If Nushawn Williams had not come to a place like Chautauqua County, he probably would have kept on spreading the AIDS virus without getting caught, the federal government's most experienced expert on the disease said Thursday.
"This whole thing would have been missed if it happened in New York City," said Dr. Anthony S. Fauci, who headed the federal fight against AIDS through the 1980s and now oversees it as director of the National Institute of Allergy and Infectious Diseases.
In an interview after a U.S. Senate hearing on AIDS, Fauci said Thursday he was stunned by the number of young women whom Williams appears to have infected with the deadly virus during his year in Chautauqua County. That number might have been even larger, he said, if Williams had stayed in New York City.
"The fact that this happened in a small community is important," he said. "It allowed the epidemiologists to track what happened. If it had happened in a big city, that would have been very difficult. It could easily fall through the cracks."
In a small rural county, Fauci said, it was relatively easy for local health officials to detect a sudden increase in HIV infections caused, apparently, by one man. In a place such as New York, the huge population and comparatively large number of people with HIV would have made it possible for Williams to go undetected.
Judy Moore, director of the Jamestown Boys and Girls Club, which runs a teen pregnancy prevention program, agreed.
"In a bigger city, you might never know about someone like this," she said. "Here we only have three offices of the Health Department, and they work together pretty closely. When the cases kept popping up, they were able to put the pieces together, and that's why the focus is on us."
Fauci stressed that the Williams case is highly unusual in many ways. He said it is very rare for someone with HIV to continue to have unprotected sex with so many people and to infect such a high percentage of his partners.
"What is extraordinary is the efficiency of transmission," Fauci said. Normally, he said, the chances of an HIV-positive man spreading the disease to a woman are from one in several hundred to one in several thousand.
But Williams apparently infected at least 10 of the 50 to 75 women he had sex with. "His rate is about 20 percent," Fauci said. "The proportion of people he infected is very, very high."
Other AIDS experts agreed.
"The infection rate is incredible to me," said Daniel Zingale, executive director of AIDS Action.
Fauci and other experts offered several possible explanations for why Williams infected so many of his partners. Fauci said Williams might be infected with an especially virulent form of the HIV virus, which could develop with another communicable disease.
Victoria Sharp, director of the AIDS Center of St. Luke's-Roosevelt Hospital in New York City, said Williams might have an unusually high amount of the HIV virus in his bloodstream. Or perhaps he engaged his partners in activities -- such as anal sex or violent sexual activity -- that are more likely to result in HIV transmission than vaginal sex is.
AIDS experts were disheartened that Williams could spread the virus so far and wide after years of publicity about the effects of HIV and the dangers of casual sex without the use of condoms.
"What disturbs me the most is that many young women thought it was OK to have unprotected sex with this guy," Zingale said.
Such ignorance is not limited to Chautauqua County. An average of two young people contract HIV every hour nationwide, Zingale said. "There's this misperception that the worst is over regarding AIDS," he said. "The new treatments have fostered complacency."
Unfortunately, those new treatments are imperfect.
At the Senate Labor and Human Resources Committee hearing on the matter Thursday, Donna McCullough, an AIDS patient from Vermont, described how protease inhibitors had restored her immune system to its best health in years. But she also noted that the drug therapy is so regimented and inconvenient, involving so many pills, that it dictates her life's activities.
Protease inhibitors block the operation of protease, an enzyme used by the human immunodeficiency virus to make copies of itself. They are the strongest additions to the growing arsenal of more-powerful AIDS weapons and are used in combination with two older AIDS drugs: AZT and 3TC.
Most patients receive these triple-punch "cocktails." Often people start on them as soon as they learn they are infected.
In some patients, the combinations have slowed and perhaps stalled the fatal disease, although they are too new to know whether they will have a lasting effect. In others, the new treatments fail.
"Our experience has shown that the earlier a patient starts treatment, the better they fare. But it's hard to say. The virus doesn't act the same in person to person," said Maureen Maliszewski, nurse practitioner at Evergreen Health Services, the medical center of AIDS Community Services of Western New York.
She said failure to take the medicines on schedule probably is the main reason for failure.
In some patients, the drugs do not block the appropriate enzymes.
It may be that the HIV virus is able to develop a resistance to the protease inhibitors over time, according to some research.
Worse yet, Fauci said, "it's impossible to give a timetable for development of a HIV vaccine. We're not going to have a vaccine for the next year or two. At best it's going to be several years."
News Medical Reporter Henry L. Davis contributed to this report.