problem of HIV requires knowledge of the local communities and an understanding of the cultural realities of those who live there. The inner-city poor may live in New York City, but they do not live in the same New York City as those who are more affluent and better protected from the epidemic (and many other risks) by regular employment, health care insurance, and lower crime rates. Those with HIV/AIDS among the inner-city poor often live and die in invisible neighborhoods within the segregated communities of the city. The February 1991 end of the Citizens Commission on AIDS for New York City and Northern New Jersey was an important signal of the changed political and economic context at the beginning of the second decade of the HIV/AIDS epidemic. The commission was a major example of a foundation-supported volunteer attempt to provide private-sector leadership and offer a nonpartisan influence on public policy in dealing with HIV/AIDS. Its demise, after somewhat less than 4 years of life, can be attributed to the normal processes of wear and tear on volunteer efforts, the completion of some of the original tasks set by the organization, and the declining interest of the private funding sector in supporting organizations dealing with the HIV/AIDS epidemic. Indeed, in its final report, the commission reflected on the unfinished task and what lies ahead in what may yet be the most devastating phase of the epidemic (Citizens Commission on AIDS for New York City and Northern New Jersey, 1991): The AIDS epidemic continues its relentless course, with no end in sight. But AIDS is fading from public concern. When the Citizens Commission on AIDS was created three and a half years ago, AIDS was an unpopular cause. It is now rapidly becoming a "post-popular" cause, without ever having truly engaged widespread public support. Such a conclusion after the first decade of an epidemic that has taken a minimum of 30,000 lives in New York City requires an attempt to understand a catastrophe that may ultimately take nearly 200,000 lives in New York City, cost billions of dollars, and leave untold numbers of shattered lives, but will have passed through the city without fundamental impacts on the overall life of the city. Epidemics appear to have much in common. They share a common dramaturgical form of progressive acknowledgment, collective agreement on an explanatory framework, and a negotiated public response (Rosenberg, 1989). They differ, however, according to the particular social and biological environments in which they take place. HIV disease in New York City

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The Social Impact of Aids in the United States occurs increasingly in the context of socioeconomic and ethnic deprivation, as well as among populations already suffering high levels of morbidity and mortality. The New York City epidemic is thus exceptional in certain ways, but it is not exceptional in that it is embedded in the ongoing life of the city (to some extent, in the life of Northern New Jersey and San Juan, Puerto Rico, as well). The particular impact of the HIV/AIDS epidemic can only be appreciated when one examines the complex of social and biological problems with which it constantly interacts. Such an examination, even though only partially covered in this report, has revealed that the synergism of plagues that converges on certain areas of New York City and the people who dwell in them creates the seedbed for an epidemic that will devastate those people far more seriously than HIV/AIDS will devastate the nation at large. In those areas—as in similar areas in cities throughout the country—the social institutions that might control the spread of the disease and provide care for those who suffer from it are already overburdened or nonexistent. The panel does not believe one can generalize from New York City to the United States; at the same time, the panel suggests that monitoring the impact of HIV/AIDS, that is, attempting to see the epidemic's course in light of the social context in which it moves, will show similar patterns elsewhere. NOTE 1.   In August 1991 prisoners known to be infected with HIV were allowed to participate in the Family Reunion Program of the state prison system, which allows inmates overnight visits with their spouses. This participation had been denied to HIV-positive prisoners for 10 years, and the denial had survived court tests by prisoners rights groups in the past. The reason offered for the change in policy was that there had been an evolution in the understanding of the disease by the prison authorities over the past 10 years (Verhovek, 1991). REFERENCES ACT-UP/New York (1991) ACT-UP New York: Capsule History. New York: ACT-UP. Abrams, E.J., and S.W. Nicholas (1990) Pediatric HIV infection. Pediatric Annals 19(8):482-487. Adam, B.D. (1987) The Rise of a Gay and Lesbian Movement. Boston: Twayne Publishers. Altman, L.K. (1991) New York moving to limit TB spread. New York Times December 8:A1. Andrews, R., B. Preston, E. Howell, and M. Keyes (1989) A Comparative Analysis of AIDS Service Demonstration Projects in Los Angeles, Miami, New York, and San Francisco. Washington, D.C.: SysteMetrics/McGraw Hill, Inc. Aral, S., and K. Holmes (1990) Epidemiology of personal behavior and sexually transmitted diseases. In K. Holmes, et al., Sexually Transmitted Diseases. New York: McGraw Hill. Aral, S.O., and K.K. Holmes (1991) Sexually transmitted diseases in the AIDS era. Scientific American 264:62-69. Association of the Bar of the City of New York/Joint Subcommittee on AIDS in the Criminal

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