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Chapter 6 HIV / AIDS in Injection Drug Users T HE FIRST five cases of what later came to be known as Acquired Immune Deficiency Syndrome (AIDS) were reported in the Morbidity and Mortality Weekly Report (MMWR) on June 5, 1981, under the enigmatic title, “Pneumocystis pneumonia—Los Angeles.” On June 12, 1981, the “afternoon mail brought from the United States [to Dr. Willy Rozenbaum, Paris physician and infectious disease specialist] the MMWR describing the pneumonia outbreak in Los Angeles” (Shilts 1987, 72). Earlier that same day, Rozenbaum had diagnosed Pneumocystis in a gay man and, as Shilts describes, based on his interviews with Rozenbaum, immediately made the connection with the MMWR report. Communication within the international medical community about this new and strange syndrome was virtually instantaneous.1 The lay press was quick to follow with its accounts.2 The United States, Great Britain, Canada, and France were each confronted at essentially the same time with the same clinical data: an apparently new, frightening, possibly infectious disease among young homosexual men. What each country made of this new information was, in large part, a product of old social and political patterns, well-established in response to earlier critical periods in public health. Stories of AIDS have been told and will continue to be told many times, from many perspectives. Early histories as well as political and cultural analyses were dominated by the experience of gay men (for example, Shilts 1987; Fee and Fox 1988). Not only were gay men publicly identified with AIDS from its inception, they were also articulate in speaking on their behalf and in positions to make themselves heard. The international scandal of France’s delayed response to the danger of AIDS-tainted blood, the construction of transfusees as innocent AIDS victims, and an organized movement of hemophiliacs have ensured that the contentious cultural politics of AIDS and blood received substantial attention as well (Morelle 1996; Setbon 1993; Steffen 1996; Kirp 1997, 1999; Feldman and Bayer 1999). 160 Once a blood test for the causal agent (HIV) became available in 1985, each country confronted questions about who should be tested, when, under what circumstances, and with what consequences. There is a very large literature on the difficulties that these questions presented (and still present) and on the differences in countries’ responses (see, for example, country reports in Kirp and Bayer 1992; Feldman and Bayer 1999 as well as a recent analysis by Baldwin 2005a). The stories least often told, however , and the ones that I will tell, are about AIDS and injection-drug users.3 These stories are inseparable not only from the larger history of the AIDS epidemic, but also from the much longer history of the West’s war on drugs. AIDS made its public debut in the summer of 1981, reported almost simultaneously from New York and California in the form of two relatively rare conditions, Kaposi’s sarcoma (a type of skin tumor) and Pneumocystis carinii pneumonia (CDC 1981a; 1981b). Nearly all of the reported cases were among homosexual men.4 Before the year was over, three cases had been reported from Europe, again in homosexual men, of whom two had visited gay venues in the United States within the past year. By December 10, 1981, when the New England Journal of Medicine published three papers accompanied by an editorial on this “unexpected outbreak,” more than 160 cases had been reported, reports were coming in at the rate of five or six a week, and the outbreak had become firmly identified with young male homosexuals practicing what these sober medical reports described as “liberated” or “promiscuous” lifestyles.5 The magnitude of the AIDS epidemic as it has evolved over time is measurable in several ways, none of them wholly satisfactory.6 However, AIDS case reporting is reasonably complete in industrialized countries (Low-Beer et al. 1998). I use the number of reported cases per 100,000 total population per year for a broad comparison across the four countries included in this study. Figure 6.1 shows reported cases per 100,000 for the United States, the UK, France, and Canada from the beginning of the epidemic in 1981 through 2004.7 The drop in incidence in the mid-1990s is attributable to the influence of new drug therapies in delaying progression from HIV infection to AIDS (CDC 1998, “Commentary”).8 The apparent surge in cases in the United States in 1992 and 1993 was due to an expanded...

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