AIDS cannot be viewed in isolation. The map of HIV disease in New York City is also a map of the epidemic spread of other diseases, including sexually transmitted viral and bacterial diseases, as well as some nonsexually transmitted diseases, particularly tuberculosis. AIDS cases are also concentrated in zones of urban poverty, poor health care, drug addiction, and social disintegration.

Gonorrhea, syphilis, and chancroid—the three classic venereal diseases that had nearly disappeared except for momentary and treatable recurrences—are increasing at epidemic rates among urban minority populations in the United States (Aral and Holmes, 1991). Syphilis and herpes have been associated with HIV infection in heterosexual men and women and homosexual men in the United States. HIV infection leads to altered manifestations of sexually transmitted diseases (STDs) and is thought to promote their spread. Thus, it has been suggested that HIV and other STDs interact to facilitate the sexual transmission of HIV (Aral and Holmes, 1991:66).

The recent spread of nonsexually transmitted infectious diseases is also occurring in neighborhoods already suffering from a high concentration of AIDS and other STDs. Certain parts of urban centers of the United States have become "islands of illness" (Rosenthal, 1990:1) as their residents experience a resurgence of measles, mumps, rubella, and whooping cough—all of which are diseases that can be prevented with vaccines. In addition, during the 1980s (following almost two decades of decline), New York City experienced a 132 percent increase in the incidence of tuberculosis (New York City Department of Health, 1991). New cases rose by more than 38 percent in the city in 1989-1990, almost four times the rate of increase in the previous year. The highest rate was found in central Harlem, where there were 233.4 cases per 100,000, more than 23 times the national average. Although African Americans made up 28.7 percent of the city's population in the 1990 census, they accounted for 58 percent of the tuberculosis cases. The association between tuberculosis and HIV disease has been documented in a number of studies (see, e.g., Barnes et al., 1991).

The rise of tuberculosis in impoverished communities is in part linked to the movement of people in and out of prison and jail systems in which crowded conditions, inadequate health care, and the presence of HIV/AIDS facilitate the transmission of the bacillus. The annual incidence of tuberculosis in the New York State correctional system increased from 15.4 cases per 100,000 in 1976-1978 to 132.2 cases in 1988. African Americans and Hispanics aged 30 to 39 who had used intravenous drugs were those usually infected, as one might expect. There is no evidence for a common source of the epidemic within the institutions, a finding that would confirm the view that the epidemics in New York City and in the prisons are part of a common epidemiologic community (Hammett et al., 1989).

The increase of tuberculosis in New York City was accompanied by an



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