TB v HIV

[alisenjafi]

There is a story in the headlines on a man who has an untreatable form of TB. Imagine if this man was practicing  unprotected sex and was poz, how both the media and the CDC would handle it  I hope some HIV advocates point this out.  The so called experts on tv are also treating this lackadaisical.  I hope the people on the flights sue his ass.
The New York Times
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May 30, 2007
TB Patient Is Isolated After Taking Two Flights
By LAWRENCE K. ALTMAN

Federal and international officials are tracking down passengers and crew members on two trans-Atlantic flights earlier this month who may have been exposed to a man infected with an exceptionally dangerous form of tuberculosis.

The male passenger flew to Paris from his home in Atlanta on May 12 on Air France 385 and arrived in Paris on May 13. He returned to the United States on May 24 after taking Czech Air 104 to Montreal from Prague. The man drove into the United States that day and entered a hospital in New York City on May 25.

The man is now in an Atlanta hospital under federally enforced isolation after he was flown there from New York City on Monday in a plane owned by the Centers for Disease Control and Prevention in Atlanta.

Dr. Martin S. Cetron , an agency official, said he reached the man on his cellphone while he was in Italy to inform him that tests performed before he left for Europe showed that he had a form of tuberculosis that was extremely resistant to standard antibiotics. Dr. Cetron said that he advised the man not to take commercial flights home from Europe and that a United States Embassy would provide assistance, including examination by a tuberculosis expert.

While the agency began to explore ways to bring the man home, he flew to Montreal and drove into the United States. Then, after agency officials made contact with him, he followed their instructions to drive safely into New York without risk to the public.

The New York City health department said the man spent 72 hours in a hospital in isolation and did not interact with anyone other than trained medical workers.

The disease control agency said that because it was the first airline contact investigation for extremely drug resistant tuberculosis, it was not sure that current recommendations were adequate to determine the possible range and risk of transmission on infection.

Dr. Julie L. Gerberding, director of the C.D.C., said her agency was advising passengers on the commercial flights to be tested for tuberculosis even though they are believed to have a low risk of infection.

That appraisal was based on tests showing that the number of tuberculosis bacteria in the man’s sputum were too low to be detected but still enough to infect others. Dr. Gerberding said her agency was erring on the side of caution because the form of tuberculosis, known as XDR TB, was often fatal and a growing public health threat in many countries.

The advisory applies only to the crew members on the man’s flight and to his fellow passengers, particularly those who were seated next to him and in the two rows behind him and the two rows in front of him.

“We’re not concerned about a generic threat to travelers,” Dr. Gerberding said.

Drug-susceptible, or regular, TB and XDR TB are thought to be spread the same way. The TB bacteria become aerosols when a person coughs, sneezes, speaks or sings. The bacteria can float in the air for several hours, depending on the environment. People who breathe air containing these bacteria can become infected.

The risk of acquiring any type of TB appears to depend on several factors, such as the extent of disease in the person who is the source of the bacteria, the duration of exposure and ventilation.

People who become infected have usually been exposed for several hours or days in poorly ventilated or crowded environments. An important way to prevent the spread and transmission is by limiting an infectious person’s contact with other people. People who have a confirmed diagnosis of TB or XDR TB are placed on treatment and kept isolated until they are no longer infectious.

Contact passengers will be advised to undergo a medical evaluation and testing and then have follow-up tests 8 to 10 weeks later.

Dr. Gerberding said doctors had not determined the source of the man’s infection. Molecular fingerprints used to distinguish among bacterial strains so far do not match that of any other known case, she said. People who think they may have been exposed to TB or XDR TB can call (800) CDC-INFO for more information.

Home

 

Copyright 2007 The New York Times Company

   

[joemutt]

The man apparently didnt know he had the untreatable strain of TB.

[Ann]

Joe,

He didn't know when he left the States, but he found out in Italy and flew anyway.

Dr. Martin S. Cetron , an agency official, said he reached the man on his cellphone while he was in Italy to inform him that tests performed before he left for Europe showed that he had a form of tuberculosis that was extremely resistant to standard antibiotics. Dr. Cetron said that he advised the man not to take commercial flights home from Europe and that a United States Embassy would provide assistance, including examination by a tuberculosis expert.

While the agency began to explore ways to bring the man home, he flew to Montreal and drove into the United States. Then, after agency officials made contact with him, he followed their instructions to drive safely into New York without risk to the public.

I agree it's not a lot different than going out and having unprotected intercourse after getting an hiv diagnosis. Maybe not quite the same as being the insertive partner, where the risk of passing the virus on is greater, but it is similar to being the receptive partner where the risk is less, but still a risk nontheless.

As far as suing the guy goes, it would be silly to sue if nobody became infected through this guy's actions, but if someone did become infected, they should either prosecute him or throw the hiv legislations off the books. Can't have it both ways!

Ann

[Ulong]

He knew he had some type of resistant TB. According to the Atlanta paper, he had already arranged for treatment of his TB before he left, it's not like he was over in Italy and got a call out of the blue with this new piece of information. He claims no one told him he "couldn't" travel. Whatever.

Let me try a link here to a story with a spin from the TB infected guy; I think this is interesting because it's becoming a he-said (frequent-flyer TB guy) she-said (head of the CDC) thing. It certainly has raised issues in the media about disclosure, public health, and quarantine.

http://www.ajc.com/health/content/health/stories/2007/05/29/0530meshtb.html

[Bucko]

I know I'm pointing out the obvious here, but TB is communicable through the environment and HIV is not.

I'm sorry, but I'm not getting the connection.

Brent
(Who is fuzzy-headed when he first gets up)

[Buckmark]

Putting aside the mode of tranmission (airborne versus sexually transmitted),
I believe the question is:  does this guy have the same obligations (legal, ethical,
moral, or otherwise) to prevent the transmission of TB to others, as we have to
prevent the transmission of HIV to others?

If he had transmitted HIV, he could be facing jail time.  But since it is "only" TB,
he probably has not broken any laws.  On face value, it appears like a double standard,
as both HIV and a resistant TB strain are deadly diseases.

Now let's factor in the mode of transmission.  With a sexually transmitted disease,
many people know there is a risk and should be protecting themselves.  These
poor folks who were just sitting on the airplane, however, had no idea that there
was a potential risk of transmission of a deadly disease.   If indeed he knew that
he had a resistant form of TB, then I'm not sure the mode of transmission makes
a difference.

Why doesn't he have a responsibility under the law to disclose?  Granted, he may
be suffering the consequences, since in one of the stories it was reported that
this is the first time in over 40 years that the US has issues a quarantine order for
an individual.  Still, that's a far cry from criminal liability, as there is with HIV.

Regards,

Henry

[ACinKC]

My favorite quote from this guy is the following...

"I'm a very well-educated, successful, intelligent person," he told the paper. "This is insane to me that I have an armed guard outside my door when I've cooperated with everything other than the whole solitary-confinement-in-Italy thing."

Isnt that like OJ saying, he was very well educated, successful and intelligent, other than that whole murdering my wife and lover thing.....

What a dumb ass answer!

[jack]

why did the dumbshits in Atlanta let him go back out in public? Thats what blows me away. If they let you go home, I guess he figured it couldnt have been too bad. Probably Bushes fault.

[SASA39]

One small thing : to pass a HIV you need two persons in very intimate relationship and any of those two would have to be  imprudence so to speak , and for TB  you need just ONE . So the guilt in TB case ( if he knew that he has a TB and he apparently did) is 100% HIS.
Also in a 8 hours time frame he could pass a virus to a much more number of people than he was HIV infected ( if we put aside some group activities  )
I mean 5 rows 80 passengers and 25 crew members 
2cc
                                 Al

[alisenjafi]

Henry hit it on the nail-as well as Al.  This guy knew and then tried to make it out that the doc's weren't that concerned.  My bigger point is the relaxed manner the news reports this.  If this was an HIV case the person would be vilified and I suspect his name would be in all the papers,

I also wonder in this age of super suspicion how a walking bio hazard entered Canada- doesn't the American authorities ever talk to anyone?
And again if this was HIV everyone would be sueing his ass as he gets a life sentence!

[Matty the Damned]

Actually the media reports here in Australia reflect the position that Johnny reported in his OP. Apparently this chap knew he had this sort of TB and defied a flight ban.

Matty the Damned appreciates the parallel that Johnny has drawn between this case and public/official reactions to people with HIV.

MtD

[jack]

the strain of TB this guy has is very hard to stop and drugs dont do much. I think I heard that this type of TB hadnt been seen in 40 years. If the Atlanta center knew this,he should not have been allowed to re-enter the population.
I have no idea how anyone can relate this to HIV. You do not need to touch someone to pass this on. The government agency who let this guy go should be sued by anyone who was infected.

[Matty the Damned]

Well Jakey,

TB isn't as contagious as some people think it is. Within the re-circulated air environment of a plane it's a worry and there certainly is a risk under other circumstances too, but it's not necessarily a case for major panic as long as this fellow is mindful of his condition and his responsibilities to others.

The special concern here is the drug resistance nature of the bacteria this chap is carrying.

I suspect that Johnny was noting that when HIV positive people are accused to spreading the virus wantonly and without due regard for others that there is widespread hysteria.

Such as we see here in one of our ubiquitous disclosure threads.

MtD

[jack]

news reports were this strain is very,very contagious. This is like some super TB shit. Anyways,if they didnt want the son of bitch in circulation they shouldnt have let him out.

[Matty the Damned]

Very, very contagious? Really? Not according to the news report I linked above, which draws as it's sources the New York Times and AP. To wit:

Though medical examinations have been recommended for all cabin crew members and passengers sitting within two rows of the man, tests indicated the amount of TB bacteria in his body was low, so passengers were not considered to be at high risk of infection, Dr Cetron said.

MtD

/emphasis added by Matty the Damned/

[jack]

the story has been changing all day. You really dont want to use the New York Times a source. Very unreliable. US newspapers,except for the WSJ,are just glorified tabloids. Other than the crossword and the Style section, the NYT is worthless.

[J.R.E.]

This was the story I received today from MedPage :

By Michael Smith, Senior Staff Writer, MedPage Today
May 30, 2007
 
   
Grady Memorial Hospital

 
ATLANTA, May 30 -- The Georgia man with extensively drug-resistant tuberculosis (XDR-TB) who sparked an international hunt for contacts is asymptomatic and feeling well, officials said today.

Testing continues to determine what drugs can be used to treat the man, now under a federal isolation order in Grady Memorial Hospital here, according to officials of the CDC.


The man, not identified because of privacy concerns, was confined in isolation because he violated a "covenant of trust" by flying to Europe after being advised not to travel, said the CDC. Then he flew back from Prague on a commercial jet after being begged to stay put while safe travel was being arranged.


Contact tracing in several countries was under way to find and test more than 100 passengers and crew members from two aircraft. They were deemed at highest risk of infection from the Georgia man. Although he flew on several aircraft, the investigators homed in on two flights of eight hours or more, and on passengers in nearly rows on those flights. All crew members were also considered at risk.


The CDC said the risk of infection was low, and no worse than any form of TB, but it was not zero.


The man broke no laws, said the CDC, but has lost his freedom for the time being. Arrangements were underway to transport him safely to National Jewish Hospital in Denver, which has an expertise in XDR-TB.


Martin Cetron, M.D., director of the CDC's division of global migration and quarantine, said the man's wife tested negative for TB on an initial test, which still must be confirmed in several weeks to allow the slow-growing TB bacteria to manifest themselves if she has been infected.


Nevertheless, he said, health officials are "greatly reassured by her initial test."


There were about 80 passengers seated within two rows of the man during long-haul flights from Atlanta to Paris and from Prague to Montreal.


Those passengers, as well as the 27 crew members on the two flights, are considered to be at greatest risk of infection, Dr. Cetron said, although he reiterated that the man's disease is not currently considered highly infectious.


Passengers and crew members of several short-haul flights the man took in Europe will also be contacted, although Dr. Cetron said the risk of infection for those people is much smaller, because the time they were exposed is much shorter.


He said the man's TB was first diagnosed in January after a chest x-ray was taken for another reason, The TB was confirmed by an exploratory procedure to obtain samples of his respiratory secretions.


The man was then and remains sputum-negative, Dr. Cetron said.


The TB bacterium was cultured and found to be multi-drug resistant only shortly before he began his international trip. The man was informed he had multi-drug resistant TB and was "clearly advised" not to travel, according to Kenneth Castro, M.D., director of the CDC's TB elimination section.


But the man departed for Europe before he received a formal letter advising against travel, Dr. Castro said. The man told an Atlanta newspaper he was on his honeymoon.


Once the CDC learned the man's TB was extensively drug resistant, Dr. Cetron said, officials reached him by cell phone in Rome, "begging him and asking him to stay put and not to travel" while the agency tried to find a way to get him back to the U.S. safely.


But before those arrangements could be completed, the man had flown from Rome to Prague and on to Montreal on May 24, where he and his wife crossed into the U.S. by car.


The man told the Atlanta Journal-Constitution that the CDC had asked him to turn himself in to Italian authorities for isolation and treatment and had told him he was not to fly commercially.


"I thought to myself: You're nuts. I wasn't going to do that. They told me I had been put on the no-fly list and my passport was flagged," the man said.


He and his wife decided to sneak back into the U.S., because he feared he wouldn't get proper treatment outside the U.S.


Dr. Cetron said the man was reached May 25 by cell phone "between Albany and New York City" and agreed to go to a hospital in New York that had a respiratory isolation facility.


"Since we issued the federal isolation order, he has been fully compliant," he said.


The man told the newspaper he found the situation absurd. "This is insane to me that I have an armed guard outside my door when I've cooperated with everything other than the whole solitary-confinement-in-Italy thing," he said."


A TB strain is defined as XDR if it is resistant to at least rifampicin and isoniazid from among the first line anti-TB drugs, as well as to any fluoroquinolone, and to at least one of three injectable second-line drugs (capreomycin, kanamycin, and amikacin).


The two long-haul flights involved in the case are Air France 385, which left Atlanta for Paris May 12, and Czech Air 0104 which traveled from Prague to Montreal May 24. The Air France flight is also a Delta codeshare, flight 8517.


Dr. Cetron said the federal isolation order - last used in 1963 - is applied to an individual who is sick with or has been infected by a contagious disease. A quarantine order, on the other hand, is applied to people who have been exposed to a contagious disease without any evidence that they are actually infected. 


Ray


I haven't read all the resposes , so this may just be repetetive.....

[alisenjafi]

The man broke no laws, said the CDC, but has lost his freedom for the time being.

This is what gets me- so it isn't against the law to pass on tb but it is to pass on HIV.  What bs- in fact i thought spreading any disease knowingly was considered a crime. 

[bocker3]

While I fully agree that the media would have been more severely vilifying this man if it were HIV and not TB, vs. the scare-a-thon they are doing now, I have a problem with people suggesting that this man should never have been "allowed back in the population".  Everything that I have read suggests this strain is no more contagious than "normal" TB and some stories seem to indicate that it is less contagious.  So....  are we advocating that everyone with TB be quarantined?  What about people with other sort of infections that "highly resistant" to treatment??  That seems a bit draconian -- I seem to remember many people advocating shipping all AIDS patients off to some island back in the 1980's too.  Why??  Fear.  It is always easy to vilify "others", but much harder to look at ourselves.

Now don't get me wrong, I think this man was reckless, selfish and an absolute fool -- and if he infected someone else, a civil lawsuit should be started, seeing as he didn't seem to violate any criminal laws.  I think we can rest assured that some "caring Congressperson" will soon launch a bill to criminalize this behavior too.  Politicians are nothing if not opportunists looking to get votes by "protecting" us.

Mike

[bocker3]

This is what gets me- so it isn't against the law to pass on tb but it is to pass on HIV.  What bs- in fact i thought spreading any disease knowingly was considered a crime. 

We have to be careful what we wish for......  I don't want to go to jail because I went to the office with a cold!!

Mike

[alisenjafi]

It also seems odd to me in one breath they are saying all this crap about not breaking laws and then there is a massive search on for the other passengers. The Spin Dr's are working overtime to night! Why was he on a no fly list and and had to sneak back into America then. It must one of those Judge Judy piss on my leg times.

From what i just read tb affects a third of the world's population- nothing to get excited about-1.7 billion people yearly.
http://textbookofbacteriology.net/tuberculosis.html

Tuberculosis
© 2005 Kenneth Todar University of Wisconsin-Madison Department of Bacteriology
 

Tuberculosis (TB) is the leading cause of death in the world from a bacterial infectious disease. The disease affects 1.7 billion people/year which is equal to one-third of the entire world population.

Nothing to sneeze at!

[SASA39]

He has been identified......
http://news.yahoo.com/s/ap/20070531/ap_on_re_us/tuberculosis_infection

[bear60]

Yea and he is from Atlanta!! Good lord and he's cute too. 30 years old and a lawyer.

[budndallastx]

He isn't just a lawyer but a Personal Injury Lawyer which means he is the one who would turn around and sue anything that moves if he were on the opposite site of this situation (meaning the guy on the plan with a TB Patient).  Further, his father-in-law is the TB Specialist at the CDC which makes his story even more suspicious.     

[ndrew]

We have to be careful what we wish for......  I don't want to go to jail because I went to the office with a cold!!

Mike

True, but sometimes the cavelier behavior of people with colds and flus in public irks me, as well as makes me sick...

Drew

[jack]

Have you seen his wife? WOW! I would fly anywhere,anyhow,with any disease to marry her. I dont think anyone can blame him. I am sure its just a coincidence her father works in tb lab in atlanta. who wants their daughter marrying a personal injury lawyer? Now, if someone would just die,it would make a good Law and Order.

[Matty the Damned]

Oh well since he's a personal injury lawyer that makes it all different. Fucking arsehole deserves to have TB!

Honestly, give Matty the Damned a break. If any one of you lace edged chihuahua owners broke a nail on a plane you'd be calling this bloke to file suit against the airline.

MtD

[jack]

yeah, but have you seen his wife? fuck the tb. this guy and his wife will be the medias center of attention till someone else fucks up.  Hey,whatever happened to that US congressman whose intern went missing? Gary Condit? dude was bailed out by 911. Its all we heard about for weeks and since 911 havent heard anything. that dude was really creepy. suffering from severe add

[thirtysomething]

Well, I think that this man shouldn't have gone out of the country and put other people at risk. Though he claims that he wasn't aware that he has XDR (or some of them say MDR) Tuberculosis, he could have pushed his marriage and *honeymoon* plans for a future date. It's fuckin' selfish of him to put people at risk !

I was diagnosed of latent tuberculosis after my HIV diagnosis. I took TB meds for 9 months to get it out of my system! Now I travel a lot for business, and if some jerk (like this guy in question) sits next to me in the flight, I'm friggin' doomed!

I'm glad they put him in quarantine and I hope he didn't infect anyone else.

I'm not sure if most of the guys here are aware of how deadly drug-resistant TB can be. If you have 'National Geographic On Demand' channel at home, check out the documentary on TB and let me know if you pissed in your pants after watching it !

[alisenjafi]

So this morning the couple are getting tv coverage.  Both playing the victim.  I find it hard to believe with her father in the position he has at CDC- over 30 years this crap.  Also  was the father at the wedding- in either case as an expert I feel he aided and abetted these people.
Again part anger from the fact if this was a healthy guy who gave HIV , the man would be painted as callous, not a victim. 
And another parallel, the border patrol said  this guy didn't look sick-where did I hear that before!
While part of this goof up is funny- you couldn't write it, I am sure now that our friends overseas are looking to give tb to send on American airlines to infect this nation. A new method of bio warfare? And to think people are worried if customs finds HIV meds!

[sdcabincrew74]

As a flight attendant this is pretty darn scary to me.  I always get annoyed when a sick person gets on board, coughing, sneezing, sniffling .... it always makes me wonder.  Of course, it could be allergies too, so as crew, we are basically instructed not do or say anything unless it VERY apparent that he/she is really sick.  So, folks, if you are sick, stay home.  No need to infect 150+ other people with whatever you have .....

[remo2008]

Anyone remember how back in the 1980's radical suggestions were given too treat all with HIV like they treated the TB epidemic? Involuntary isolation in TB sanitariums, the suggestion by the radical right wing was too create HIV sanitariums....., isolate until cured or died...., imagine if this suggestion had not been ruled out, for all those who raise the hue and cry for this poor fellows "lynching" one might consider beware what you wish for...! We still have those today who see all HIV+ people like biblical lepers of old, sinful, deserving of their illness as proof of god punishing them...! No matter some contracted if via non sexual modes, blood transfusion, birth, etc, all are lumped into the same pile, diseased HIV lepers, deserving of their fate! I love too read history, since the old adage do not study history and one unfortunately repeats it..! Many will not compare TB too HIV, but we with HIV are extremely suceptible too TB...! So for those who demonize this fellow, for his likely misfortune, consider if a epidemic occurs we are much more likely too get it than any average non HIV person..! Today the CDC estimates {guesses} 1% of USA population is HIV+..., out of 300 million souls this means about 3 million, with 1.9 million diagnosed cases today.., this translates too a minimum of 1.1 million walking undiagnosed cases..! With world wide infection rates at anywhere from 5% too 30% one can say we are lucky but then NYC has a rate of 10% city infection rate, Washington, DC has a higher rate than this..., so my view is CDC statistics is mere guess and anyone can venture a guess.., but if one uses the low world wide statistic of 5% then that 3 million figure goes too 15 million, and the undiagnosed too 13.1 million unfortunate souls who do not know yet..! We live in a "lynch mob society" where everyone who deems themselves superior too others demands protection from those they deem themselves superior too.., imagine some draconian federal/state legistlator greedy for election suggesting all HIV+ be required too have their status on their automobile license tag, drivers license/state ID card..? Unthinkable, they are doing it today too sex offenders, who cares you might say! Go too the Florida department of corrections web site, punch in search for sex offenders for women too cut down on your research time, and you will find many women convicted of "criminal transmission of HIV", now admittedly most of them are prostitutes, but some are not, some have only "criminal transmisson of HIV as their only offense' but they are forever labeled "sex offenders" and no distinction is made between them and a child molestor! One might say who cares, its not me, I have nothing too fear, but then the old adage of "but for the grace of god there go I", imagine some real bad case of a HIV+ man or woman dating indescriminatedly, doing no disclosure, infecting a large number of people being made a "national case of notoriety and infamous nature", and one could see a hue and cry for such draconian laws, so my view is "beware what you wish for"..! To put things in historical context, read some on the "Black death" or "Bubonic Plague of middle ages" and how it killed 1/3 of humanity, but the real story was the reactions of people, men and women whom were uninfected abandoning their children, spouses, parents, family loved ones too die in solitude and misery..! Uninfected cities becoming fortresses, denying access too those fleeing the infected cities..., even killing them in fear...! Irrational fear is what I see here, yes this man acted maybe with less than caution, maybe he truly believed he was not infectious or dangerous, maybe not, only him and CDC know the truth, with the hue and cry from government I am of the opinion the officials will lie too save their precious bureaucratic jobs over telling the truth..! No matter what the truth, there is a similiar case over a year old where a man in Arizona with same TB strain is isolated, involuntarily and until recently was denied a television, computer and any human compassion..! Sadly we live in a "lynch mob society' of its all about me and who cares about anyone else..! Such societies usually tear themselves up and destroy themselves. I love the old biblical quote from jesus when he faces off with the biblical goats whom in shock and awe cannot understand why Jesus does not know them, he told them when you ignored the poor, hungry, naked those sick and in prison you did this too the least of these you did it unto me.., I often wondered why Jesus word son the sick and those in prison were lumped into one sentence, and it dawned on me sick of body, sick of mind and sick of morals.....all would apply too the sick whether they be of body or mind and or souls..! I cannot judge this man with TB, only feel sorrow for him, pity, and see him as "but for the grace of god there go I", it is so easy too join the "lynch mob" and even harder too close ones eyes and ears too their rantings and ravings...!
I remember reading how "Typhoid Mary" until her dying day never thought she made anyone sick due too she never got sick herself.., it is easy too delude ourselves too anything if we want too..! 

[alisenjafi]

Quote from Remo2208

Anyone remember how back in the 1980's radical suggestions were given too treat all with HIV like they treated the TB epidemic? Involuntary isolation in TB sanitariums, the suggestion by the radical right wing was too create HIV sanitariums.....

Actually back then people with HIV were left to there own devices- sitting in hospital wards in their own feces and urine.  Why the American gov't hardly did anything.
Why do you think the stigma of HIV is so prevalent today? while one can blame the fact on ignorance then, there is a lot of discrimination today- it is just better tailored.

This is an upperwardly mobile  professional couple whom are connected well with the CDC.  The man new for a few months he was infected- January.  With laws stating how PWHIV  can't come into the country.  It looks as usual everyone is trying to cover their asses here.  As Stated in my original post, the media has mentioned lawsuites against this guy.  Just because he didn't infect anyone is just plain luck! So much as to judging people by their looks-which is the most likley reason many got HIV!
John