VOLUME 5, NUMBER 8 REAPPRAISING AIDS                  NOV. 1997

The Nushawn Williams Affair

Health Officials Promote Homeless Bisexual New York City Dope Injector & 10 Female Sex Partners as Heterosexual HIV Cases

Drug Injecting and Anal Intercourse, Not
Vaginal Intercourse, Are Implicated
1 in 10 Trillion Chance That Vaginal Sex is the Only
Vector When HIV+ Man Has 100 Female Partners
and 10 Become HIV+

If health officials of the upstate New York city of Jamestown suspected that Nushawn Williams was a bisexual drug injector, they didn't say so at the October 27 press conference in which they announced that the 21-year-old New York City native was HIV-positive. Although they described Williams as a crack dealer who often traded his wares for sex, they said nothing about the drug habits of his four female partners who had so far been identified as positive. Neither did they mention that the high HIV prevalence among his partners implicated drug injection or anal intercourse rather than vaginal sex.

Instead they simply proclaimed that the positive females had contracted HIV from Williams through heterosexual contact, commonly regarded as meaning coitus. They relayed a story sure to frighten anyone who thinks that HIV transmits vaginally and causes AIDS. Williams had engaged about 100 females in unprotected sex since becoming positive, they said. Furthermore, he continued his aggressive promiscuity even after being notified a year earlier of his positive status, which he never revealed to any of his partners, including dozens in Jamestown. The New York Times (Nov. 13) explained how health officers displayed his photograph, listed his various street names, and "began telling the story to the world... in the hope of finding more victims."

On November 10 Newsweek devoted a large article to the Williams affair, and the Times has covered it extensively (Oct. 30, Oct. 31, Nov. 4, Nov 13, Dec. 1). According to the Times , the publicity helped investigators to identity six additional HIV-positive females claiming to have had sex with Williams, bringing the total now to ten. Investigators say that unlike the first four, these six contracted HIV from Williams after he learned of his positive status, and that this will serve as a basis for six separate charges of first-degree assault. (Newsweek asserts that nine contacts, all from Jamestown, were identified prior to the press conference and prior to linkage with Williams. Three of these were exposed prior to Williams receiving his positive test, and six after.)

The Times has dubbed this "one of the most notorious outbreaks in the 16 years that AIDS has been known." Since about half the drug injectors and gays in large urban centers test HIV-positive (see chart), the notoriety stems from the perception that penile-vaginal intercourse explains how these eleven people (including Williams himself) became positive, and that their health and HIV risks represent those of ordinary Americans. A careful reading of these press accounts demolishes this popular view.

Bisexual Drug Injecting Transfusion Recipient?

Contrary to the impression created by health officials, it turns out that Williams belongs to an assortment of medical and social risk groups that are marked by high mortality and a variety of diseases, infections, and characteristics (such as positive HIV status) which are otherwise rare in the United States.

Four days after health officers presented the "outbreak" in purely heterosexual terms, the October 31 Times reported that New York City police officers were convinced that Williams had been injecting drugs for years. Then the November 10 Newsweek story, published two weeks after the press conference, reported that Williams had at least two homosexual relationships.

The combined details from Newsweek and The New York Times produce a portrait of Williams that bears little resemblance to the vast majority of sexually active Americans: a childhood characterized by hunger, sexual abuse, and abject poverty; a drug-addicted mother who turned their apartment into a crack house and provided no supervision; a schooling that took place in special education classes until he dropped out at age 14; a long criminal record that includes a year of hard prison time for a murder charge; a brief adulthood characterized by homelessness and sex with girls as young as 12 years old; and a gunshot wound requiring hospitalization.

Any number of these factors would preclude his medical history from indicating the health risks of ordinary Americans, and some (homosexual relations and blood injecting, and perhaps any blood transfusion he might have received for his bullet wound) prevent him from qualifying as a "heterosexual" HIV case.

Classifying Williams

The reports of drug injecting and homosexuality came after the October 27 press conference. None of the news accounts indicates how health department representatives officially categorize Williams, or if their view has been affected by the media reports. But the reports leave a strong impression that government statistics record Williams as a heterosexual case.

The media for its part has declined to push officials for clarification on this matter. The October 31 Times pursued the drug injecting angle, but all subsequent editions ignored this topic. The Newsweek piece detailed two homosexual relationships with HIV-positive men, including one which his relatives believe is the source of his positive status. Neither publication discussed how their information should disqualify Williams as a "heterosexual" case. In addition, Newsweek said nothing about drug injecting, and the Times has said nothing about homosexual activity, though there has been plenty of time for the respective reporters to read other's articles.

Nor has either publication explored the possibility that Williams may have received a blood transfusion.

Assessing the Risks

Since Williams has been presented as a warning to the general public, it is essential for health officials and reporters to very carefully establish the risk factors that characterize Williams and his HIV-positive sex partners. Most Americans believe that HIV causes AIDS, and they fear they may contract it from vaginal intercourse.

If Williams develops any of the various official AIDS diseases, it will be important to know why he may have become ill. Where AIDS pathologies -- wasting, dementia, opportunistic infections such as pneumonia and tuberculosis -- are rare in the general American public, even HIV-negative homeless drug addicts with prison records are at increased risk for them. In the only mention in any account of an AIDS condition for Williams, the Newsweek writers state that by January, 1997, he was "already looking gaunt." But gaunt from what? HIV? Years of poverty and drug abuse? In describing the squalor where Williams lived in January, 1997 -- in a one-room apartment shared by a friend and the friend's mother and sister on the 12th floor of a "notorious" New York City housing project -- the writers mention "sparse furnishings," "a pool of urine" on the elevator, and "a few skinny kittens." Might Williams be "gaunt" for the same reason his former feline roommates are "skinny?"

The general fear inspired by this affair is unwarranted if the principal parties represent special risk groups characterized by special circumstances and activities that render them susceptible to all sorts of rare medical calamities.

Anal intercourse and drug injecting are officially considered to be so much more efficient at transmitting HIV, and the HIV prevalence among gays and drug injectors are so much higher than among the general population, that patients are automatically disqualified from the "heterosexual" category if they admit to any instance of male homosexuality or drug injecting.

If Williams was a drug injector or had homosexual relationships, then he probably became HIV positive from dirty needles or receptive anal intercourse. And perhaps his female partners became positive the same way.

But government health investigators do a very poor job of identifying anal sex recipients and drug injectors in their tracking of HIV and AIDS cases. For one thing, they rely on self-identification, which involves high rates of false denials when taboo activities like anal sex and drug injecting are involved. In compiling HIV and AIDS statistics, officials accept all denials as accurate and include no adjustment factor to account for false denials.

Furthermore, they make no explicit attempt to identify anal sex recipients. Instead they employ euphemisms such as "men who have sex with men" and "women who have sex with bisexual men." That second code phrase is particularly ineffective since many bisexual men do not make their homosexual experiences known to their female partners, and it creates the impression that bisexual men are transmitting their positive HIV statuses to women via vaginal rather than anal intercourse.

Risk-Tracking Problems

The Williams affair illustrates many of the problems with HIV and AIDS risk assessment epidemiology.

The November 13 Times article said that the government contact tracer attending this case "ruled out intravenous drug use as a means of infection" for the first four females identified. Their sexual histories led to Williams, the only person named on all four lists. The tracer then interviewed Williams multiple times, and apparently concluded that Williams qualified as a heterosexual case.

Newsweek reporters, though, found agreement among relatives and neighbors who recall homosexual relations. And the October 31 Times even more convincingly established a drug injecting habit for Williams. "Law enforcement officials in Brooklyn said they were certain... that Mr. Williams had been injecting drugs, including heroin, with a needle for years," the article stated. "'We know it for a fact,' said one investigator."

The same article quotes Frederic D. Winters, a spokesman for Jamestown's Health Department as saying, "We have heard rumors, thus far unconfirmed, that he might have been an IV drug user." According to the Times writer, "Mr. Winters said that asking any HIV client about intravenous drug use is standard practice, but confidentiality laws prevented him from disclosing how Mr. Williams had answered that question."

Why is that? Winters bypassed those same laws in order to name Williams, enumerate his heterosexual contacts, disclose how many have tested positive, and reveal that after learning of his status Williams continued having unprotected sex without informing his partners.

That's pretty confidential information.

The word "unconfirmed" strongly implies that Williams denied to health investigators that he had ever injected drugs, and that they believed him. RA has found no indication in the press that the investigators have addressed the allegations of homosexuality, but it increasingly looks like officials have inaccurately identified Williams as having lacked both homosexual and drug injecting experiences. That damages the credibility of their characterization of his ten HIV-positive female contacts as heterosexual cases.

The Nushawn Ten

Where government officials and reporters have divulged many highly personal details about Williams, much less is known about his ten HIV-positive female sex partners who have been identified so far. They remain protected by confidentiality laws, and the press is not eager to uncover unsavory facts about them anyway. The contact tracer who interviewed them refuses to discuss the case in order to maintain his own anonymity.

Nine of them live in Jamestown, "a mostly rural, down-at-the-heels industrial town of 142,000" located 400 miles north-west of New York City, Newsweek says. The description brings to mind images of healthy young teenagers being debauched by Williams. But it was a pre-existing drug market that drew Williams there, and kept him coming back. This makes female drug users his most likely sex partners. Williams spent a great deal of time in Jamestown peddling drugs from about the middle of 1995 (at the age of 19, when he was released from a one-year jail stint on charges he'd hacked a man to death with a machete) until early 1997, at the age of 21, when New York City police arrested him for selling crack. Piecing together the various press accounts, the nine Jamestown girls tested positive at the ages of 12, 13, 15, 16, 17, 17, 18, 19, and 21, respectively.

Each new press account makes it appear ever more likely that these very young women and girls belong to some of the same extraordinary categories that make Nushawn Williams an inappropriate example of the general American risk for HIV and AIDS.

Although reporters say nothing about anal intercourse and its likely role given Williams' alleged homosexual history, they persistently link his female sex partners to drug use, and other factors, such as poverty, child abuse, and promiscuity.

"Mr. Williams, 21, traded on his charm and drugs for sex in [Jamestown]," the November 4 Times article said. The October 30 edition reported that Williams attracted "the Jamestown area's poorer, street-hardened and disaffected girls."

The November 13 article described "the gum shoe work of piecing together Mr. Williams' story" as being difficult because of "how hard it is to trace sexual contacts in a sub-culture of rootless young people, drugs, abandoned tenements and anonymous sex. Some of the girls who knew him in [Jamestown] are homeless, some are drug users and sellers, and many are school dropouts."

The next door neighbor of a "shabby" apartment out of which Williams sometimes operated told Newsweek that "the constant parade of local girls who flocked to Williams' door" included "runaways and street kids."
His drug selling partner Brian Jones described to the magazine how Williams liked to use crack to seduce girls. "They'd do some drugs, have sex with another capsule of crack sitting out, and he'd give her the crack when they were done."

Newsweek also described how the Williams affair showed that "at least some teens in [Jamestown] were dabbling in drugs."

Andrea Caruso, who tested positive at age 17 and has made herself available to reporters, posed for a large photo on the front page of the Newsweek article, which was subtitled, "He charmed the lost and the unwanted." The writers described her as having "a long history of emotional problems and a devastating lack of self-esteem." Her "liaison" with Williams, they continued, was "laced with drugs," though they did not specify injection drug use.
The press also describes these girls as uncommonly promiscuous. "Because sex among the group has been extensive, Mr. Williams might not have infected all the women," the November 4 Times reported. "Health officials knew of... 53 people who had sex with the ten women Mr. Williams infected."

The youngest of the nine Jamestown girls -- now 14 but perhaps 12 when she was having sex with Williams -- spoke anonymously with a Times writer, who reports nothing about her possible drug usage, but on December 1 quoted her as saying, "in a small place, everybody does everybody." The October 31 edition revealed that she had been a victim of previous sexual abuse.

Not one report suggests that any of the ten HIV-positive female contacts are drug-free. Only the Newsweek article attributed any illness in these girls to HIV. A few months after "hearing rumors" that Williams was positive, one of the girls, a high school freshman said, "I remember getting a rash all over my body. I felt sick all the time and somehow I knew I was positive." The writers simply assumed, like the girl, that a transient rash and persistent feelings of sickness are signs of HIV, rather than other factors, including drug use, or even psychosomatic effects from worrying about HIV.

The Odds

"Contracting HIV through heterosexual sex is hard to do," Newsweek reported, "and HIV infection among young women is rare." The writers intended "heterosexual sex" to mean vaginal intercourse, and probably don't fully appreciate the difficulty of vaginal transmission, or the rarity of HIV outside the risk groups.

It's not just hard to transmit HIV from a positive to a negative partner via unprotected vaginal intercourse, it's nearly impossible . The latest research puts the unprotected vaginal transmission frequency at about one per thousand contacts man-to-woman, and one per eight thousand woman-to-man (Padian N, Am J Epidemiol 146:350-357, 1997). This compares to unprotected frequencies of more than one transmission per ten contacts for all other microbes that are classified as venereally contagious.

Using the one per thousand figure, and arbitrarily assuming a sex spree involving 500 acts of vaginal intercourse spread among many women, the odds of a man transmitting HIV to ten women are 7.6 per 100 trillion, or about one per 10 trillion (see chart). Those odds are comparable to being struck many times by lightning in the same year, or winning several state lotteries.

Other factors can make HIV transmission more efficient, such as concurrent infections with true disease-causing microbes, genital bleeding and ulcers, and poor health. The press accounts describe venereal disease among Williams and some of his partners. But the Times was more impressed with the possibility of drug needle transmission. "The virus, while transmittable through heterosexual sex, is not typically passed along in that manner as efficiently as it seems to have been with Mr. Williams," read the October 31 report. "But transmission through shared needles is much more common. [Injection] drug use would... help explain why Mr. Williams appears to have been such an effective transmitter of the virus."

Health officials offered only ludicrous explanations for how heterosexual sex could explain ten positive females out of about 100 partners. They said "the relatively high rate of transmission of the virus among Mr. Williams' contacts probably reflects high-risk activity, like sex without a condom or with multiple partners," the November 4 Times reported.

But the tiny vaginal transmission rates are for condomless sex, and having multiple partners does not affect the transmission rate. Studies show that frequency of anal intercourse and blood injecting, but not vaginal intercourse, are associated with HIV seroconversions (Brody, Archives of Sexual Behavior 24[4]:383-393). The relatively high efficiency of these transmission factors helps explain why about half of all drug injectors and gay men in large urban centers test positive, and why subjects who identify themselves as belonging to either category are automatically excluded from "heterosexual" transmission status.

Furthermore, men who have sexual experiences with other men have an increased likelihood of engaging female partners in anal intercourse, and women who have sex with drug injecting men have an increased likelihood of injecting drugs themselves (Brody, ibid .). Since Williams evidently has experienced both homosexuality and drug injecting, this suggests that his ten positive female partners have as well.

So do epidemiological data (see chart). There is virtually no HIV to be found among American females who deny having injected drugs. Only one female in 10,000 who gives blood for the first time tests positive. On the other hand, HIV rates are remarkably high among anal sex recipients and drug injectors: 54% of the gay men in San Francisco test positive, as do 38.6% of the female drug injectors in New York City. If appreciable numbers of Williams' female sex partners are receiving anal intercourse or shooting drugs, it's easy to see how ten out of about 100 (10%) would turn up HIV-positive.

The "outbreak" of HIV positive test results in Jamestown, then, is best explained by drug injecting and anal intercourse. And any AIDS conditions that subsequently develop in these HIV-positive individuals will likely have non-HIV explanations.

-- Paul Philpott