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Editorial

Gordon Nary

September 1998

Alabama lawmaker Larry Sims is seeking reelection to the state senate with a campaign platform that includes banning physicians from prescribing Viagra to people with sexually transmitted diseases (STDs), including HIV disease. If reelected, Sims would also press for legislation to have the prescription of Viagra to such people defined by the courts as medical malpractice. Although Sims's Viagra strategy may be dismissed by many as a political ploy, the state senator has apparently convinced some of his constituents that an HIV-infected man with a short-term erection is more a threat to public health than the long-term absence of sex education classes in the public school system. Although the Sims platform smacks of tabloid sensationalism, his proposal may have touched on a public sentiment that could signal an impending backlash against the AIDS community. If Sims had attended the 12th World AIDS Conference in Geneva, he might have brought back to his constituents data suggesting a disquieting increase in unsafe sexual practices by some with HIV disease. Although such data is primarily anecdotal and there has always been a high incidence of unsafe sexual encounters by HIV-positive men, the tarot cards or in this case, the tarot posters on sexual behavior in Geneva could foretell a new pestilence.

State Senator Sims might also have reviewed the data on multidrug-resistant viruses which, when incubated in the petri dish of sexual irresponsibility, may have already found a home in the testes and ego, the semen of a new Patient Zero. If Patient Zero was also a bareback sex enthusiast, he may have already spread the seeds of a new HIV drug-resistant epidemic. While such a scenario is highly unlikely, it is possible. And it is that possibility that should have sent a frisson down the spine of every epidemiologist within yodeling distance of the conference center.

Against this backdrop, we have the introduction of Viagra. The unexpected high incidence of Viagra prescriptions in the AIDS community took Pfizer by surprise. Their market researchers didn't anticipate such a substantial market of young men, many of whom were fond of using recreational drugs including inhaled nitrates with their Viagra to enhance their sexual activity, a combination that has since proved lethal for some. This prescription bonanza was followed by innumerable reports of sexual excesses by some HIV-positive men at gay bathhouses, armed, if that is the correct euphemism, with their Viagra. The irony of such behavior in the Geneva bathhouse during the AIDS conference suggests that some delegates might have sadly learned more about the risk factors of transmitting HIV in that bathhouse than from any of the presentations at the conference center.

Unfortunately, such behavior by some may have obfuscated the importance of Viagra to many people with HIV disease. The hypogonadism associated with HIV disease and the erectile dysfunction that is a common side effect of many HIV/AIDS drugs often take a serious toll on self-esteem and personal relationships. Sometimes survival in a world diminished by the absence of a sustained loving relationship expressed in part by sexual union may not be perceived by some as worth the often difficult demands of an aggressive antiviral regimen. For some of these individuals, Viagra may be as life- sustaining as any of their antiviral drugs.

The populist message of the Sims reelection platform presents a challenge to both the AIDS and medical communities. There has been a general reluctance by some and possibly many AIDS community leaders to tackle the sacred cow, or in this case, the sacred bull of the what is often characterized as the "gay lifestyle" -- the freedom to have sex without restraint or accountability. Such reluctance could prove to be a cofactor in the emergence of a new HIV-drug-resistant epidemic.

The medical community also has a challenge. Anecdotally, there appears to be reluctance by some and possibly many physicians, to monitor their patients' sexual activities when such activities may have harmful consequences to the patient, their sexual partner(s), and the public health. There are new dimensions of old ethical issues being raised by the continued development and popularity of sex-enhancing therapies in this brave new world of the impending millennium that demand the medical community's thoughtful attention, discourse, and leadership.




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