Peter W. Plumley is a Fellow of the Society of Actuaries and a member of the American Academy of Actuaries. Mr. Plumley is also Chairperson of the Society of Actuaries Non-Insurance HIV/AIDS Task Force and is a member of the Society of Actuaries Committee on HIV/AIDS (which deals with insurance-related AIDS issues). A more detailed analysis can be found in his:

An Actuarial Analysis of the AIDS Epidemic in the U.S.

See also:

Latest Proof of Low Heterosexual AIDS Risk CDC HIV/AIDS Surveillance Report 1997 Year-End

Introduction

"AIDS" - its mere mention strikes fear into the hearts of millions. We hear that, while here in the United States it is primarily confined to homosexual men and IV drug users, it is increasing among heterosexuals. We are told that we should always practice "safe sex", in order to avoid HIV infection and the supposed inevitable resulting death from AIDS.

AIDS has been a serious problem for homosexual men who engage in high risk anal sex, and for intravenous ("IV") drug users. But what about the "healthy heterosexual" - that is, the heterosexual who is in good health, does not have any sexually transmitted diseases ("STDs") which might leave sores or lesions in the genital area, who does not generally engage in anal sex, and who is not sexually involved with the drug community or others at increased risk of HIV infection? Should the "healthy heterosexual" be concerned about the risk of contracting HIV from sexual activity, or is the risk too remote to worry about?

If you believe that, for the 85% to 90% of the population that are "healthy heterosexuals", the risk of AIDS is too remote to worry about, you're right. However, if you qualify as a "healthy heterosexual" but still are concerned about the risk of AIDS, read on. You'll learn about the present state of the AIDS epidemic (it's leveled off and appears to have begun to decline), whether having multiple sexual partners significantly increases your risk of HIV infection (it does not), whether condoms are really necessary for prevention of HIV infection (usually they are not), whether AIDS education for heterosexuals is doing more harm than good (it probably is), and whether HIV really does cause AIDS (many think it does not, at least not by itself).

The present state of the AIDS epidemic

Acquired immune deficiency syndrome, known as "AIDS", was first diagnosed in the early 1980s. A couple of years later, it was announced that AIDS was caused by a virus. This virus was called the human immunodeficiency virus, or "HIV".

It is important to note that AIDS is not a disease, but rather a collection of previously known diseases which have in common the syndrome of a deficiency of the immune system. The definition of AIDS has been expanded three times - in 1985, 1987, and 1993 - as it was determined that additional diseases supposedly were caused by HIV.

As of December 1994, a total of 441,528 AIDS cases had been reported to the Centers for Disease Control ("CDC") since the epidemic began. 84% of the adult/adolescent cases were attributed to either male homosexual contact or IV drug use. 7% were from heterosexual contact, with the majority of these being from contact with IV drug users. The remaining 9% were from hemophilia (1%), blood transfusions (2%) or unknown risks (6%).

AIDS is almost 100% fatal, with 270,870 deaths from AIDS having been reported since 1981. Many of those still alive were diagnosed with AIDS during the most recent few years. (While the number of AIDS deaths may seem large, during the same time period there were more than 25 million deaths in the United States from all causes. Thus AIDS accounted for about 1% of all deaths during that period.)

Is the AIDS epidemic continuing to increase?

We see newspaper articles which suggest that the AIDS epidemic is continuing to grow, particularly among young people. Actually, however, if one allows for the changing definitions of "AIDS" mentioned earlier, the number of new AIDS cases being reported appears to have leveled off a couple of years ago.

Young people are no exception. In fact, from 1990 to 1992, when the overall number of AIDS cases was still increasing, the total number of new AIDS cases at ages 13- 24 declined from 1796 cases in 1990 to 1605 cases in 1992. (It isn't possible to make year-to-year numerical comparisons after 1992 because the definition of AIDS was significantly broadened in 1993.)

Even so, shouldn't young people be more concerned about AIDS?

Perhaps some should be; however, you really can't blame them for not worrying about AIDS. Only about 2% of deaths occurring at ages 15-24 are from AIDS, and less than half of these are attributed to heterosexual contact. Young people are far more likely to die from accidents, homicide or suicide - or even from cancer - than from AIDS. For them, the principal danger of unprotected sex is that it may create a life, not that it may cost one.

How likely is the healthy heterosexual to encounter an HIV-positive sexual partner?

Highly unlikely, assuming some reasonable discretion is used in choosing sexual partners. If you avoid those who seem likely to be at a higher risk for HIV (street prostitutes, obvious drug users, etc.), there are relatively few HIV-positive people out there. Depending on where you live, the probability of such an encounter might vary from one in 1000 to one in 5000 or less.

If by some unfortunate chance my sexual partner is HIV-positive, how likely is it that I will become infected from a "one night stand"?

Again, highly unlikely. Statistical studies show that HIV is extremely difficult to transmit by penile-vaginal sex, particularly from a woman to a man. A heterosexual woman probably has an average risk of between one in 500 and one in 1000 of becoming infected from a sexual encounter with an HIV-positive man. A heterosexual man has even less of a risk if his female partner is infected. Moreover, these figures include both healthy and not-so-healthy people (i.e., those with other STDs, etc.). So if you are a "healthy heterosexual", your risk is extremely remote indeed. According to the experts, unless you have some special problem such as genital sores or lesions which might make you unusually susceptible to infection, HIV transmission from heterosexual contact generally requires repeated exposure to HIV, and therefore usually occurs between regular sexual partners, one of whom is HIV-positive, rather than from one night stands.

So what is the risk to the healthy heterosexual of HIV-infection from the "one night stand" with a seemingly healthy partner?

Virtually zero - usually less than one-in-a-million. In fact, you're probably more at risk of being killed in a car accident on the way to the "no-tell motel" than you are of getting HIV infection once you arrive there.

Does having multiple sexual partners significantly increase the risk of HIV transmission?

Contrary to popular belief, it does not. It can be proven mathematically that the lower the efficiency of transmission, the less important the number of partners becomes. For the more easily transmitted STDs, the number of sexual partners makes a big difference. However, for HIV, if you are a healthy heterosexual the transmission efficiency is so low that the number of partners makes virtually no difference.

Should I worry about whom my sexual partner has been with previously?

Not really, unless you have some reason to believe that he or she has had a regular sexual relationship with someone, such as a drug user, who was at increased risk of HIV infection. The more easily transmitted STDs travel from man-to-woman-to-man-to-woman, etc., and so one's prior sexual partners are important. However, because HIV is so difficult to transmit heterosexually, "tertiary" transmissions among healthy heterosexuals (where someone gets infected heterosexually from someone else who also became infected in the same manner) are extremely rare.

Can I get HIV infection from oral sex or shaking hands, kissing, etc.

There are no proven instances of HIV transmission from oral sex or "casual contact". There have been some alleged instances, and there are those who warn about the theoretical possibility of it happening if someone engages in oral sex with an open cut or sore in his or her mouth. Even so, the risk is so remote that it probably isn't worth thinking about (unless your partner is believed to be HIV- positive, in which case some caution might be a good idea).

Condoms and hard hats - or, how important is "safe sex"?

We hear a lot of talk about the need for condoms. However, they are intrusive in the love making process, and so most people don't like them. But are they really necessary for the healthy heterosexual?

Do you wear a hard hat all the time? No, of course not. They are worn only by such people as construction workers, those engaging in sports such as football and hockey, and some motorcyclists and bicyclists - in other words, people who are engaged in work or play involving a significantly increased risk of injury to the head.

Is this because for others there is no risk at all of getting hit on the head? Not at all. Many people have been hurt or killed from head injuries that might have been prevented if they had worn a hard hat while going about their daily lives.

Then why doesn't everyone wear a hard hat all day long? The answer is simple. It's because (1) for most people the risk of a head injury is very small ("one in a million", or less), and (2) a hard hat is inconvenient and uncomfortable to wear. So unless you are a construction worker or an athlete, you are willing to take this small risk in order to avoid the inconvenience and discomfort of a hard hat, even at a very small risk to your life.

The same can be said about condoms. Yes, it's theoretically possible that the failure to use a condom could cause you to become infected with HIV, just as it's possible that failure to wear a hard hat could turn out to be fatal. But do you really want to spend your life worrying about "one-in-a-million" risks that will almost surely never happen to you?

Should anyone bother with condoms?

Not everyone needs to use a condom, any more than we all need to wear hard hats. But should anyone use a condom? Certainly, just as some people should use hard hats.

Condoms should be used to reduce the risk of unwanted pregnancy - a serious problem for some segments of the population - if no other method of birth control is being used.

Condoms should be used by homosexual men when engaging in anal sex, particularly if many partners are involved, to prevent the transmission of all STDs.

Condoms should be used by heterosexuals for the prevention of other STDs when either partner is at increased risk for such diseases. For example, they should be used when one's partner has a history of STDs, or has some current symptoms, such as lesions, sores, or genital warts, or is particularly susceptible to exposure to STDs (such as might be the case with a street prostitute). And of course they should be used if one's partner is known to be HIV-positive.

But usually if your concern about HIV and other STDs is so great that you feel the need to use a condom, you probably shouldn't be in the bedroom in the first place! (Would you feel safe walking through a bad neighborhood, just because you were wearing a hard hat to protect yourself from a rap on the head by a mugger?)

The dangers of "condomania"

Today we are in the midst of an epidemic of "condomania" - i.e., emphasis on the need to use condoms to prevent HIV transmission. While the AIDS epidemic is confined almost entirely to homosexual men, IV drug users and their regular sexual partners, "condomania" has permeated much of our society. It is a part of the larger epidemic of "AIDS paranoia". Because of AIDS paranoia, there have been tens of thousands of cases of discrimination against those known or even suspected of being HIV-positive. Dozens of laws have been passed to "protect" the public against HIV infection and AIDS. Many of those laws have been ill-advised and counterproductive.

"Condomania" has done little to prevent the transmission of HIV except among homosexual men. But has it done any harm?

Unfortunately, it probably has. First of all, there is some evidence that condoms can cause irritation, inflammation and other medical problems, particularly when used with Nonoxynol 9 - the procedure recommended to ensure prevention of the transmission of HIV.

But the psychological impact is even more serious. Think of the harm we are doing. It is one thing to teach young people about sexual responsibility, and to tell our daughters not to get pregnant until they are married and ready for children. But we are teaching children and adults alike that "intimacy means death". In the process, we are interfering with one of the most basic human desires - that of sexual intimacy - by telling millions of people, most of whom have little or no risk of HIV infection, that sex may kill them unless they "protect" themselves from their sexual partner, who may be carrying a deadly, and sexually transmittable, virus. We are telling them that they may die a horrible death unless they intrude on the lovemaking process by using some artificial means to prevent their body fluids from intermingling, even though for many that intermingling is an important part of the sexual experience. Surely for the healthy heterosexual the stress we are creating is doing more harm than the warnings are doing good.

Does HIV really cause AIDS?

Up to this point, we've been assuming that HIV is the cause of AIDS. However, in the last few years, an increasing number of respected scientists have come to the conclusion that the relationship of HIV to AIDS is far more complicated than simply "HIV causes AIDS". Some of these scientists believe that HIV is a harmless virus that has nothing to do with AIDS. Others believe that HIV is related to AIDS in some way, but that it requires some immune system damaging "co-factor" to be harmful. Still others believe that HIV is only one of a number of immune suppressing factors which, when taken in combination with other such factors, ultimately destroys the immune system and creates the medical illness we call "AIDS".

While we don't know all the answers, we do know that in virtually every case in which "AIDS" has been diagnosed, there is some provable and identifiable risk factor present (besides HIV) which would tend to damage the immune system. In his book Rethinking AIDS, Dr. Robert Root-Bernstein gives a lengthy list of drugs and other conditions which are known to damage the immune system. These include not only IV drugs, but also non-IV "recreational" drugs, as well as certain prescription drugs such as AZT, and some of the stronger drugs prescribed for the treatment and prophylaxis of some sexually transmitted diseases (drugs which are frequently taken in large quantities). It also includes immune system abnormalities such as hemophilia. It is very unusual to find someone with AIDS who doesn't have one or more of these risk factors.

The risks and rewards of life

Do "healthy heterosexuals" get AIDS? There are a few heterosexuals without known risk factors who have been diagnosed with AIDS. But these are rare cases. Many more healthy heterosexuals have died because they weren't wearing a hard hat.

But healthy heterosexuals are not going to start wearing hard hats - nor should they lie awake worrying about AIDS. No matter how hard we try, we cannot avoid all risks in life - only some of the bigger ones. Even a life of celibacy doesn't totally protect against HIV infection - neither a hard hat or a condom would protect you against someone stabbing you with an HIV-infected needle while you were walking down the street.

This is not to suggest that we should not be sexually responsible. Both men and women have a responsibility to avoid unwanted pregnancies. We should be aware of the symptoms of STDs, and get prompt treatment when such symptoms appear. (Fortunately, except for HIV, all STDs except herpes, which is not life threatening, are curable with proper treatment.) We should always tell our prospective sexual partners of any transmittable diseases we have - even a common cold. And we should keep our own bodies healthy and drug-free, and avoid sexual contact with those whose bodies are not equally healthy and drug-free.

But at the same time, we should not permit ourselves to become victims of AIDS paranoia. AIDS may be only one of a number of legitimate health concerns for the "not-so-healthy heterosexual". However, for the healthy heterosexual, AIDS is truly a "one-in-a-million" risk - the kind we take several times every day just going about our daily lives. For example, consider a skiing trip. Just getting to the ski resort probably involves a risk of death from a car accident of several times "one-in-a-million". Then there is the accident risk on the slopes, to say nothing of the dangers of overeating and drinking. And finally, there is the accident risk once more when making the trip back home. Yet those who are skiers don't worry about these risks, because the rewards make the risks worth taking. Nor do we condemn the ski resort operators for encouraging people to take such risks.

Even if we avoid such "extra" risks as a ski trip, just living a day in our lives involves a risk of death from natural causes of more than one-in-a-million when we are young, and then gets gradually larger - much larger - as we age.

We will never get out of life alive, so we might as well enjoy it while we are around to do so. There's little point in reaching a ripe old age thinking about how much of life's pleasures we missed in order to avoid a few of those "one-in-a-million" risks.