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Notes -
To be fair to Shilts, he does highlight some people where the line between ignorance and confusion to at least motivated ignorance was blurry at best. One repeat character early in the book is Bobbi Campbell, and Shilts claims that he continued to go to bathhouses (allegedly, though to Shilts' skepticism, not for sex) even well after he'd started plastering posters of sarcomas outside of the baths.
Dugas (aka "Patient Zero", though this is a bit of a myth) plays a more plainly villainous role in the telling, and while some of that is Shilts exaggerating matters at his editor's prodding -- there's a rather infamous bedroom conversation that portrayed Dugas as intentionally spreading the disease, "I've got gay cancer. I'm gonna die, and so are you", that doesn't really make sense given Dugas' public positions at the time and may never have happened -- but him going to bars for casual sex while AIDS Vancouver was telling him to knock it off was pretty well-supported.
And this sort of thinking didn't die with him, or with the availability of blood tests; Shilts points to the theory that HIV required some other cofactor to progress into symptomatic AIDs. This form remained common among a weird baptist-and-bootleggers alliance of gay men and religious types if publicly marginalized into the early-00s! It was wrong as a behavior even by its own merits -- asymptomatic transmission was well-established by '85 -- but as incubation times became well-established the bootlegger side of this theory became more and more obviously self-delusion. I think the author oversells this, while downplaying other plausible arguments that were reasonably-but-wrongly held. For a lot of his focus time period, the effective advise was not to simply wrap it up or abstain from casual sex, but that far broader lifestyle (during the "GRID" days) or casual contact (until mid-1983, a lot of medical professionals believed touch or even indirect contact played a significant transmission method!) changes.
There's some other later bits about gay activists putting often-steep political demands to insure that new anti-HIV efforts would not become anti-gay efforts, most impactfully around the dawn of testing.
On the other side, Shilts' narrative is far more aggressive about the failures of virology and medical research as a class. There's some Goldilocking here: the NCI (and the original sarcomas fell under cancer) research too slow-paced, NIID research underfunded, the NIH uninterested except in the broadest health impacts, the FDA (which controls blood products) unwilling to piece together disparate symptoms to the specific disease, NIH funding too broad, statutory funding too over-specified. But the full combination did lead to a painfully slow understanding of the disease, and release and delayed adoption of blood tests, often marred by politics. These are villains in the more Brazil sense, but they're still villains by Shilts' version of events.
Re: Casual contact transmission of AIDS
One of the other great works of AIDS literature is of course Larson's Rent. Larson wrote many drafts over the years, and who had AIDS and how bad and how they got it varied throughout. In early drafts, which date to the late 80s, the hetero non addict characters are also infected, or assume that they probably are or will be from living in close proximity to infected persons. There's much more of a fatalistic tone to early drafts, everyone is going to die, even the heteros and lesbians and non addicts, and die soon.
As drafts progressed, Mark stopped having, then stopped assuming he would get, AIDS, and Roger's infection was more clearly tied to intravenous drug use and his dead ex rather than just sort of having it because idk reasons. Much of Mark's character arc becomes about surviving his friends, as Larson did, and documenting and immortalizing his dead and dying friends, but also the strange isolation of being the survivor, the normie of the group, the straight white non addicted ally.
Much of this reflected the progression of medical knowledge in real life, and the final script in turn has become more a period relic than a reflection of modernity, by the time the movie came out it had a totally different valence. Treatments were different, prognoses were different.
The song that really has the most currency to today's world, and best reflected how the world would progress, is probably Santa Fe, which predicted without realizing it the development of the restaurant industry in small towns across America.
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Shilts actually doesn't spend that much time in the book on the specific "Patient Zero" claim, which seems like a bit of a red herring by Dugas supporters to concentrate on anyway, but there's multiple scenes of people reporting that Dugas (or someone matching Dugas's description) knowingly bragged of spreading gay cancer or the disease, not just the most infamous line.
Yes, where I felt Shilts was being the most unfair was the parts where he accused the authorities of just doing something wrong but then had multiple conflicting views of what they were doing wrong. I also noted that Shilts blames the media for not reporting on HIV earlier and more aggressively, but many of the cases where media reported on it they seem to just have spread wrong views or caused panic; wouldn't earlier and heavier reporting just have led to more of that?
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I'm certainly advocating for people who knowingly and non-consensually infect others with a lethal illness being slow roasted over a fire. If Douglas was fucking around, he deserves to find out, and not his unwitting partners.
My understanding is that HIV doesn't usually kill you by itself, it's the immune suppression that leaves you open to everything else (yeah, is it the bullet, gun or shooter who kills someone etc etc). But I think it's reasonable to call that a "cofactor", if you miraculously managed to keep a person with AIDS in a perfectly sterile environment and scrubbed their microbiome, I'd expect them to live a lot longer (not that deleting a microbiome is a good idea in the least).
Even the sarcomas are due to opportunistic infection by HHV-8 and friends.
So a cofactor isn't really a bad description as far as I'm concerned.
I don't blame them, I can easily see how it could have gone that way. Of course, I am not necessarily opposed to mandatory testing, for human beings who have any reason to interact with anyone else, which is just about all of them. I've browsed enough /r/Grindr to know that while some of the more fastidious ones can make a song and dance about using condoms, getting tested and PREP, if the bussy is tight enough they'll usually relent. I'm sure most straight men would do the same, if they had even the same OOM odds of getting casual sex on demand.
Looking at the horndog behavior of gay men today, even accounting for how HIV has become largely inconsequential with modern anti retroviral therapies, I think revealed preferences strongly suggests many/most of them are willing to die sooner if it means they can bareback more partners. Sure, I have nothing against them for doing so, that's their prerogative, and I doubt there's a significant number of utterly naive gay men around who have no idea what that practise entails.
I could well be overstating my competence, but if I was in charge of the CDC or FDA, I think I could, at least with a bit more study of epidemiology and stats than my standard curriculum provided, have done a better job than the incumbents during COVID. Certainly I would have at least deferred to superforecasters or polymaths like Zvi much earlier, if I felt I couldn't handle it. I would certainly have pushed for the end of lockdowns and masking much earlier than they petered away.
But putting myself in the shoes of the FDA/CDC in the 70s? I can't see myself doing better really.
My personal definition of villainy, even for institutional incompetence or sub-optimality, isn't that harsh.
There's an increased rate of certain wasting cancers that start to occur after certain thresholds of HIV infection hit, but that wasn't recognized until the late 80s, but the theory I'm motioning around was a little different.
The (later disproved) hypothesis was not that HIV alone couldn't directly kill you short of other external factors, but that it would not progress to immune deficiency in a large portion (usually 50-95%) of those who carried the virus: either their immune systems would fight it off, or it would only have some marginal impact that would never progress to recognizable symptoms. Usually the claim was that full-blown AIDs was limited to those who abused certain hard drugs or had diseases like hepatitis, though more rarely they'd point to a genetic or full-body health version.
This wasn't as crazy at is seems at first glance -- some healthier people, and those with lower initial viral exposures, often did have much longer incubation periods, at a time where all of the virologist modelling expected an incubation time in the area of months or a year. And some of the craziness that did come about wasn't just limited to the self-motivated gays, as even before HIV was isolated or AIDS formalized, the NIH spent as much time seriously entertaining theories about poppers or sperm causing the immune deficiencies due to their chemical makeup, rather than a viral contagion. Shilts has a section where one of the early gay activists does a statistical analysis for the known cases among the (wildly) sexual active men, their expected number of sexual partners, and claimed times of original infections a year earlier, and then comes up with some astronomically low odds ratio (billions-to-one?) for the then-current number of cases.
But then it turned out the disease couldn't be transmitted casually, and almost all of the healthy people in that analysis ended up just being in the incubation stage, probably had reduced T-cells even at the time, and eventually developed symptomatic AIDS, and a large portion (around two-thirds?) died before protease inhibitors were on the market.
That's part of it, but there were also expectations that the tests could and would be used as a proxy -- both to blacklist HIV-positive men from places and activities where they would not be at unusual risk of transmitting the virus, and to Notice men who got tested repeatedly (even if they tested negative) as gay and having gay sex at a time where this was often illegal.
Dunno. It's easier, looking back that far, to see what of our vision is hindsight, but there's also a lot more fog between the mistakes of that era and today. Shilts focuses a lot on the homophobia -- and while he exaggerates the sense that the CDC didn't care about gay men dying, he isn't totally unfounded -- but there was a lot of fatheaded provincialism and simple status quo bias, too.
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