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This chapter discusses the modes of transmission, worldwide distribution, and environmental conditions necessary for the spread of HIV. It explains the epidemiological framework for understanding disease spread, which includes characteristics of the pathogen, the host, and the environment. The appendix to this chapter presents cross-national survey data on sexual behavior. The data demonstrate that there is no correlation between higher national prevalence of HIV and countries with higher rates of early initiation of sex, premarital sex, or multipartnered sex.

This chapter examines the economic and health variables that distinguish sub-Saharan Africa from affluent countries which have lower rates of HIV. It shows the biomedical effects of economic conditions in Africa — such as poverty, inequality, lack of transport, lack of sanitary infrastructure, and lack of access to medical care — that contribute to poor health in general and consequently high rates of HIV transmission. Widespread malnutrition, malaria, schistosomiasis, and other parasitic diseases in sub-Saharan Africa contribute to higher risk of HIV transmission. This economic/biomedical conclusion implies a broad policy response for confronting HIV/AIDS in Africa, Asia, and Latin America.

This chapter describes the pandemic by region, highlighting the changing dynamics of HIV transmission and the diverse patterns of infection found worldwide. The epidemic remains extremely dynamic, growing and changing character as the virus exploits new opportunities for transmission. Virtually no country in the world remains unaffected. The epidemic is not homogeneous within regions; some countries are more affected than others. In reality, like the pandemic, the national picture is made up of a series of epidemics with their own characteristics and dynamics. The number of people living with HIV has been rising in every region, with the steepest recent increases occurring in East Asia, Eastern Europe, and Central Asia. In the coming years, as access to life-prolonging antiretroviral treatment increases, more people will be living with HIV. Providing treatment is both a humanitarian and a human rights issue.

This chapter brings together the results of numerous scientific studies on the biology of immune function and disease. It presents the biomedical evidence that malnutrition and parasite infection contribute to greater susceptibility to any infectious disease, including those which are transmitted sexually. The conditions of poverty increase HIV susceptibility, not only to opportunist diseases after HIV infection but also to HIV transmission, just as they increase vulnerability to other infectious diseases.

The chapter develops a forward-looking analysis of the cost-effectiveness of HIV prevention interventions, taking into account HIV transmission dynamics and spending commitments implied by new HIV infections. The dynamic and population-level effects of averting an HIV infection differ because an individual not infected because of an intervention does not infect others and so on, but he or she may become infected at a later time. As HIV is predominantly transmitted sexually, the impacts of HIV prevention interventions differ according to risk behaviour, but also to factors (e.g. age) of the individuals targeted. The chapter discusses HIV infections averted and financial savings achieved through condom use across age groups; population-level effects of averting one HIV infection across risk groups; the effectiveness, cost-effectiveness, and the financial returns to investments of male circumcision; and the cost-effectiveness of treatment, in terms of immediate health outcomes and HIV prevention.

One of the most taxing issues in the prevention of heterosexual transmission of HIV in Puerto Rico is culture itself. Researchers point to the need to change cultural norms related to gender and sexuality to reduce HIV transmission: traditional gender roles that dictate the need for unprotected sex as a measure of relationship trust, understanding monogamy as an HIV prevention strategy, and the role of religion in discouraging condom use as a prevention effort. Although these issues are complex enough when addressing individuals, they become even more multifaceted when addressing couples that feel safe from HIV by having steady partners. However, when one partner in the dyad is HIV positive, implications for prevention are even more daunting. The purpose of this chapter is to contribute to a better understanding of HIV risk and protection in serodiscordant couples in Puerto Rico, by employing exploratory qualitative interviews with 20 such dyads.

This chapter assesses the risk of HIV transmission in several infant feeding strategies. It presents a model of the trade-off between preventing maternal-infant HIV transmission and increasing non-HIV sources of mortality. The model evaluates month-by-month risks of fatal adverse events for infant feeding strategies such as breastfeeding, never breastfeeding, or breastfeeding for some specified period and then switching to formula feeding. The model is applied to eight geographic settings and for varied assumptions about perinatal antiretroviral therapy.

This chapter examines the overall cost-effectiveness of methadone treatment for injection drug users (IDUS) as an HIV prevention measure. It begins by reviewing several studies that document the efficacy of methadone treatment. It then discusses two models: a basic model of HIV transmission without treatment and a simple model that incorporates methadone treatment. Analysis suggests that methadone treatment significantly reduces disease prevalence at a cost of $100,000 to $300,000 per infection averted.

This chapter focuses on the care of people with HIV/AIDS in the UK, and assumes that, for the foreseeable future, AIDS will be fatal and HIV will be transmissible only through certain body fluids or sexually. It contends that in the industrialised world specialist palliative care is still relevant to HIV disease, although the context and character of its practice will vary over time. It also argues that the lessons palliative care specialists have learnt from the care of patients with HIV/AIDS give valuable insights for other diseases.

HIV antiretroviral treatment (ART) can prevent the onward transmission of HIV. This prevention potential of treatment raises several ethical and economic questions. How and how strongly should HIV-infected individuals be motivated to initiate ART for prevention of onward transmission of HIV alone (i.e. during disease stages when they do not yet need ART for their own health)? Considering both treatment and prevention effects of ART, how should ART be prioritized across different populations? How can identified victim effects bias be avoided in the resource allocation to HIV treatment for prevention? This chapter describes and discusses these and related issues, which will increasingly gain policy importance as countries with high HIV prevalence are considering treatment-as-prevention strategies

This chapter focuses on the three different problems faced by the children in South Africa which include the increasing prevalence of AIDS and transmission of HIV virus from mother-to-child, the increasing abuse of children, particularly girls and infants and the state of orphans in South Africa. It refers to the struggle of Nkosi Johnson, a HIV-positive child abandoned by her mother, which made South Africans aware of the epidemiological reality of the HIV infection and conceives a different moral representation of AIDS. The HIV-positive children in South Africa were the victims of both the reckless behavior of their parents and the inappropriate decisions of the government that was too slow to introduce programs for reducing the rate of transmission from mother to child. It also reveals how the issue of orphans and more generally of children separated from their parents is not just the consequence of a biological misfortune, but also the result of historically constituted structural inequalities in the society.

It has been argued that epidemics have played a major role in human history. For example, the arrival of the British in Australia triggered a deadly wave of smallpox infections, with the estimated death of half of the indigenous Australians. The same virus wiped out the population of Easter Island, and measles eliminated a third of the inhabitants of Fiji. New threats have also emerged as human populations explode and pressure on ecosystems crosses sustainability thresholds. In order to understand how to deal with epidemics and eradicate them, there is a need to first understand how they spread. This chapter begins with a discussion of epidemic modeling, specifically the SIS model. It then covers the SIS model in space and graphs, modeling HIV-1 transmission, and halting viruses in scale-free networks.

This chapter proposes a research design for estimating the protective effects of prophylactic vaccines. Following the structure of the HIV vaccine trial of the Bangkok Metropolitan Administration cohort of injecting drug users (IDUS), the chapter simulates HIV transmission within this trial structure to investigate whether the proposed design is sufficiently powerful to estimate vaccine efficacy.

This concluding chapter discusses how the concept of culture is used in communication about HIV risk and prevention, and looks specifically at how Trobrianders' conceptual engagement with HIV and AIDS is mediated by cultural knowledge and social practice. There is widespread awareness among Trobriand men and women that condoms provide the means for preventing HIV transmission. To some extent, condom use is influenced by the perception that HIV risk is something that exists beyond spatial boundaries of familiarity. Young men report that because of limited condom supply, they tend to save condoms for use with partners from outside their immediate network of relationships. Ultimately, young people's preference for forming steady relationships with partners from their own village or villages proximate to their own reflects how sexual networks assume spatial dimensions that define both tubwa membership and established exchange networks within and between affiliate villages.

This chapter focuses on Papuan waria—men who dress as women and identify themselves as women—and their risk of HIV transmission. The prevalence of violence and coercion in the lives of waria brings conditions of acute risk of HIV transmission to them and their sexual partners. Indeed, data show that waria tend to engage in sex without condoms, in unsafe locations, and with multiple sex partners. However, it also suggests that a particular group of waria—young Papuan men who seek to have sex for pleasure rather than for money—are in fact at greater risk of unsafe practices than those who transact sex for financial gain.

Shilts joins The San Francisco Chronicle as its first openly gay reporter on the newsroom staff. Hired to cover the “gay beat” in San Francisco, Shilts also is given general assignment stories. Shilts coordinates Chronicle coverage of the deadly October 1989 Loma Prieta earthquake. Newsroom colleagues overcome suspicions of the new “gay reporter” as Shilts lobbies publishers for non-discrimination policies and domestic partner benefits. Shilts picks up on rumors of a “gay cancer” affecting gay men in the Castro district. Reporting includes very first stories attempting to link exotic immune system related diseases with homosexual men in San Francisco and elsewhere. Shilts is becomes convinced the AIDS story is a major story and devotes himself nearly full-time to the subject.

Shilts and book editor Michael Denneny make controversial decisions about how to get And the Band Played On properly promoted and reviewed. The New York Post’s screaming headline about “Patient Zero” sets in motion worldwide publicity for the concept that one man, Gaetan Dugas, was responsible for spreading AIDS in North America. Shilts’s review of Dr. William Darrow’s cluster study of gay men in Los Angeles proves faulty, although mainstream journalism quickly goes with the “Patient Zero” concept and Shilts is quickly cast as a national expert on HIV-AIDS. Shilts unveils his “AIDS was allowed to happen” posit. A subsequent review of Shilts’s work is mostly critical, particularly from LGBT sources who fault Shilts for allegedly scapegoating Dugas.

Timing played a key role in all of Shilts’s success, and failures. His reporting and books on cutting-edge issues in the emerging gay liberation movement withstood strong push back on his work while establishing himself as an openly gay reporter in mainstream journalism. Shilts unapologetically approached his reporting as he had approached his earlier life – that information granted power and understanding and journalists played a key role in conveying that information. Important questions remain about whether Shilts helped or hindered the understanding of AIDS in the context of the gay community, with serious reservations raised about his use of the “Patient Zero” posit. He was praised, however, for advocacy for gay rights via Conduct Unbecoming.