CHAPTER 6 AIDS

Of all the deadly infectious diseases that are discussed in this book, acquired im­mune deficiency syndrome (AIDS) is perhaps the most culturally constructed one, whose ever-shifting “metaphors” relative to each society's attitudes and be­haviors are intimately connected with the clinical and biological manifestations of the disease.

First, we should briefly recount what we know thus far about the unique biol­ogy and origins of this complex disease. AIDS is caused by the human immuno­deficiency virus (HIV), which, like the viruses that cause influenza, mutates rather prolifically, about once in every replication cycle, making the disease dif­ficult to counteract with a vaccine or a cure. However, HIV is different from smallpox or influenza viruses in that, with the aid of an enzyme called reverse transcriptase, its RNA is able to make DNA copies of itself, which it then incor­porates into the nuclear chromosomes of the host cell so that it manufactures more viral RNA and hence more viruses. Microbes with this ability are called retroviruses, because they actually reverse the normal order of cell biology, which is to transcribe DNA into RNA.

Within this devious family of retroviruses, HIV has the further dastardly ca­pacity of specifically targeting cells that are crucial for marshaling our immune defense system. These are namely the helper T-lymphocytes, or T-4 cells, which signal other cells to start producing antibodies in our blood and which also mo­bilize a cellular immune response to the virus; yet, T-4 cells are particularly prone to invasion by HIV because they contain CD4 protein molecules on their sur­faces with which HIV happens to bind. Another type of immune cell called macrophages, which are phagocytes or white blood cells that devour other, viral- infected cells, also contain the CD4 receptor and thus can be infected by HIV. Unlike other retroviruses, however, HIV usually kills off the T-4 cells after it has used them to replicate, although in some of these cells and in macrophages it becomes latent, only to be reactivated later. So far as we know, HIV and related viruses in animals—including monkeys, cats, sheep, goats, and horses—are unique in terms of this immune-suppressing quality, forming their own genus or subclass of retroviruses known as lentiviruses (meaning slow to cause disease). HIV is therefore a particularly insidious kind of disease organism in that it seeks out and destroys or else incapacitates the very cells upon which our bodies rely in order to fight off an infection.

But because HIV is a latent and slow-acting virus, usually patients will go for long periods, often years, without any noticeable symptoms (and are therefore called asymptomatic), during which time they might be blissfully unaware that they have the disease even as they are still infectious in terms of the virus passing through their blood, semen or vaginal secretions, and breast milk, although it should also be pointed out that HIV’s presence in these fluids is often low or variable. However, some do show symptoms immediately upon infection with HIV, which can include a flulike illness and swollen lymph glands, or what is called acute infection syndrome, which is nonetheless practically indistinguish­able from many another disease. Later, some more characteristic symptoms might manifest themselves, including low T-4 cell counts, night sweats, persis­tent low-grade fever, diarrhea and loss of appetite (often brought on by thrush) accompanied by a dramatic drop in weight, and general nausea and fatigue; these symptoms were originally referred to collectively as AIDS-related complex (ARC), but this term is now no longer used in the field because it tends to con­fuse people as to whether or not patients actually have AIDS. Instead, experts prefer to see ARC as part of a continuum eventually leading to full-blown AIDS, especially given that the same symptoms can reappear at that time.

Eventually, full-blown AIDS emerges because the body, left helpless without a properly functioning immune defense system, is prone to opportunistic or secondary infections—far more deadly and aggressive than normal—which is what the AIDS patient usually dies from, rather than from HIV itself.

Transmission of HIV from person to person is now well understood and documented. Fortunately for us, HIV is a fragile virus that cannot long survive outside the host; therefore, it must be passed directly in certain bodily fluids from one contact to another. Since HIV is mostly present in blood, semen, vaginal secretions, and breast milk (while only present in tears and saliva in trace amounts), this means it can be spread through limited routes of entry into the body that can mostly be regulated by a conscious choice of social behaviors. The most efficient mode of transmission is transfusion of HIV-tainted blood, with a 90 percent infection rate, but since 1985 all blood products in the United States have been screened for presence of the virus (as detected by an antibody test), so this is currently a rare mode of transmission, at least in Pattern I countries.

The usual strategy of combating an infectious virus like HIV is to develop vaccines, as has been done with smallpox and influenza. However, HIV presents an unusually challenging microorganism to vaccinate against, for both biological and some socioeconomic reasons. As we have already seen, HIV integrates its genome into the DNA of the host cell, where it can lie dormant or hidden for years safe from any antibodies generated by a vaccine. Once activated or trig­gered, HIV then replicates rapidly within the cell and thus mutates quite easily, making it a moving target for vaccination, much like influenza. There is also concern about whether inactivated HIV used in a vaccine could become active again, as does indeed happen in people naturally infected by the virus. Another possibility is that an AIDS vaccine could harm the immune system just as much as priming it against HIV, since antibodies would have to mimic the same CD4 proteins that HIV binds to on T-4 cells and macrophages. Given these difficul­ties, some have argued for developing a “therapeutic” vaccine rather than a “pre­ventative” one, which would stimulate the immune system to fight and eliminate the virus once it is established inside the body, thus preventing progression to the full-blown disease of AIDS rather than warding off HIV infection itself. This would also have the advantage of reducing the risk of person-to-person infection, including MTCT. But other difficulties besides biological ones have intervened to forestall HIV vaccine development: difficulty in finding animal models and human volunteers to undergo vaccine trials, length of time involved in demon­strating the efficacy of the vaccine, ethical questions with regard to control groups and conducting trials in poorer countries, and economic disincentives such as liability issues and threat of lawsuits, high costs of development, low rates of return in developing countries—where most of the vaccine market is currently located rather than in the more affluent West—and, after years of trying to find a vaccine, simple disillusionment and discouragement in the wake of failure.⁴ Nonetheless, a six-year trial that concluded in 2009 found that a combined vac­cine that stimulated both a cellular T-4 immune response as well as an antibody response had a 26 to 31 percent effectiveness rate in preventing HIV infection, rekindling hopes that eventually a viable vaccine will be found.

Of more proven effectiveness to date have been ARTs that reduce the viral load in the blood. These include reverse transcriptase inhibitors (which interfere with the production of viral DNA), such as azidothymidine (AZT), also known as zi­dovudine or retrovir; protease inhibitors (which interfere with the assembly of the protein coat in new viruses); fusion inhibitors (which prevent HIV from fusing with a host T-4 cell); entry inhibitors (designed to prevent HIV from entering a host cell); and cytokine-based drugs such as interleukin-2 that help stimulate the production of more T-4 cells in the body's race against viral replication. Usually, a “cocktail” combination of such drugs is prescribed to AIDS patients who can afford it (at a cost of fifteen to thirty thousand dollars in the West) in order to circumvent the potential emergence of HIV resistance. As we will see, this highly active antiretroviral therapy, known by the acronym of HAART, has greatly pro­longed the lives of AIDS sufferers in Pattern I countries and transformed the disease into something that is still chronic but manageable, instead of one that has invariably spelled impending death. ART has also demonstrated its ability to prevent MTCT. And yet, it must be emphasized that ART is not a cure for AIDS, because HIV will eventually and inevitably acquire resistance to any drug cocktail due to its mutating ability. It is for this reason that new drug therapies must con­stantly be devised for HIV—for example, at least ten nucleoside and nonnucleo­side reverse transcriptase inhibitors, such as nevirapine, are currently being mar­keted in addition to AZT—and why ART is now started only after an HIV-infected patient has become symptomatic, rather than administering it to one whose viral count is already low. Nonetheless, antiretrovirals have made hefty profits for the pharmaceutical industry precisely because they must be adminis­tered over long periods of time in ever-changing varieties, as opposed to vaccines that theoretically confer lifetime immunity after just one dose. Now that all nine genes of the HIV genome have been mapped and identified, gene therapy may provide a promising alternative to drugs or vaccines in the future.⁵

Last but not least, we should consider the geographical origins of AIDS. This is a controversial topic owing to the stigma attached to any part of the world held responsible for giving birth to so dreaded a disease. We have already seen how, in the nineteenth century, India was blamed as the “home of cholera,” which natu­rally associated the perceived filthy living conditions of the natives with its fulmi­nant diarrheal symptoms that were so disgusting, at least to Western sensibilities. But there is also a biological and historical basis for making such identifications, which can help advance our knowledge of the disease and ultimately our ability to combat it. We have to remember that AIDS is still a very new disease in hu­mans, especially compared to other ills such as plague or tuberculosis that have been around for centuries. With time, the stigma attached to the endemic origin of AIDS in western and central Africa, which currently is still a topic that must be tiptoed around with caution at AIDS conferences, will fade. No one now thinks any less of Central Asia for being the probable origin of the Black Death; it is simply a historical question to be explored and elucidated. We are still coming to terms with living in a world marked by the presence of AIDS.

The scientific evidence for AIDS originating in sub-Saharan Africa is strong. Much research has been done on the simian immunodeficiency virus (SIV) found in monkeys native to Africa. Three of the SIV strains isolated from chimpanzees have been found to be genetically very close to the three groups of the HIV-1 virus that cause almost all cases of AIDS in humans. (The M group alone is re­sponsible for 99 percent of cases, while the O and N groups have been found in patients in Gabon and Cameroon in West Africa, exactly corresponding to the natural range of chimpanzees harboring the SIV strains.) It is therefore believed that HIV first crossed over into humans from chimpanzees, much like smallpox or influenza have historically crossed from cows, birds, and pigs. Africa also holds the most genetic diversity of HIV anywhere in the world. It is the only region to contain all ten subgroups of the M version of HIV-1 as well as the most recom­binant strains of these subgroups, and an HIV-2 strain confined to West Africa is practically identical in its genetic makeup to that of an SIV strain found in local sooty mangabey monkeys. (The relative prevalence of all these strains of HIV may partly explain why AIDS behaves differently in various parts of the world.) Since chimpanzees in the wild do not normally develop AIDS, despite having a genome that is over 98 percent identical to that of humans, it seems clear that chimps have evolved a mutual adaptation with the virus, just as waterfowl have with influenza, and that their resistance mechanism can perhaps be of future benefit to us. This is also, of course, an argument for respecting and preserving the natural boundar­ies of these animals, as likewise holds true for wild birds as the endemic source of influenza. The oldest HIV-positive blood result has been obtained from a native of Kinshasa on the eastern border of the Democratic Republic of Congo (formerly known as Zaire) who died in 1959. Genetic mapping of progressive changes in the HIV genome indicates that the first infection of humans from chimpanzees probably took place during the 1930s, which coincided with massive conscription of natives for railroad construction in the French colonies of west-central Africa, where famine forced workers to consume wild animals, including monkeys. From its “ground zero” point of contact, HIV then spread rapidly in human popula­tions throughout Africa and around the world through the new, interconnected global networks of the second half of the twentieth century. The most likely means by which HIV was able to cross over from chimps to humans was through a sore or wound on a hunter handling the bloody remains of “bush meat” used to supplement the diet of those living in rural areas of Africa. Transmission of SIV (not AIDS) to hunters was found to be still taking place in Cameroon in the early twenty-first century. The theory that AIDS was cultured by Western labs in the Congo that used the kidney cells of chimpanzees to develop and test a polio vac­cine during the 1950s has an attractive air of ironic drama to it—modern medi­cine in the very act of trying to use its technology to save lives gives birth to a new plague!—along with overtones of political correctness in terms of chronicling the ongoing negative impacts of Western imperialism in the third world.⁶ But it has now been proven that there is no connection between AIDS and the Congo polio vaccine. Independent laboratory analyses of frozen samples of the original vaccine found no traces of either HIV or chimpanzee cells—the vaccine was actually cultured in Asian macaque monkeys; moreover, the chimpanzees from the region of the Congo where the scientists originally worked do not harbor the ancestral SIV of AIDS. Historically speaking, it now seems quite likely that the crossover occurred before the polio trials of the 1950s. Contaminated needles used for medicinal or vaccination purposes may still have played a role, however, in rapidly cycling SIV through African populations, allowing it to be converted into HIV.⁷

A word here should be said about “dissident” scientists, such as Peter Dues- berg, who cast doubt on whether HIV causes AIDS or that the disease originated in Africa. Setting aside the more far-out conspiracy theories such as that AIDS came from outer space or that it was intentionally developed by Western labora­tories as a biological or racial weapon, Duesberg's dissidence has to be taken seri­ously because he is a respected research scientist at the University of California at Berkeley who specializes in cancer-causing viruses, although he is also known within the scientific community for his contrarian views. Duesberg does not deny the existence of HIV but rather contends that it is a harmless passenger in the bodies of infected victims and that the disease of AIDS is instead brought on by lifestyle “stressors” such as poor diet and nutrition, recreational drug use, or even by the very antiretroviral therapies currently used to control and manage the disease. This is not simply the harmless hypothesis of a marginalized crank, because although opposed by the “mainstream” scientific community, Duesberg's theory has been taken up by a handful of other “dissident” scientists, including his cancer research colleague David Rasnick; the Columbian physician and spe­cialist in tropical infectious diseases Roberto Giraldo; the Belgian professor of pathology at the University of Toronto Etienne de Harven; the mathematical biologist Rebecca Culshaw; and the Nobel prize-winning chemist Kary Mullis, some of whom have formed their own advocacy group called “Rethinking AIDS.” In addition, AIDS dissidence has been championed by some “investiga­tive” journalists, such as John Lauritsen, Henry Bauer, and Janine Roberts, and most prominently outside the United States by the former president of South Africa Thabo Mbeki, who provided a forum for Duesberg at the 2000 AIDS conference in Durban and who opposed ART implementation in his country largely on the strength of Duesberg's objections, despite drastic price concessions from pharmaceutical companies supplying AIDS drugs. Therefore, it could be argued that this is no mere academic debate but rather one with the lives of mil­lions of men, women, and children at stake. In popular culture, Duesberg's ideas also receive a hearing in the news media, science journals, and through Dues- berg's own publications, such as his 1996 book Inventing the AIDS Virus and his own personal website (augmented by the publications and websites of other dis­sidents). Complicating this controversy is that the lifestyle cofactors favored by Duesberg do seem to play a role in the onset of full-blown AIDS after HIV infec­tion, and that viral loads in asymptomatic AIDS patients can be so low as to be virtually undetectable, even though a diagnostic test for HIV infection can still be devised by measuring antibodies. AIDS denial also perhaps plays into a wish fulfillment to blot out the horrors of this world, akin to the motives of some deniers of the Nazi Holocaust.

One of Duesberg's most cogent criticisms is that HIV does not fulfill scien­tific protocols for identifying a disease agent, such as the “postulates” drawn up the bacteriologist Robert Koch in 1890. It should be pointed out that even Koch could not fulfill all of his postulates when identifying the bacterial causes of cholera and leprosy, and that to a certain degree we have to accept practical lim­its on how well the correlation between a given microbe and a disease needs to be proven before it can be accepted and put to use. Moreover, HIV is an extraor­dinarily complex microbe unlike any that Koch had to face. Its fragility outside the host cell, for example, makes it extremely difficult to grow the virus pure in culture, as one of the postulates insists. Even so, some would argue that in fact all of Koch's postulates have by now been fulfilled with respect to AIDS, includ­ing the one in which the disease must be reproduced by artificial introduction into a human host. While a deliberate experiment in this regard is ethically un­tenable in the case of a deadly, incurable disease like AIDS, three laboratory workers who tragically exposed themselves by accident to HIV did indeed go on to develop AIDS. A large amount of circumstantial evidence also supports link­ing HIV with AIDS, such as that HIV can be tested in all patients with full­blown AIDS while almost no one who is HIV negative has gone on to develop the case definition of the disease; likewise, in no country around the world has AIDS appeared without HIV infection manifesting itself first. We also have to recognize that AIDS is a unique illness, in that it comes about through a latent suppression of the body's immune system and by means of coinfection with an opportunistic disease or cancer. There is therefore no direct, immediate cause and effect from a single microbial invasion, as in the case of most other infectious diseases.⁸ Despite the dispiriting counterblast with which Duesberg opens his 1996 book—“By any measure, the war on AIDS has been a colossal failure”—in fact, the lives of countless AIDS patients around the world have been almost returned to normal by the very antiretroviral therapies he condemns. HIV may well be an ancient microorganism centuries or even millennia old,⁹ as Duesberg contends, but this still doesn't explain how the virus established itself in the hu­man community, and the recent emergence of the current AIDS pandemic ar­gues for a strong connection with recent historical trends that are particularly apropos to sub-Saharan Africa, such as encroachment on wild animal habitat, widespread migrations of human populations and disruptions of their settlement patterns, and the relaxing or changing of traditional sexual mores. A crossover from monkeys as the natural reservoirs of the virus to humans in Africa remains so far the most plausible explanation of the origin of AIDS.

The focus of most historical narratives on AIDS has been the United States and sub-Saharan Africa. It was in the United States that public awareness of the emerging AIDS pandemic began, even though the crisis in sub-Saharan Africa has by now completely eclipsed the epidemic in Pattern I countries. The first notice taken of the new disease seems to have occurred in June 1981, when the Centers for Disease Control (CDC) published an article in its Morbidity and Mortality Weekly Report that detailed the strange case of five young gay men from Los An­geles who all had come down with a rare lung disease, PCP, as a result of a “pro­foundly depressed” immune system. This was shortly followed up in July with two dozen more cases of PCP in conjunction with an equally rare skin cancer, Kaposi's sarcoma, occurring once again in gay men with dysfunctional immune systems, most of them from New York City. By the following year, 1982, hun­dreds of cases of the new disease were being reported to the CDC, representing a doubling in the size of the epidemic every six months, and of these cases 40 per­cent or more were dying. We now know that these cases had probably been incu­bating for a decade or more since the late 1960s and 1970s. A teenager who died in St. Louis, Missouri, in 1969 of symptoms that suggest PCP and Kaposi's sar­coma was confirmed as perhaps the first American victim of AIDS when his frozen blood and tissue samples tested positive for the virus in 1986. It was also becoming evident by 1982 that the disease was now affecting populations aside from gay men. The CDC came out with its so-called 4H high-risk groups of heroin addicts or IDUs, hemophiliacs, and Haitian immigrants, in addition to homosexuals. In this same year, the CDC officially adopted AIDS as its preferred name for the disease over other alternatives such as gay-related immune deficiency (GRID). By 1983 and 1984, it was becoming clear that AIDS could be spread by heterosexual intercourse and MTCT, which meant that theoretically almost no part of the general population could assume itself to be safe from the disease; meanwhile, the gay community, particularly in San Francisco and New York, began modifying their “risk” behaviors, such as by reducing the number of sexual partners and increasing their use of condoms, so that by 1985 the number of new cases among gays began leveling off. At the same time, greater medical under­standing of AIDS was quickly emerging, especially with the announcement of the discovery of HIV, which was jointly attributed to Luc Montagnier of the Pasteur Institute in Paris and Robert Gallo at the National Cancer Institute in the United States, although it is now conceded that most of the credit should go to the French. The shelved cancer drug AZT was also found to be the first effective antiretroviral treatment for AIDS, which was administered to human subjects in 1985. The death of movie star Rock Hudson in October of that year raised aware­ness of and seemed to give a public face to the disease.¹⁰

The rest of the 1980s decade saw many of the social issues associated with AIDS play themselves out on the American stage. Some of the leading actors in this drama were the Gay Men's Health Crisis (GMHC) in New York and the AIDS Coalition to Unleash Power (ACT UP), both founded by the activist Larry Kramer. While GMHC pursued what could be called a low-key role as an AIDS service organization (ASO) or informational and resources clearinghouse for AIDS victims, ACT UP took a much more confrontational approach toward its political agenda, such as by performing “zaps” against perceived obstructionist targets, which famously included the seat of the Catholic archdiocese of New York at St. Patrick's Cathedral, where a communion mass was disrupted in 1989. A central focus of AIDS advocacy at this point was to preserve civil liberties, particularly confidentiality and privacy concerns, in the face of public health imperatives to contain an epidemic through such measures as testing, contact tracing, and occasionally quarantine. Remarkably, AIDS activists were able to reverse a long precedent, going back in the United States to almost a century with respect to infectious diseases like syphilis, influenza, and tuberculosis, whereby individual rights had been superseded in the interests of preserving the public health. Instead, AIDS testing and notification, using the enzyme-linked immunosorbent assay (ELISA) and the “Western Blot” tests, first developed in 1985, were to be strictly voluntary with certain exceptions, such as recruits to the U.S. military or applicants to the diplomatic corps. Even by 1997, only half the states in the union required reporting by name of individuals who tested positive for HIV A number of circumstances were responsible for this AIDS “exception­alism,” including concerns about false positives (although when used together the two tests were nearly foolproof), the self-defeating specter of AIDS patients being driven underground for fear of discrimination, the unproven efficacy of past public health efforts, and the recent example provided by civil rights agita­tion in the 1960s and 1970s (including the gay liberation movement beginning with the Stonewall uprising in 1969). A recurring refrain at this time was that anyone could get AIDS and thus any oppressive measures would potentially encompass everyone, but this claim was rather specious given that already by the late 1980s evidence pointed to the epidemic, at least in the United States, be­coming entrenched among certain sectors of the population who engaged in “high-risk” behaviors, namely, unprotected anal intercourse, multiple sexual en­counters (i.e., prostitution), and IV drug use. By the early 1990s, it was clear that AIDS was not going to break out into the general population and become the universal scourge that everyone so feared, especially when it was estimated that the vast majority of Americans had five lifetime serial sex partners or fewer. Yet, the interests of continued AIDS funding dictated that the threat-to-all ortho­doxy be maintained even by medical authorities who knew better, and it was debunked only by a vilified few, such as Michael Fumento, author of The Myth of Heterosexual AIDS.^1,1 One myth that was worth debunking, however, was that AIDS was supposedly spread by casual contact, such as coughing, sneezing, touching, kissing, sharing of surfaces or public spaces, mosquito bites, and so forth. On the contrary, the difficulty with which AIDS is spread—as well as the fact that its contagion is largely determined by premeditated and voluntary social behaviors—made it much less of a compelling health threat than, say, a disease like tuberculosis that is communicated involuntarily by airborne droplets. Yet, AIDS paranoia did not stop the installation of “touchless” hand dryers, soap dispensers, faucets, and toilets in public restrooms, which were to become ubiq­uitous, and, in the end, completely unnecessary. It also did not help the public health cause that some made extreme recommendations, such as perennial presidential candidate Lyndon Larouche, whose ballot initiative in California to quarantine all AIDS victims (presumably for life) went down to resounding de­feat, or the conservative commentators William F. Buckley and Ann Coulter, who proposed tattooing HIV-positives on the buttocks or genitals. On the other hand, it is also undoubtedly true that, due to civil rights agitation, some oppor­tunities to contain the scope of the epidemic were tragically missed. The notori­ous San Francisco bathhouses, for example, which served as almost perfect breeding grounds for AIDS with their abundant opportunities for anonymous, promiscuous sex, were finally closed down by the city's Public Health director, Mervyn Silverman, in 1985 with little fanfare or protest, but by then it was largely a moot gesture as most of their clients had already made the conscious choice to change their “high-risk” behaviors.

There were plenty of other social conundrums with respect to AIDS. Housing and job discrimination against AIDS patients, which had received the tacit bless­ing of the attorney general, Ed Meese, was overturned by the Supreme Court on the grounds that their condition qualified them for handicapped or disabled sta­tus, and yet misinformed bigotry continued to occur nonetheless, such as doctors and ambulance personnel refusing to treat people known to be HIV infected, police officers wearing gloves and other protective gear when forced to interact with people with AIDS, insurers denying coverage on the basis of membership in one of the “high-risk groups,” and immigrants denied entry on the basis of AIDS screening, which played havoc with attempts to host international conferences in the United States on AIDS. (This last policy has only now been reversed by the administration of U.S. president Barack Obama.) Particularly heartbreaking were the so-called innocent victims of AIDS, namely, hemophiliac children (who relied on blood products combined from many different donors) denied access to schools after they tested HIV-positive, owing to false fears that they could spread the disease in certain (highly unlikely) scenarios, such as bloody sports contact. Such was the case of Ryan White of Indiana, or the Ray brothers from Arcadia, Florida, whose family quit town after their house was burnt down.

Aside from civil rights, another major agenda of ACT UP at this time was to improve access to experimental treatments for AIDS patients, whose mortal outlook obviated the usual bureaucratic protocols surrounding new drugs and who often lacked the financial wherewithal to pay for them. Thus, “die-ins” were staged at regional offices of the Food and Drug Administration (FDA), and a group of protestors chained themselves to the VIP balcony at the New York Stock Exchange. It could be said that the impact of these protests produced the desired result, for the FDA subsequently approved AZT relatively quickly, in a matter of months rather than the usual years, and Burroughs Wellcome, the manufacturer of AZT (with considerable help from the National Cancer Insti­tute), nearly halved the original ten-thousand-dollar-per-year price tag of its drug. Anthony Fauci, director of the National Institute of Allergies and Infec­tious Diseases (NIAID), earned praise for his championing of an unprecedented “parallel track” approach designed to get investigational new drugs (INDs) into the hands of AIDS patients excluded from clinical trials or “compassionate use” programs from drug manufacturers. At the same time, however, Fauci was heav­ily criticized for failing to produce any new effective treatments from his AIDS Clinical Trials Group (ACTG), and sometimes the side effects of the new drugs were so severe that patients preferred to die rather than continue treatment.¹²

In terms of presidential policy, the Republican administration of President Ronald Reagan betrayed considerable insensitivity to the plight of AIDS victims, since the disease itself was not publicly acknowledged by the president until 1987, undoubtedly due to its strong associations with the gay community. And yet, for a fiscally conservative administration, the federal AIDS budget grew as­tronomically during the Reagan years, from $5.5 million in 1982 to over $900 million by the end of the presidency in 1988. Meanwhile, Reagan's outwardly staid surgeon general, C. Everett Koop (known for his signature bow ties), sur­prised everyone with his AIDS report in 1986 that recommended comprehensive and “value-neutral” sex education in all primary and secondary schools as part of an effort to combat AIDS spread, which nonetheless proved unpalatable to the majority of U.S. households, especially in the conservative heartland. The subse­quent administration of a more moderate Republican, President George H. W. Bush, signaled a greater willingness from the president to empathize with AIDS patients and champion antidiscrimination laws, even as he was criticized for fail­ing to provide substantial leadership in the fight against AIDS. Appointing the HIV-positive basketball star Earvin “Magic” Johnson to the National AIDS Commission might be called an empty gesture, but the administration did put its money where its mouth was, increasing federal funding for AIDS-related re­search to over two billion dollars by 1992 and passing the Ryan White Care Act in 1990, which helped funnel special AIDS funds to the neediest cities. Indeed, AIDS funding could be said to be enormously disproportionate when compared to that for other diseases. The amount spent per AIDS death was four to five times higher than that for the next most expensive diseases, despite the fact that AIDS afflicted a relatively small number of patients, at 120,000 in the United States in 1992, a small fraction of the fifty million estimated Americans suffering from the leading ills of heart disease, stroke, and cancer. The succeeding Demo­cratic administration of President Bill Clinton naturally continued or amplified these trends, yet even Clinton found there were limits to what he could do in terms of AIDS policy. He backed away from federal funding of needle exchange programs, despite the fact that they were proven to be effective in limiting the spread of HIV among drug users and that such programs were already in place in several dozen cities, often in defiance of state laws.¹³ He also failed to secure passage of universal health care legislation, which was needed to help poorer patients gain access to ever more expensive treatment regimens for AIDS and to relieve the financial burden on Medicaid (where each patient on triple combina­tion therapy cost the program thirty thousand dollars per year). Although uni­versal health care reform was finally passed under President Obama, it remains to be seen how it will be implemented on a local level in each of the fifty states, some of which are pursuing legal challenges to the new law.

The Clinton era of the 1990s represented a seismic shift in the medical treat­ment of and overall culture surrounding AIDS. In 1996, a new treatment regi­men was announced, called “combination therapy,” in which a drug “cocktail” of two different reverse transcriptase inhibitors, such as AZT, nevirapine, or dideoxyinosine (ddI), was combined with one of the newly developed protease inhibitors, such as Crixivan, in order to deliver a triple knockout blow that was found to reduce viral loads to undetectable levels for over a year, in effect elimi­nating all traces of the virus. Its drawbacks were an extraordinarily complicated pill-taking regimen, which increased chances of noncompliance and hence po­tential drug resistance in HIV; increased possibilities of side effects; and an ex­ponentially greater expense, which posed a problem for the increasing propor­tion of AIDS patients too poor to afford the drugs. Nonetheless, combination therapy held out the promise of a return to an almost normal lifestyle, with po­tentially decades added on to an AIDS victim's life expectancy. This in turn ne­cessitated a reconfiguration of support services for AIDS patients, from end-of- life issues to now more mundane concerns of continued housing, employment, financial planning, and so on. Indeed, so successful was combination therapy in turning AIDS into a chronic and manageable disease that a sense of complacency now crept in among both infected victims and “at-risk” groups. In the gay com­munity, AIDS was transformed from the “gay plague” into the “gay diabetes,” and there was a noticeable “backsliding” in safe sex practices and precautions that had been championed earlier, perhaps under the mistaken belief that undetect­able viral loads in the blood meant that the disease could not be transmitted. As a consequence, new infections among the gay community began to rise once again during the 1990s.¹⁴ Thus, combination therapy achieved some dramatic benefits in the years immediately following its introduction, but in the long term it seems to have brought us to no more than an impasse or deadlock in relation to the disease. By the end of the 1990s, for example, the number of new HIV infections and AIDS deaths in the United States as reported to the CDC had fallen to forty thousand and less than twenty thousand, respectively, down from highs in the first half of the decade at eighty thousand and fifty thousand. Since then, however, these numbers have scarcely changed: As of 2007, new AIDS diagnoses stand at just over 37,000 while annual deaths from the disease are at roughly 14,500 or maybe higher. Currently, over half a million people have died of AIDS in the United States, and more than a million are estimated to be living with the disease.¹⁵

There were other ways in which the late 1990s foreshadowed trends that were to emerge in the third decade of AIDS in the United States, or in other words the first decade of the third millennium. If there was a certain complacency to­ward AIDS among the gay community as a result of its being perceived now as a successfully treatable disease, this was even more noticeable among the general population at large. AIDS can now be said to have earned the title of “forgotten epidemic” that was formerly reserved for influenza. Partly, I think this has been the result of an inevitable backlash against the overhyped threat of AIDS in its early days, as the general public intuited data that suggest that the disease had yet to make much headway among the majority heterosexual population. AIDS was also bound to fade from the public consciousness as its morbidity and mor­tality rates declined and then leveled off and as it was no longer perceived as a death sentence due to new and improved antiretroviral therapies. This growing obliviousness toward AIDS was reflected in popular culture. Attention garnered by AIDS perhaps peaked in the late 1980s and early 1990s, as the AIDS quilt was unveiled several times at the national mall in Washington, D.C., and made regional tours throughout the United States, while the mainstream Hollywood film Philadelphia, released by TriStar Pictures in 1993, earned an academy award for best actor for Tom Hanks, who portrayed a gay lawyer suing his firm for unlawful dismissal after coming down with AIDS, and who was represented by an initially homophobic black colleague, played by Denzel Washington. But by 1998, AIDS was given absolutely no mention in the comedic film The Wedding Singer, which was steeped in 1980s nostalgia, and the 2009 “mockumentary” Bruno, about a fictional gay Austrian fashion journalist who interacts with real people primarily on homoerotic themes, mentions chlamydia, but not AIDS. (When asked on the online interview program Digg Dialog to name “the hottest illness around now,” Bruno cited “bulimia,” the joke being that this is really a noninfectious eating disorder rather than a disease proper.) And yet AIDS histo­rian Susan Hunter warns in a 2006 book, AIDS in America, that there is the potential for AIDS to flare up again in the United States with even greater force than in the early 1980s and to spread far more deeply than ever before into the mainstream white heterosexual population. Hunter's claims rest on a number of contentions that are mainly supported by anecdotal evidence, such as that large numbers of heterosexuals secretly practice homosexual intercourse on the “down low,” that teens engage in promiscuous anal and oral sex as a way of technically fulfilling abstinence-only pledges, and that AIDS statistics reported by the CDC vastly underestimate the true scope of the epidemic. It is undeniable, however, that young people and women are making up greater proportions of new HIV infections; that unprotected intercourse, prostitution, and drug use continue to grow as contributing factors of infection; and that AIDS has established a dis­proportionate presence in America's growing prison population.¹⁶

An additional factor in the marginalization of AIDS is the continued margin­alization of its “high-risk” groups. Even as AIDS was making a resurgence in the gay community in the late 1990s, it was also migrating toward racial minority groups, namely, blacks and Hispanics, a trend that had commenced since the late 1980s. At the end of the 1990s, blacks' overrepresentation in HIV infections was becoming quite dramatic, at 45 percent of all new cases, even though blacks made up only 12 percent of the general population. This disparity was also evident in the subpopulation of HIV-positive black women, who outnumbered their white female counterparts by a ratio of fifteen to one in 1995. These trends have hardly changed in recent times. As of 2007, blacks made up 44 percent of all people liv­ing with AIDS, while whites constituted the next largest group at just over 35 percent; and Hispanics, at 19 percent. Male-to-male homosexual contact was al­legedly behind 47 percent of these existing AIDS cases in the United States, while high-risk heterosexual contact and injection drug use are roughly equivalent at 24 and 22 percent respectively.¹⁷ Even though it has been speculated that blacks have a genetic predisposition to AIDS, it is in fact far more likely that certain environ­mental cofactors are responsible for the higher rates of HIV infection among blacks through IV drug use and homosexual and heterosexual intercourse, such as higher rates of needle sharing and greater prevalence of STDs, including syphilis, chancroid, genital warts, and herpes. (On the other hand, researchers have found that a significant minority of the Caucasian population do have defective genes encoding the CCR5 coreceptor for HIV, which gives them partial or almost com­plete immunity to the disease. The theory that this was inherited from European ancestors immune to the Black Death is, however, almost pure speculation.¹⁸) Some argue that to lower AIDS incidence among blacks, efforts should be focused on improving their socioeconomic status and tailoring educational materials to their specific culture. It is likewise claimed that black churches and communities have historically been reluctant to face up to issues of sexual promiscuity, drug use, and homophobia, which have only contributed further to the furtive advance of AIDS. In addition, substantial percentages of surveyed minorities profess themselves disposed to believe in erroneous conspiracy theories about AIDS, such as that the disease was manufactured in government laboratories as an instrument in racial or biological warfare, perhaps because their faith in institutional medi­cine has been compromised by such real scandals as the Tuskegee syphilis experi­ment.¹⁹ Meanwhile, research on heterosexual transmission, such as that conducted by Nancy Padian in San Francisco, suggests that women are up to twenty times more susceptible to HIV transmission than men due to a combination of factors: greater presence of the virus in semen as opposed to vaginal secretions, prolonged exposure of the vagina to semen ejaculations, and higher incidences of the vaginal wall being compromised through STDs (which are more likely to remain unde­tected in women as opposed to men) and through violent or prolonged penetra­tive intercourse as occurs during sexual assaults and recreational drug use.²⁰ Even when drug use is not of the intravenous variety that can directly transmit HIV, it can act as a cofactor of sexual transmission of AIDS by impairing the cognitive ability to select safe sex behaviors—and also, in the case of certain drugs such as cocaine, methamphetamine (“crystal meth”), and ecstasy, by enhancing sexual performance and thus the likelihood of epithelial trauma during “dry sex.”²¹ Many of the issues identified in AIDS transmission among black and female populations in the United States serve as a microcosm for the larger tragedy un­folding in sub-Saharan Africa.

The gay community, which originally bore the brunt of the AIDS epidemic in the United States and continues to do so to this day, is faced with an ongoing ambivalent legacy from its close association with the disease. On the one hand, the AIDS epidemic threatened to set back by at least a decade greater public ac­ceptance of and civil rights for gays. Early in the epidemic, for example, some despicable comments were made by conservative commentator Patrick Buchanan and Moral Majority leader Jerry Falwell that suggested AIDS was a just punish­ment for the gay lifestyle, all of which were very much in the mode of medieval pronouncements about plague as divine retribution for humanity’s sinful behav­ior. (Indeed, a popular acronym used by the political right at this time for the disease was wrath of God syndrome, or WOGS.) Even though most church congregations tried to balance their moral and humanitarian impulses in their responses to AIDS patients, violent assaults on gays were on the rise, and the political climate seemed ripe for discrimination, if not outright oppression, under the guise of preserving the public health. Yet, we would be less than honest if we failed to point out that at least some of the harm was self-inflicted. There is a certain amount of nihilistic disregard for one’s own bodily health in indulging in hundreds of anonymous sexual partners every year, as the patrons of bathhouses were allegedly doing (just as there is in injecting drugs into one’s veins), and even before the advent of AIDS, an astonishingly high incidence of STDs in the gay

community was already laying the groundwork for the emergence of a more fear­some disease. But the moral opprobrium expressed by the Christian right never saved any lives, and it had long before proved its impotence against syphilis, when the target had been prostitutes. One also has to understand that, for the gay community, promiscuity was a sign of its liberation and “coming out” in the face of an adversarial society during the 1970s. And yet AIDS could equally well be said to have opened the door of opportunity to gays in the United States in terms of galvanizing them for civil rights advocacy in a way that still eludes that other major victim group of the disease, drug users. Perhaps as a result of the necessity of changing risk behaviors in response to AIDS and caring for sick loved ones, the gay community seems to have shifted its agenda in recent years to agi­tating for recognition of partner benefits and same-sex unions and marriages. While some, even in the gay community, may deplore this domestic agenda as depriving gays of their distinctive identity, it does seem to be facilitating greater acceptance of gays in mainstream society, even as the old political fault lines still seem to apply. My home state of Vermont was the first to recognize civil unions that extended full partner benefits and rights to same-sex couples (although a more watered-down version of “reciprocal beneficiary registration” had been available since 1997 in Hawaii), and Vermont is now one of five states that allow same-sex marriage, in spite of the federal Defense of Marriage Act that restricts marriage to members of the opposite sex. These achievements, it could be argued, might not have come about if not for AIDS.

A final aspect to consider in the so-called third phase of AIDS policy in the United States is the greater emphasis upon surveillance and coercion toward HIV-positive individuals since at least 1997. This coincided with the year of the Nushawn Williams case in New York, where an HIV-positive man was reported to have infected thirteen women, most of them teenage girls, out of some fifty to seventy-five sexual contacts over a two-year period, despite allegedly knowing of his own seropositive status. This led to the adoption in New York and in least twenty-six other states of laws requiring names reporting, contact tracing, or even criminalization of sexually active people who test HIV-positive. Further impelling this change of policy was the stated motive of improving access to new and improved treatments and more accurate monitoring of new AIDS cases. Yet, accepting public assistance now meant that AIDS patients had to submit to far greater surveillance and control. From 2003, the CDC announced that HIV testing of at-risk populations would from now on be the focus of its prevention efforts, and it pressured community-based organizations receiving its funding to “elicit number of partners and contact information” when providing counseling and referral services. It should come as no surprise that the George W Bush administration’s assault upon civil liberties during its so-called war on terror should extend to people with AIDS, but AIDS advocacy groups also seemed to surrender the initiative and abandon the stance on AIDS exceptionalism. The push for an abstinence-only approach to sex education and a continued ban on needle exchange programs were also criticized for being counterproductive and against all the evidence on HIV/AIDS prevention.²²

AIDS also has a very personal resonance with me, for its social history in the United States that I have just outlined above happens to almost exactly coincide with my own most socially and sexually active years and experience. I remember that when I graduated from college and first entered the workforce as a journalist in 1985, AIDS was simultaneously cresting in public awareness and paranoia in the United States. Fears about this new disease were almost palpable, largely due to the big unknowns still surrounding AIDS and the fact that medical authorities at this point made only qualified statements with regard to its transmission and spread. What was especially terrifying was that here was an invariably fatal disease but one that liked to linger, drawing out its death sentence into a long, exquisite torture. (Unlike our medieval ancestors, we seem to prefer the mercifully quick kill.) Particularly tragic and heartrending were victims who had to tell their fami­lies for the first time that they were gay and then immediately inform them that they had AIDS, exposing themselves to a double indemnity of prejudice. As I helped prepare a monograph on AIDS: The Workplace Issues, I heard stories of people refusing to touch coffee cups or sweaty keyboards used by an office mate rumored to be infected with HIV, or of a disgruntled fired employee kissing co­workers good-bye with the words “I just gave you AIDS.”²³ (We now know, of course, that AIDS cannot be communicated by casual contact.) Even if we did not get AIDS or know someone who did, it seemed we were all somehow indel­ibly marked by it, should we wish to remain in any way sexually active. It seemed cruel when my mother, echoing surgeon general C. Everett Koop, warned me that “if you sleep with someone, you’re sleeping with all their other past partners,” which certainly did not make the venture very appealing. If AIDS was a punish­ment for “deviant” behaviors, then we were all in bed together, gay as well as straight. I resented the earlier generation that got to enjoy a guilt- and worry-free sexual revolution, while I felt that I now had to pay for the pleasures of my par­ents’ generation. At the same time, I almost envied the old, who with their dimin­ished sex drives and stable relationships, could no longer be touched by AIDS.

Later, when I finished grad school and started my first teaching job in the mid- to late 1990s, I noticed a dramatic shift occurring in cultural attitudes toward AIDS within my local community here in Vermont. When I mentioned AIDS to my students, their eyes glazed over as if they had no idea what I was talking about (as they do so even more now). I tried to draw parallels in my history classes be­tween Giovanni Boccaccio’s three psychological responses to the Black Death in Florence of isolation, denial, or moderation and sexual responses to AIDS of ei­ther abstinence, unprotected sex, or wearing a condom, but the analogy seemed to fall flatter and flatter as the years went by. I must confess that I myself had unprotected intercourse with a few (female) sexual partners, but later my future wife did insist that we both get tested before we commenced intimate relations. (Both of us tested HIV-negative. A couple of states such as Illinois and Louisiana have in fact tried, and ultimately failed, to make AIDS testing mandatory before marriage.) When I had the campus nurse come in to my first-year seminar class at a local Vermont college to talk about sex education, she dwelled on the dangers posed by STDs such as genital warts and herpes, but not AIDS. Meanwhile, my local church wrestled with becoming an “open and affirming” congregation that would allow for civil unions to be performed by our pastor.

Nowadays, it seems our society has come to a stalemate, or a kind of equilib­rium, with AIDS. It remains stubbornly incurable, unlike syphilis, but then what viral disease, even the common cold, has been cured? Instead, we seem reconciled to just living with it, both collectively and individually, as just another chronic, largely sexually transmitted disease that, like herpes, forever marks one with the taint of a moral lapse, however undeserved, but that refuses to kill its victims out­right and keeps them in an agonizing pathogenic limbo. For most of us in the West, AIDS now exists on the margins of our consciousness—a disease of the “other” that perpetually hovers but never quite fully emerges into the light of day.

The other tale of AIDS that we need to tell is set primarily in sub-Saharan Africa and other unfortunate theaters of the third world. Even though awareness of the existence of AIDS in Africa came after its discovery in the United States, it is now thought that an epidemic had been incubating on that continent for far longer, since at least the late 1950s, with an epidemic fully emerging at the virus's most likely place of origin, west equatorial Africa, during the 1970s. To be even more specific, one can point to the year 1975 in Kinshasa, the capital city of the Democratic Republic of Congo, where hospital records point to large numbers of case definition conditions of AIDS, such as Kaposi's sarcoma and severe wast­ing disease, occurring at this time.²⁴ Currently, sub-Saharan Africa contains the vast majority of AIDS cases and newly emerging HIV infections, to the point that AIDS is now widely regarded as a distinctly “African disease.” As of 2008, two-thirds of people living with AIDS and three-quarters of AIDS-related deaths occurred in Africa; 2 million Africans were newly infected with HIV in that year out of 2.7 million worldwide (bringing its total to approximately 22.4 million out of 33.4 million worldwide), and 1.4 million Africans died that year of the disease out of 2 million worldwide. Out of the twenty-five million deaths to date around the world from AIDS, most of these are thought to have occurred in Africa. Africa also had fourteen million “AIDS orphans” or children who lost one or both parents to the disease, as of 2008, and considerably more women than men in the region are infected by HIV, at a ratio of 60 to 40 percent, or 1.5 to 1. However, there are also signs that Africa's AIDS epidemic is by now maturing or leveling off. For example, in the worst-hit part of the continent, southern Africa, country after country is reporting substantially lower HIV prevalence rates in their adult populations as of 2007, compared to four years earlier, in 2003. Among the most dramatic drops are those in Swaziland at 26.1 percent, down from 38.8 percent in 2003; Botswana at 23.9 percent, down from 37.3 percent; Lesotho at 23.2 percent compared to 28.9 percent; South Africa at 18.1 percent from 21.5 percent; Zimbabwe at 15.3 percent from 24.6 percent; Na­mibia at 15.3 percent from 21.3 percent; and Malawi at 11.9 percent from 14.2 percent. Overall, HIV prevalence throughout Africa has declined slightly from 5.8 percent in 2001 to 5.2 percent in 2008. Since newly emerging infections continue to outpace deaths, these declining prevalence rates seem to be due pri­marily to the slowly declining infection rates that have been achieved in sub­Saharan Africa—as of 2008, new HIV infections throughout the continent de­clined 25 percent from the height of the epidemic in the mid-1990s. Greater access to antiretroviral treatment has meant that fewer people in Africa are now dying of AIDS, but this also means they are living longer, so that in absolute numbers the figure of people living with AIDS continues to rise, despite declin­ing infection rates or prevalence. Indeed, the fact that such high proportions of the population in some countries continue to live with the disease means that the AIDS epidemic will persist as a major health crisis in Africa for some time to come. South Africa, with nearly six million people living with AIDS as of 2007, remains the country with the largest AIDS population in the world.²⁵

Aside from the sheer scale of its epidemic, Africa's AIDS crisis also differs from the West's in terms of how the disease is thought to be transmitted—primarily through heterosexual intercourse in Africa as opposed to homosexual intercourse and drug use in Pattern I countries—although some would argue that anal sex is vastly underestimated in Africa largely due to homophobia, underreported inci­dence among heterosexual couples, or cultural misunderstandings as to what constitutes such an act.²⁶ Yet, this bare, banal fact alone, that AIDS in Africa is a widespread disease among the general population spread by a common and, one might almost say, biologically necessitated behavior among humans, namely, (unprotected) heterosexual intercourse, is precisely what makes the African AIDS epidemic so different from that in the West and comprises perhaps the most con­troversial statement in the AIDS discourse today. For it naturally implies that, in order for both epidemiological models in Pattern I and II countries to be valid, heterosexual sex must be of a radically different sort in sub-Saharan Africa as op­posed to what is practiced in the United States or Europe, and indeed this is ex­actly what we get in much of the early literature on the African AIDS epidemic, such as that published by the Australian researchers John and Pat Caldwell and which continues to be repeated in some form among certain publications. But all too often assumptions about sexual promiscuity in Africa are based on outdated or strictly anecdotal evidence that play into centuries-old racial stereotypes about the exotic, hypersexed African.²⁷ However, some recent observers of the African AIDS crisis continue to insist, on the basis of focused surveys and mathematical models, that African sexual behaviors do differ in significant ways from those in the West and other countries around the world, particularly in terms of maintain­ing multiple concurrent partners (as opposed to serial relationships) that in turn make Africans substantially more susceptible to HIV infection.²⁸ And yet to make broad-based generalizations and comparisons about intensely personal behaviors is difficult and dangerous. If African culture does sanction sex outside marriage, early teenage sexual initiation, and sexual predation of younger females by older males, then very similar observations are also generally made of Western culture. This does not mean, of course, that, as in the West, sexual behaviors among cer­tain “high-risk” groups in Africa—such as commercial sex workers, migrant populations, and urban dwellers displaced from their traditional rural environ- ments—have not historically contributed to Africa's AIDS epidemic and continue to do so.²⁹ For example, the transient mining community in Carletonville, South Africa, some 65 percent of whom were found to be HIV-positive in 1999, the highest seroprevalence rate at that time anywhere in the world, undoubtedly played an incubating role in the spread of AIDS within their familial and social networks that was akin to what the bathhouses did for the gay community in San Francisco in the United States, among whom HIV infection rates likewise reached 65 percent by 1984.³⁰ Anecdotal reports of exotic sexual activities in Africa con­tributing to AIDS—such as “dry sex” (inserting drying agents into the vagina in order to increase male sexual pleasure), genital mutilation, and “widow inheri­tance” (a sexual “cleansing” ritual in which a widow must have sex with her hus­band's nearest male relative)—all might have some basis in reality within select groups in certain regions. These groups include commercial sex workers in South Africa, Muslim communities in east Africa, and tribal communities in the Rakai district of Uganda and in southern Zambia, but these can hardly be extrapolated to the general population throughout the entire continent.³¹ In the end, it is important to keep in mind that heterosexual intercourse is no longer sufficient as the sole explanation of Africa's unprecedented and atypical AIDS epidemic; it is certainly a factor, and a very important one, but it is still just one among many that cannot be so easily disentangled from each other.

More recent studies of the African AIDS epidemic are now placing greater emphasis on poverty, famine and malnutrition, and opportunistic or coexisting diseases with AIDS, namely, tuberculosis; STDs such as syphilis, gonorrhea, chlamydia, and chancroid; and a host of parasitic illnesses that include malaria, leishmaniasis, schistosomiasis or bilharzia, filariasis, typanosomiasis or sleeping sickness, and helminth infections. Some of these diseases, such as malaria, schis­tosomiasis, and typanosomiasis, are well known to have a long, endemic history on the African continent, and their prevalence there, alongside extensive poverty and malnutrition, could be said to be an important distinguishing feature that makes Africa's situation different from the West's. What is more, all these cofac­tors have a synergistic relationship with HIV and AIDS. The link between STDs and HIV infection is a rather obvious and well-established article of faith, since both are sexually transmitted and the former produce inflammation or lesions in the genital area that facilitate (by as much as five times the norm) transmission of HIV. STDs also concentrate CD4 immune cells—the target of the AIDS vi­rus—in the genital area and increase viral shedding in seminal fluids. There is also much evidence from prenatal clinics that STDs are quite common in Africa even as they go untreated or undiagnosed, particularly in female patients. What is not so well known, however, is that other diseases as well as malnutrition that are not normally associated with AIDS can likewise contribute in a direct, bio­logical way to HIV transmission, just like STDs. For example, schistosomiasis, a parasitic worm disease carried by snails living in natural and artificial bodies of water, infects the genital tract and causes the same lesions and immune cell con­centrations that facilitate HIV transmission in STDs; moreover, it is highly en­demic to Africa, which hosts the vast majority of the world's second-most com­mon tropical disease, and its prevalence has only become worse in recent decades with new dam construction and other projects that create surface water sites and that have spread the disease from rural to urban areas. Other parasitic diseases that are especially prevalent and acute in equatorial Africa, such as malaria, can greatly increase HIV viral loads in AIDS patients or trigger latent viruses into replication by stimulating the immune system. Malnutrition and vitamin defi­ciencies can also promote viral replication, weaken epithelial barriers to the virus, and increase the likelihood of MTCT. Tuberculosis, the leading cause of death of people with AIDS in Africa, may in turn increase susceptibility to the disease in HIV-negative populations due to its impact upon the immune system; most of the widely prevalent cases of TB in Africa in fact exist independently of AIDS and are especially rampant among young people. While both TB and AIDS are latent diseases, either can easily be reactivated by coinfection with the other. In addition to TB, AIDS can likewise make patients more vulnerable to all the above diseases. Like AIDS and TB, some of these diseases are asymptomatic, and their presence has been equally overlooked by researchers searching for more typical behavioral risk factors of HIV.³²

Poverty also has a synergistic relationship with AIDS but in a more indirect way, by forcing people to engage in risky behaviors such as commercial sex work or migrancy (where a “survival strategy” becomes a “death strategy”), and in turn AIDS can amplify poverty or malnutrition by diverting scarce resources to health care or funerals and by incapacitating or removing wage earners and care givers.³³ Even though the scale of Africa’s poverty dwarfs that of the West, poverty's con­nection with AIDS is nonetheless something that both Africa and the United States share, for one of the highest risk groups for AIDS in America today are poor minorities. Instead of AIDS being primarily a behavioral problem for Afri­cans, therefore, poverty, climactic-related famines, and contingent diseases all make it more of an ecological or environmental one, with far less of the moral­istic and cultural complications and judgmental comparisons that go with the former. On these grounds, there are now calls for a complete rethinking of inter­national AIDS policy, particularly in Africa, as coordinated (since 1996) by the United Nations agency, UNAIDS. Since, it is argued, poverty all too often re­moves individual autonomy in choosing risky social behaviors, which are of course also impacted by cultural expectations, especially in terms of male-female relationships, intervention efforts should instead focus on the root cause of such behaviors (namely, poverty) or on biological cofactors such as malnutrition and other diseases besides AIDS—especially when, provided distribution mecha­nisms and political stability are adequate, these are more easily addressed through food aid or existing antibiotics (except for MDRTB). In this scenario, a whole decade or more has been lost to inappropriate and largely ineffective AIDS pre­vention strategies, which are now also being superseded by more effective anti­retroviral (ARV) treatment programs. In response, some will point to the success of behavioral modification programs in places like Uganda (where it was fa­mously called “ABC”—abstinence, be careful, use condoms) and Zimbabwe in reducing HIV prevalence rates, or that education and counseling programs have at least been proven effective in reducing risk behaviors and increasing condom use in countries like Tanzania, Kenya, Trinidad, and South Africa.³⁴ However, considerable debate still exists as to whether behavioral modifications are due to government programs or rather to simple fear and community awareness of AIDS, while others question how much of the decline in HIV prevalence is due to changes in behavior or instead to an inevitable maturing of the epidemic? But an even more apropos concern with an overly narrow or exclusive focus on pov­erty and malnutrition in AIDS strategy is the fact that these factors alone will not explain the unique severity of Africa’s AIDS epidemic. Within Africa, for example, how do we account for a high HIV prevalence rate in the richest coun­try on the continent, South Africa, but an exceptionally low one in a poor coun­try like Senegal (where a third of the population lives on less than a dollar a day); how do we explain why in other regions of the world that are just as poor as Africa, such as India or parts of Southeast Asia, AIDS infections and deaths have yet to reach the levels seen in Pattern II countries?³⁵ We also have to be mindful of the fact that some, such as former South African president Mbeki, have used poverty as a cover for denying the existence of AIDS or for abrogating their re­sponsibilities in providing all possible treatments for the disease. In actuality, most historians are quick to point out that they are arguing for poverty having an intimate, synergistic relationship with HIV and AIDS, rather than that there is no relation or that poverty is an independent cause altogether.³⁶

Despite all the attention being paid to poverty or sexual behaviors as the cause of AIDS in Africa, comparatively little notice has been taken of the actual history of the epidemic on the continent, for a third, and perhaps decisive, contributory factor to why Africa has the worst AIDS epidemic in the world is the simple reason that “it had the first AIDS epidemic.”³⁷ This rather obvious fact has been somewhat obscured, however, by the controversy surrounding the origins of HIV in Africa, where some scholars have accused the theory of having an under­lying racial prejudice that would naturally associate black Africans with mon­keys, even though there is a sound scientific basis for doing so in terms of the specific disease of AIDS.³⁸ Granted there may really be some discrimination in this regard that is part of human nature and has always been a part of the history of disease, but this still doesn't obviate the necessity of arriving at a true under­standing of the history of AIDS in Africa, if only to better understand how to draw up the right policy in treating the disease on the continent. Africa's early history with AIDS was largely determined by the latent, asymptomatic, and slow-to-progress qualities of the disease, which made it difficult to identify and target on a continent whose medical technology and health care system remain far behind those of the West; oftentimes AIDS' silent insidiousness was aided and abetted by attitudes of studied ignorance or outright denial, at both a local or individual level (reflected in a widespread reluctance to get an AIDS test) and even at the level of official government policy in some countries, such as the Democratic Republic of Congo and Zimbabwe. Whereas AIDS was confined fairly quickly in the United States to certain high-risk groups such as homosexu­als and intravenous drug users, the epidemic in Africa was allowed to fester for a decade or more and was not fully addressed in most places on the continent until the late 1980s and 1990s. Thus, AIDS managed to insinuate itself deeply and broadly into African society, afflicting many more sectors of the population than just one or two “high-risk” groups, as in the United States. And just like its synergistic relationship with poverty and other diseases, AIDS also has a mutual, two-way dynamic with African history: at the same time that AIDS is having a unique impact upon the continent by virtue of the kind of disease it is, so mod­ern trends in Africa during the twentieth century have paved the way for AIDS to make a tenacious home there, which include the political and socioeconomic legacies of colonialism; soaring populations after successful eradication of some deadly diseases, such as smallpox; rampant urbanization and displacement fa­cilitated by new, transnational highway networks; ecological infringement upon previously isolated animal habitats; and widespread medicalization, including greater use of blood transfusions and injections, all of which contributed to the spread of AIDS in both direct and indirect ways. Rather like the Black Death, the current pandemic of AIDS in Africa seems destined to endure for quite some time, though what the end will be and how it will ultimately affect the history of the continent is still a mystery.³⁹

Another way in which Africa differs from the rest of the world in its experi­ence with AIDS is the sheer variety of circumstances and contexts in which the disease has historically evolved and currently exists in its status quo on the con­tinent. In western equatorial Africa, where the disease most likely began, the epidemic matured early and has for the moment stabilized at seroprevalence rates of around 6 percent or less. Factors that have facilitated AIDS' spread there are thought to include widespread poverty, prevalent tropical diseases, wide sexual networks in some urban areas, such as Kinshasa, and the popular use of blood transfusions and syringe injections; on the other hand, the almost universal prac­tice of circumcision (thought to limit the spread of STDs), as well as the diffi­culty of travel in the region and transport disruptions caused by war, are likely to have helped curb the scope of the epidemic.⁴⁰ In east Africa, where the disease migrated next, HIV prevalence rates are likewise currently stable at 6 percent or less, which represents a dramatic decline from highs in the teens and twenties in some countries, such as Uganda, during the 1990s. Transmission factors in this region include transient populations—such as truck drivers and migrant labor­ers—who traveled along the trans-Africa highway, an associated service economy of commercial sex workers, soldiers and refugees dispersed by civil wars, net­works linking urban and rural areas, and a patriarchal and prudish culture (espe­cially toward condoms and circumcision) in Christian communities. Uganda under President Yoweri Museveni is often held up as an example of the beneficial results of an enlightened AIDS policy, where as early as 1981 the government embarked on an open and frank discussion of the epidemic and took a “multi­sectoral” approach to changing high-risk behaviors, such as by advocating “zero grazing,” or monogamy, on billboard signs. This was not entirely smooth sailing, as Museveni for a time opposed condom distribution and had a nasty tendency to stigmatize commercial sex workers (stereotyped as “Africa's urban witches”) for spreading AIDS; he also displayed a willingness to privilege traditional, home­grown healing methods despite the fact that some healers and their clients attributed the disease to witchcraft.⁴¹ In West Africa, the AIDS epidemic almost from the very beginning has been contained in many countries at low seropreva­lence rates of 1 to 2 percent or even less, due largely, it seems, to Islamic cultural restraints on sexual promiscuity (despite sanctioning of polygamy), high rates of circumcision, less mobility and concentration of populations in large urban ar­eas, greater economic opportunities for women (hence obviating the need to become commercial sex workers), and the endemic presence of HIV-2, a strain that is apparently far less virulent and infectious than HIV-1. Highest seropreva­lence rates in the region, currently at 3 to 4 percent, are in Cote d'Ivoire, Nigeria, and Chad, where there are higher populations of migrant laborers, wider client networks patronizing commercial sex workers, and greater economic instability and poverty.⁴²

We have already seen how many countries in southern Africa are currently laboring under the highest HIV prevalence rates on the continent, which were even higher just a few years ago. Many see this as chiefly due to the region's legacy of white domination, which lasted the longest of anywhere on the conti­nent. The apartheid regime in South Africa, for example, was not toppled until 1994. Others view the epidemic's severity here as a product of the silent insidi­ousness of AIDS, which perhaps has been allowed to incubate unnoticed, whether deliberately or not, for an inordinately lengthy period of time when compared with other regions. But in a way this is not so different from the po­litical question, for the two are closely linked: the dysfunctional regimes that emerged in much of southern Africa after independence were poorly equipped to tackle AIDS. Zimbabwe, for instance, has been ruled dictatorially under Rob­ert Mugabe since 1980 and in addition has been racked by civil war; one-party rule has likewise characterized much of the recent history of Zambia, Malawi, and Tanzania. Swaziland is still anachronistically in the grip of a ruling monarch, King Mswati III.⁴³ And yet democracy is no guarantee of a more enlightened AIDS policy. While the response to the disease under the former apartheid re­gime in South Africa was characterized by neglect, prudishness, and distrust, under the democratically elected rule of the African National Congress (ANC), the country is still struggling to come fully to grips with its AIDS epidemic. Other factors amplifying AIDS's presence in southern Africa include migrant labor associated with the region's diamond, gold, and copper mines; female pov­erty and lack of economic opportunity that drive women to resort to commercial sex work; rapid urbanization and population growth, as well as a mutually infec­tive relationship between rural and urban areas; and the severe social and eco­nomic disparities that persist throughout the general population.⁴⁴ AIDS, in turn, has only fed into all these social and economic problems that are helping to drive the disease crisis in southern Africa. Because of its extraordinarily high infection and death rates, AIDS has substantially lowered life expectancies in the region (by as much as twenty to thirty years), shifted the age distribution of the population to extremes at either end of the spectrum (AIDS typically targets those between fifteen and forty-nine years of age), and has artificially lowered, and in some cases even reversed, rates of population growth and economic ex­pansion. Some would even argue that AIDS poses a threat to national security in certain countries.⁴⁵ Since the forces of disease and socioeconomic causes are thereby mutually reinforcing in southern Africa, this has created an almost self­perpetuating epidemic.

South Africa under the former ANC presidency of Thabo Mbeki (1999— 2008), aided and abetted by two successive health ministers, presents a unique, some would say indeed bizarre, case of an AIDS policy that has been not only counterproductive but even quite harmful to the cause of AIDS patients in the country.⁴⁶ This is an excellent example of how just the way in which humans think about and define a disease can have significant and very real biological impacts. The world first learned of Mbeki's skepticism about HIV being the cause of AIDS in a remarkable public letter to world leaders that he sent out in April 2000, just before hosting the thirteenth international AIDS conference in his home country, where he provided a forum for dissident scientists like Peter Duesberg. Mbeki's letter was also noteworthy for its harnessing of antiapartheid rhetoric in support of the dissidence cause and for declaring that, since the Afri­can AIDS crisis was so different from that in the West in terms of its hetero­sexual transmission and sheer scale, this in turn necessitated a uniquely “African solution,” a position that, for all the contrasts drawn between their respective responses, was actually quite close to that of Museveni of Uganda as gleaned from his own speeches about AIDS.⁴⁷ Some of Mbeki's positions can indeed be said to have some validity, such as that poverty has played a greater role in Africa's AIDS crisis than previously thought or at least admitted, but in the end these have only served as political cover or posturing for a blanket rejection of Western drugs and vaccines, which Mbeki perceived as being proffered by a pharmaceuti­cal industry that was out to profit from an overhyped epidemic as a new form of racist imperialism. This is in spite of the fact that antiretrovirals had long been proven to not only prolong the lives of AIDS patients but also significantly re­duce MTCT, and that they were now being offered by pharmaceutical compa­nies at cut-rate or at-cost prices (some as low as one hundred dollars or less for a year's treatment, down from about twelve thousand dollars), after they had un­successfully pursued a lawsuit (dropped in 2001) in the South African courts to try to protect their drug patents from generic manufacturing. Ironically, by de­nying or delaying delivery of badly needed ARVs, Mbeki was in fact creating a new apartheid in South Africa, in which AIDS treatment was affordable only to some few thousands while the rest of the millions of people living with AIDS were in effect condemned to an early death. Many also observed hypocrisy in Mbeki's distrust of ARVs as potentially harmful to AIDS patients while at the same time promoting a home-grown drug, Virodene, which was shown to be actually toxic, or in his protests of lack of funds to finance ARV administration even as the government was pouring millions of rands into unnecessary defense spending. Mbeki's argument was also undercut by the fact that neighboring countries in southern Africa, including Botswana, Namibia, Swaziland, and Zambia, were concurrently implementing successful ARV programs that were reaching thousands of patients, representing 13 percent to as much as half of all those eligible for treatment; such programs were also being pioneered in several countries in West Africa, while in Uganda, the government was able to supply 40 percent of its need-based patients in 2004 by relying on free drugs supplied by international donors (mostly in the United States), whom it actively court­ed.⁴⁸ Other aspects of South Africa's AIDS policy, such as health minister Manto Tshabalala-Msimang's contention that AIDS was a nutritional disease (an idea she seems to have gotten from her adviser, Giraldo) that could be treated with an herbal concoction of lemon, ginger, olive oil, garlic, and beetroot, would be simply laughable if so many lives were not at stake. The silver lining in all this tragic denial has been that it sparked a political activism among AIDS sufferers in Africa who are demanding greater access to treatment, which can be compared to what the gay community achieved a decade earlier in the United States. It started in South Africa with the Treatment Action Campaign (TAC), led by the AIDS activist Zackie Achmat, which forced the Mbeki government to reverse course in 2003 and give at least a verbal commitment to making ARVs more available, and such political mobilization on behalf of AIDS victims has since spread to other countries including Ethiopia, Nigeria, Namibia, and Kenya. HAART has also been helped along in Africa by generic drug manufacturers, such as the Cipla corporation of India, which have made drug combinations much more affordable as well as easier to take in a single pill format (thus reduc­ing the likelihood of drug resistance emerging from incomplete adherence to regimens) and by philanthropic nongovernmental organizations (NGOs) such as the Bill Gates Foundation and Medecins Sans Frontieres (Doctors without Bor­ders) that have provided funds and distribution mechanisms to help administer the drugs.⁴⁹ The latest UNAIDS report is that, as of 2008, antiretroviral therapy is available to 44 percent of all Africans living with AIDS, up from just 2 percent five years ago.⁵⁰ This has greatly lengthened the life expectancies of AIDS vic­tims, reduced the number of AIDS orphans and MTCT transmissions, and probably helped to reduce AIDS stigma and reluctance to be tested for HIV, but some worry that it will not do much to reduce new HIV infections since there will now be longer windows of opportunity for transmissions, and that the cost of drugs will divert resources needed to address other health and socioeconomic problems, some of which are cofactors of AIDS.⁵¹ Most recently, as of 2010, it has also been observed that ART programs in many African countries such as Uganda have stalled or flatlined due to caps placed on outside donations in the wake of a global recession and a shift in priorities toward treating less expensive diseases than AIDS, such as pneumonia, diarrhea, malaria, measles, and tetanus. This raises the dispiriting prospect that hard-won gains made in the fight against AIDS in Africa will be reversed in the near future.⁵²

A final factor that distinguishes Africa's AIDS crisis from the rest of the world's, particularly in the West, is the unique vulnerability of the continent's women and children to the disease.⁵³ We have already seen that HIV infection rates in Africa are heavily skewed in favor of women, in contrast to what we find in Pattern I countries, and UNAIDS reports that young, teenaged women are particularly vulnerable to the disease in some African countries, such as Kenya, where they are three times as likely to be infected as their male counterparts.⁵⁴ Aside from their greater biological susceptibility to HIV, women caught up in Africa's AIDS crisis are also said to be victims of the patriarchal culture and gen­der inequality prevalent throughout much of the continent, which has not known the feminist liberation movements that have characterized much of mod­ern history in the West, although some would argue that in any case Western­style feminism is simply inappropriate or inapplicable to the different culture of Africa.⁵⁵ In such an environment, it is claimed, women, both commercial sex workers with many partners and married women with only one, find it difficult to negotiate safe sex strategies, such as using condoms, for both economic rea­sons (the need to find clients) and social ones (that asking a partner to wear a condom signals a lack of trust). Women, particularly commercial sex workers and widows, have also borne the brunt of the stigmatizing and scapegoating tendencies associated with AIDS in Africa. And yet, being married is of course no guarantee against not being infected by a promiscuous partner, so that mar­riage itself can be a “high-risk” behavior for women in some circumstances, while the lack of economic opportunities for women in many African countries places single females and widows in conditions of poverty that tend to lead to another high-risk behavior for AIDS, namely, commercial sex work, or casual sex in ex­change for “gifts.” Early ages for marriage and sexual initiation, economic pres­sures to pay for necessities such as school fees, and even alleged rumors that sex with a virgin can cure AIDS have all placed younger women at greater risk. Women in Africa are also disproportionately burdened in terms of nursing and caring for AIDS patients, which can further restrict their economic and educa­tional opportunities. Particularly heartbreaking has been the psychological and economic stress upon older women, such as grandmothers, who must care for their grandchildren orphaned by the disease at the same time that they mourn their children.⁵⁶ When familial networks prove unequal to the task of caring for Africa's numerous “AIDS orphans,” their upbringing poses a challenge to state institutions, and there is a danger that, due to stigma or poverty, these children will then grow up to become alienated from their societies. Still, there is hope for women and children in Africa in the age of AIDS: greater access to antiretroviral treatments is allowing AIDS parents to live longer, while the disease is also driv­ing various cultural changes and opportunities that can benefit women. For ex­ample, in Tanzania it is anecdotally reported that the AIDS epidemic has strengthened family bonds and partner fidelity, increased acceptance of con­doms, improved women's access to education and legal ability to inherit, facili­tated formation of women's clubs and other female-oriented community groups and organizations, and generally made society more aware of the special issues faced by women as a result of the disease.⁵⁷ In South Africa, a grassroots femi­nism movement seems to have been galvanized by the 2005 rape trial of the current president, Jacob Zuma, who was acquitted but whose testimony during the trial underscored some of the larger issues at stake in oppressive attitudes toward women that make them particularly vulnerable to AIDS. Zuma testified that he felt himself “obligated” to have sex with his alleged victim by her pro­vocative dress and demeanor (his further claim that denying an aroused women is “tantamount to rape” defies logic), and that he was not concerned about con­tracting AIDS despite his alleged victim's HIV-positive status because he had showered afterward. Above all, the case demonstrated a need to address gender inequalities and sexual violence, even in a country with the most liberal demo­cratic constitution in Africa, which nonetheless is reputed to have the highest incidence of rape in the world.⁵⁸

Within the Caribbean, AIDS scholarship has naturally focused on Haiti and Cuba, even though AIDS has established a presence throughout the region. Be­cause the epidemic here is primarily driven by heterosexual transmission, it has been classified as among Pattern II countries, along with those in sub-Saharan Africa. But there are other reasons for linking the Caribbean with Africa in terms of AIDS incidence: poverty, malnutrition, lack of safe drinking water, STDs, and other coexistent diseases are likewise prevalent throughout the region and are important cofactors of AIDS. Many Caribbean countries are also plagued by low ratios of doctors and poor availability of health services among the general population, and, as in Africa, commercial sex workers and migrant laborers are among the leading members of the “high-risk” population for AIDS. For in­stance, UNAIDS reports that, as of 2008, 27 percent of commercial sex workers in Guyana are infected, and in the Dominican Republic, the bateye migrants from neighboring Haiti who work on the country's sugarcane plantations are particularly vulnerable. Compared to other regions except for Africa, the Carib­bean also has a high AIDS incidence among women, who currently make up about half of all infections, and as in Africa HIV prevalence is especially high among younger women; the Caribbean also ranks just behind Africa in terms of its overall seroprevalence rate, which currently stands at 1 percent of its general population, even though this is still a fifth of Africa's.⁵⁹ The spread of and re­sponse to AIDS in the Caribbean is heavily impacted by its long legacy of having been subjected to imperialist domination, which during the twentieth century prior to the epidemic came from the United States, just as Africa was likewise emerging from under European rule in the decades leading up to AIDS.

There are, however, circumstances that are unique to the Caribbean's experi­ence with AIDS, which are best illustrated by the oft-cited case studies of Haiti and Cuba. Owing to its international sex tourism trade, including child prostitu­tion (which is also prevalent throughout Latin America), the Caribbean, and Haiti in particular, is thought by many observers to have served as the key nexus, or Bermuda triangle if you will, of the global AIDS pandemic. It is possible, for example, that AIDS was imported to Haiti by French-speaking guest workers in the Belgian Congo or Zaire, as it was known then, during the 1960s and 1970s; the virus would then, in this scenario, have been imported to the United States and Europe through the gay sex tours that had long operated in impoverished Haiti.⁶⁰ Others point out, however, that AIDS did not emerge in Haiti until after 1980, at exactly the same time as in the United States, so that it is just as likely that the United States exported the disease to Haiti. (The five Caribbean basin nations with the most AIDS cases in 1986—Haiti, the Dominican Republic, the Bahamas, Trinidad/Tobago, and Mexico—also happen to be those most eco­nomically linked to the United States in terms of tourism and trade.)⁶¹ In any case, because the CDC in the United States early on in the epidemic identified Haitians as one of its four “high-risk” groups for AIDS, in spite of the fact that they allegedly did not admit to engaging in gay sex or IV drug use, Haitian im­migrants in the United States suffered terrible discrimination throughout much of the 1980s. Stories were told of taxi drivers hiding their identities, schoolchil­dren abused and beaten up, employees fired or refused work, and so on. This was most unjust, as subsequent research and reinterviewing of subjects revealed that, early on at least, HIV transmission in Haiti closely paralleled that in Pattern I countries such as the United States, namely, that the vast majority of victims were men having sex with men or who were bisexual, with the disease gradually spread­ing into the heterosexual population. (High HIV prevalence rates among men who have sex with men are still found in Trinidad/Tobago and Jamaica.) Outside the capital of Port-au-Prince, seroprevalence in Haiti was actually quite low in comparison with elsewhere in Latin America and even compared with some American cities, such as New York. Racial prejudice and misunderstandings abounded on both sides, in the United States and Haiti. Americans took seriously ridiculous rumors of exotic voodoo blood rituals and cannibalistic practices that allegedly spread AIDS in Haiti, while Haitians were willing to believe conspiracy theories that their powerful neighbor to the north had deliberately devised and exported the disease in an effort to further subjugate them.⁶² Even though the Catholic culture prevalent throughout Latin America since the time of Columbus has impeded preventative efforts such as increasing condom use, HIV infection rates in Haiti have declined dramatically since the late 1980s, when they peaked at around 12 percent of some sampled populations; next door in the Dominican Republic, UNAIDS reports that recent reductions in HIV infections are due to sexual behavioral modifications, such as increased condom use and reduced part­ner exchange. Nonetheless, Haiti remains the region's epicenter for the epidemic. Haiti has by far the most people living with AIDS in the region, currently num­bering 120,000, which represents half of the entire AIDS population in the Ca­ribbean, and its seroprevalence rate is double that of the neighboring Dominican Republic.⁶³ Haiti's tourism economy has also taken a beating from AIDS. When the disease first became known in 1981—1983, the number of visitors to Haiti dropped by as much as 75 percent, and discrimination against Haitians has also been slow to die, since as late as 1990 they were still forbidden to donate blood in the United States.⁶⁴ And even though the Caribbean has benefited from the fifteen billion dollars in Emergency AIDS Relief pledged by the United States under former president George W Bush, this has come at the price of enforced emphasis upon abstinence-only programs instead of more proven prevention techniques, such as condom distribution and education.⁶⁵

The other anomaly in the Caribbean AIDS epidemic is, of course, Cuba. Ow­ing to a decades-long trade embargo imposed by the United States against the Communist regime of Fidel Castro, some might think that Cuba's low incidence of AIDS might be due to its diplomatic isolation, but that is not actually the case. (To date, there are just over six thousand people living with AIDS in Cuba, for a seroprevalence rate of 0.1 percent, six times lower than that of the United States.) The first AIDS cases in Cuba are thought to have occurred among the hundreds of thousands who served as soldiers on military duty in Africa, such as Ethiopia and Angola, or those who participated in cultural exchange programs abroad. Rather, most scholars agree that Cuba's success in containing AIDS has been chiefly due to its mass testing program, which was first applied to high-risk groups such as expatriates and tourism industry workers but which was gradually extended to almost the entire population, and to its policy of quarantining all HIV-positive persons in special “sanatoriums” distributed throughout every province of Cuba.⁶⁶ Although Cuba's approach was unique in all the world, it was not developed in isolation, as its main motivating factor seems to have been a propagandistic desire to outperform the United States in terms of health care, for which AIDS provided a golden opportunity from the Cuban point of view, since it seemed to be a product of American “decadent” behaviors, such as ho­mosexuality—nor was the Cuban response without historical precedent, as the sanatorium system was obviously pioneered during the era of tuberculosis in the nineteenth century, and quarantine was indeed adopted on a small scale during New York City's tuberculosis epidemic during the 1990s. But Cuba's policy was a direct contradiction of the privileging of individual rights over society's welfare, for which AIDS proved to be a turning point in the United States, and human rights organizations criticized Cuba's sanatoriums on the grounds that quaran­tine detention was for an indefinite period, despite the fact that its victims were otherwise healthy and could only infect others through conscious, intimate be­haviors, and for inhumanely separating couples or even separating parents from their children if only one family member tested HIV-positive. While the Los Cocos sanatorium just outside Havana, which had originally been a rest and recreation center for military officers and therefore was easily transitioned into a facility servicing returning HIV-positive soldiers, showcased the apparent hu­manity of the system, with medical and housing facilities that, it was pointed out to visitors, were superior to those available to most Cubans on the outside, some inmates told a different tale that included homophobic beatings by guards, at­tempted suicides, and prisonlike surroundings.⁶⁷ By the early 1990s, Cuba began modifying its sanatorium regime, at the same time as placing greater emphasis on AIDS education, which some argue it should have done from the very begin­ning. These changes were partly in response to international pressure; partly in response to a growing economic crisis caused by the collapse of Cuba's leading economic and political partner, the Soviet Union, in 1991; and finally in re­sponse to a home-grown protest movement, known as the roqueros or “rockers,” a music subculture of young people who self-injected themselves with HIV- tainted blood as an act of political defiance but whose numbers were also swelled by spouses who wished to join their loved ones sequestered in the sanatoriums. Though their numbers were relatively small, about two hundred by 1992, the roqueros grabbed some international media attention even if Cuban Americans in the United States were loath to embrace such a bizarre, some would say almost perverse, method of protest. At the present time, it is reported that most AIDS patients in Cuba reside in their local communities and receive care at outpatient clinics, while the sanatoriums now function as educational or training centers for an initial three-month period or else as a home base for those who otherwise live and work on the outside. Cuba has also stepped up its antiretroviral program, whose drugs are manufactured internally due to the embargo and which Cuba offers at low prices to other Caribbean nations.⁶⁸ In contrast to elsewhere in the region, homosexual intercourse, long a taboo subject in the country, may now be driving a rising incidence of AIDS in Cuba. One other territory that is bucking the trend in the Caribbean is Puerto Rico, where most HIV transmissions are due to intravenous drug use, accounting for 40 percent of new infections among men and 27 percent among women as of 2006.⁶⁹

In Central and South America, AIDS has generally followed the transmission patterns that have also held true in the United States and other Pattern I coun­tries, namely, being largely driven by homosexual intercourse and IV drug use, although there are exceptions, such as Honduras, which early on became the epicenter of the AIDS epidemic in Central America and where infections were attributed to heterosexual behaviors, especially among commercial sex workers.⁷⁰ As in the United States, men outnumber women in terms of those infected and living with AIDS, but again this may change due, it is said, to the possibility that bisexual behaviors may be underreported owing to the different ways in which gay sexuality is defined and understood in Latin America, where only transves­tites and receptive partners are perceived as actually engaging in homosexual sex. Latin America also mirrors the United States in terms of its low seroprevalence rate, currently at 0.6 percent, almost exactly that of the United States, and in its higher than average provision of antiretroviral treatment to its HIV-positive population, which was 54 percent as of 2008. And yet, Latin America has many of the same disadvantages and cofactors for AIDS that we have seen operating in Africa and the Caribbean, namely, widespread poverty and income disparities; malnutrition; predisposing disease environments, such as malaria; a large mi­grant labor population; and, associated with that, a high incidence of sexual ex­ploitation and prostitution.⁷¹ Some countries in Central America, particularly Nicaragua, El Salvador, Guatemala, and Panama, have also known recent mili­tary intervention from the United States or else civil unrest just prior to and during the AIDS epidemic, while in South America numerous countries have until quite recently experienced brutal dictatorial regimes or domestic violence from drug cartels and guerrilla groups, such as in Colombia and Peru.⁷² How, then, do we explain the region's relative success in combating AIDS?

The answer seems to be found in the country that has attracted the dispro­portionate share of AIDS observers' attention to the region: Brazil. As the largest and most populous country in Latin America with a reputedly liberal sexual culture (both gay and straight), wide gaps in wealth distribution, prevalent drug use and a vulnerable population of street children in the city's favelas or slums, a recent history of military dictatorship, and an underfunded health system, Bra­zil's prognosis for beating the AIDS epidemic was not good. Moreover, begin­ning in the second half of the 1980s, Brazil embarked on an AIDS policy that emphasized treatment in addition or even in preference to prevention, which most said was beyond the means of poor, developing countries in the third world. In 1991, the government began distributing AZT to AIDS patients, and in 1996, the year that triple combination drug therapy was announced to the world at the international AIDS conference in Vancouver, it took the remarkable and unprecedented step of offering HAART free to all who needed it, the first program of its kind in the world. Brazil also proved that developing countries could achieve high rates of compliance, and thus low rates of drug resistance, in treatment therapy programs. Much of the initiative for the Brazilian law mandat­ing ARV access came from hundreds of local AIDS NGOs, many of which had sprung up at first in the gay community whose members were relatively affluent and unstigmatized in Brazilian society. As the disease spread into more and more regions of the country and affected not only high-risk groups but also all sectors of the population, especially the poor, political pressure began building on Bra­zil’s politicians to take a more proactive approach to the epidemic. But even as the NGOs were organizing demonstrations and sponsoring lawsuits on behalf of its AIDS constituency, state and federal governments did prove responsive and headed off much of the confrontation through its bold ARV program. In a sense this was already predetermined by the country’s 1988 constitution, which en­shrined a universal right of access to health care for all its citizens, and AIDS proved to be the first big test of the young democracy (established in 1985). Despite the cost, antiretrovirals were also a good investment, as they kept pa­tients out of hospitals (where treatment would be even more expensive), reduced viral loads and therefore the risk of new infections, and allowed patients to re­main active members of society, whereas otherwise their lost productivity would be another drain on the country’s economy.⁷³

Yet, an even bigger challenge was to come from outside Brazil. In 1994, Bra­zil had signed the international Agreement on Trade-Related Aspects of Intel­lectual Property Rights (TRIPS), and in 1996, the country passed its own indus­trial property law recognizing pharmaceutical patents. In order to be able to af­ford its free drug distribution program, Brazil began manufacturing generic versions of antiretrovirals in its own manufacturing facilities and administering them through a home-grown network of dispensaries, in itself no mean feat. Brazil justified its generics program in legal terms on the grounds of an exception clause in TRIPS that allowed for violations in cases of “national emergency” and that its drugs were those manufactured prior to 1997, when its national patent law went into effect. Nonetheless, the pharmaceutical industry, with the backing of the U.S. government and the World Trade Organization (WTO), threatened a legal challenge and tariff sanctions since it perceived the Brazilian program as simply the start of a domino effect whereby other third world countries would seek to mimic Brazil's end run around the prohibitive cost of ARVs at Western prices. The end result of this standoff was that U.S. drug companies such as Bristol-Myers Squibb, Merck, Roche, and Abbott negotiated drastic price reduc­tions (down to about $140 for a year's worth of treatment) in exchange for a suspension and notification of compulsory licensing of patented drugs. This was a clear victory for the third world's right to access the same “miracle” treatments for AIDS that were enjoyed by the affluent West, which in some ways could be considered a natural extension of political AIDS activism that had emerged in the early 1980s in the United States. Brazil won in part because it was able to mobilize world opinion on its side, even to the point of securing World Bank loans for its program. However, there is ongoing conflict about Brazil's efforts to export its logistical and technical expertise to other poor nations seeking to start their own generic drug programs, particularly elsewhere in Latin America and the Caribbean and in sub-Saharan Africa.⁷⁴ On one side of the debate is the ar­gument that “Big Pharma,” by the very nature of its business of health care, has a moral and social obligation to help sick people in need, especially when its companies are some of the most profitable on earth and many of its products are developed with the aid of public money or institutions, such as the National Cancer Institute; on the other hand, it is pointed out that drug companies will have little financial incentive to develop new antiretrovirals and protease inhibi­tors that are much needed in the fight against AIDS unless there is a sufficient profit motive to do so, and the industry itself claims that it needs to charge high prices in order to recoup the millions of dollars that are invested in research and development of new drugs, most of which do not end up being marketable.⁷⁵ Some also question whether Brazil's success story can be imitated around the world, given its unique context. It could be said that Brazil at this point in time had a most fortuitous combination of circumstances, including democratic re­form, an existing (if poorly endowed) health infrastructure, biomedical know­how, a mobilized and tolerant civil sector on behalf of AIDS victims, and the economic wherewithal, political will, and diplomatic credentials to bring its program to fruition. But Brazil, by its very example of beating great odds to show that Western-style treatments for citizens with AIDS can be done in a developing country, is a powerful counterargument to naysayers and has given hope and inspiration to other activists who have had to prod their governments into pro­viding similar antiretroviral programs, such as we have seen in South Africa. What is more, Brazil has adopted a leadership role in this effort to expand access to HAART around the world, and not just in terms of lending advice and sup­port already mentioned but also in the very act of making bulk purchases of the active ingredients of drugs and negotiating price reductions from drug manufac­turers, by means of which it has made antiretrovirals that much more affordable for other countries.⁷⁶

One other success story in Latin America that we should mention is Mexico, which aside from Cuba has one of the lowest HIV prevalence rates in the region, currently at 0.3 percent of the adult population (half of Brazil's 0.6 percent). Mexico has achieved this in part by means of a network of proactive AIDS NGOs, free distribution of antiretrovirals, and an educational program that oper­ates with the tacit complicity (or benign neglect) of the Catholic Church, just like in Brazil. But Mexico also has a policy of closely monitoring and regulating its (legal) prostitution population, which has reduced cofactors such as STDs, de­creased drug use, and increased availability and acceptance of condoms, placing it more in the mold of Thailand.⁷⁷ As a consequence, married housewives are said to be as much as ten times more likely to get AIDS than commercial sex workers in Mexico; thus, the country still faces a threat of AIDS spreading into the wider heterosexual population and into rural areas, largely through migrant labor, hid­den bisexual behaviors, and drug use, especially along the U.S. border.⁷⁸

Finally, let us briefly address the Pattern III countries, where the AIDS pan­demic is still emerging and much of whose history with the disease is yet to be written. In Asia, dire predictions of a “second wave” of HIV infection, particularly in India and China, that would catapult the region ahead of sub-Saharan Africa with tens of millions of AIDS victims by 2010 have so far failed to materialize.⁷⁹ As of 2008, there were 4.7 million people living with AIDS in the region, about half of whom were in India alone. This still places Asia second only to Africa in terms of numbers of people living with AIDS (which is perhaps inevitable given that the region is home to 60 percent of the world's population), but the epidemic there does seem to be stabilizing. Overall, new HIV infections and AIDS-related deaths have so far been on the decline during the twenty-first century, with some notable exceptions such as China, Pakistan, and Bangladesh, and adult seropreva­lence rates are below 1 percent everywhere except Thailand.⁸⁰ Nonetheless, Thai­land is widely touted as one of the greatest success stories in the region and a model that has influenced adjacent countries such as Cambodia and Laos. An epidemic that was rampaging in the 1990s, fueled by the country's commercial sex industry intertwined with IV drug use, was contained by means of a targeted program that promoted AIDS education and universal condom use in brothels and which was led at the highest levels by government officials such as Senator Mechai Viravaidya (affectionately nicknamed “Mr. Condom”). Thailand has also benefited from hundreds of proactive AIDS NGOs which, as in Brazil, have lob­bied for increased access to antiretrovirals and manufacturing of cheap generic drugs in spite of patent protections such as TRIPS, and which have also helped administer ARV distribution through district hospitals and gain acceptance and tolerance of people with AIDS in Thai society.⁸¹ Thailand’s seroprevalence rate and AIDS population has been brought down from 2 percent and nearly eight hundred thousand, respectively, during the 1990s to current levels of 1.4 percent and just over six hundred thousand, while the number of AIDS deaths has been cut in half from over sixty thousand per year between 2000 and 2003 to just thirty-one thousand today. Equally impressive are containment efforts in Japan and South Korea, where HIV prevalence rates are practically zero—each country as of 2008 reported only several thousand cases of people living with AIDS (most of whom got the disease through homosexual and heterosexual contact) out of total populations in the tens of millions. Such results have apparently been achieved through a combination of AIDS education and awareness programs, free voluntary HIV testing and counseling, and public health support networks that provide access to antiretrovirals and other medical services.⁸²

Prevention programs targeted at commercial sex workers have also proven ef­fective in stabilizing the epidemic in south India, mainly by increasing condom use and reducing STDs, even though there is a history of discrimination and vio­lence against high-risk groups for AIDS in the country. Meanwhile, another area where the epidemic has been localized for the present is northeastern India, where the disease is mainly fueled by intravenous drug use, as is likewise the case for neighboring Pakistan and Bangladesh.⁸³ The extent of China’s AIDS epidemic is still somewhat of a mystery. As of 2008, its population of people living with AIDS was reported to be three-quarters of a million, for a seroprevalence rate of 0.1 percent, but credible figures on annual rates of HIV infection and progression to AIDS have been released only in the last few years, and the first admission of transmission among men having sex with men was not made until 2005. Initially, China’s epidemic was said to be almost exclusively confined to IV drug users, but lately heterosexual transmission—primarily through the country’s underground network of commercial sex workers—has overtaken drug use as the leading risk behavior for AIDS, according to the most recent UNAIDS report.⁸⁴ While China has adopted some harm reduction measures such as methadone maintenance and needle exchange programs, these are undermined by oppressive actions by the Communist government, such as condemning drug users and sex workers, both officially classed as criminals, into undergoing “reeducation” or “rehabilitation” in forced labor camps. Hence, needle sharing remains high and condom use low owing to victims’ fear of prosecution and police crackdowns; criminalization and stigmatization of AIDS victims has also hampered efforts at HIV testing, as was likewise true until recently in India. China and India also share a high level of ignorance or misconceptions about AIDS (such as that healthy looking people are not infective) among the general population. Some of China’s epidemic has been self-inflicted. During the 1990s, a “bloodhead” scandal erupted in Henan prov­ince in east-central China, when whole villages and as many as fifty thousand people were infected with HIV owing to a business scheme whereby blood plasma was donated and then the remaining blood cells from different donors was mixed all together and reinjected into “blood sellers” (using reused needles) in order to allow them to keep donating on a continual basis; those who have not died are currently being treated with antiretrovirals.⁸⁵

Elsewhere around the world, another region of concern is Eastern Europe and Central Asia, where the AIDS epidemic has grown rapidly in the twenty-first century, increasing by 66 percent since 2001 and currently afflicting one and a half million persons throughout the region. Ukraine, Russia, and Estonia all cur­rently lead the region in HIV prevalence rates, which are over 1 percent of the adult population in each country.⁸⁶ Intravenous drug use has to date been the main engine of the epidemic here, although heterosexual intercourse has been steadily on the rise as an associated risk behavior, especially among commercial sex workers. Facilitating transmission of the disease have been an economic and social collapse in the aftermath of the disintegration of the former Soviet Union and its satellite states, high rates of migration in search of work, rise of a criminal mafia controlling drug and sex trafficking, and a concurrent tuberculosis epi­demic, including MDRTB, which is especially prevalent in Russia and its prison population. The only hope for the region seems to be an expansion of ARV treat­ment and harm reduction programs, access to which is currently below the global average.⁸⁷

A very different picture emerges of the Oceania region, encompassing Australia, New Zealand, and the Pacific Islands, where HIV prevalence rates are close to zero and a total of fifty-nine thousand people living with AIDS were counted as of 2008. The one exception is Papua New Guinea, which accounts for the vast major­ity of AIDS cases in the region and whose seroprevalence rate currently stands at 1.5 percent of the population. Here, heterosexual transmission seems to be behind the epidemic, but its true nature and extent is largely unknown due to the lack of good information available in a country that is highly rural and diverse.⁸⁸ (Over 850 different languages and tribal societies have been identified in Papua New Guinea.) Reliable epidemiological data is also in short supply in the Middle East and North Africa, where HIV testing and access to ARV therapy remains low and the disease is associated with certain marginalized “high-risk” groups such as drug users, gay men, prostitutes, and migrant laborers.⁸⁹ However, what information we have does suggest that the region's epidemic is on the rise, increasing by about 65 percent during the first decade of the twenty-first century, with thirty-five thou­sand new AIDS cases, representing 11 percent of the total, in 2008 alone.⁹⁰

To conclude, AIDS has always been a ripe disease for drawing historical parallels and analogies. At first, we naturally compared it to other, terrifyingly deadly infectious diseases of the past, such as the medieval Black Death or plague, because it seemed to be all encompassing of our society, but as we learned of its continued entrenchment in certain high-risk behaviors, the rele­vance of this comparison seemed to fade. Now, AIDS seems to lend itself to being compared with other chronic diseases like syphilis, cancer, or tuberculo­sis, at least in their untreatable forms.⁹¹ AIDS is thus a kind of catchall for every social issue associated with disease. For example, transmission of AIDS involves some morally stigmatizing behaviors that have also informed syphilis and some types of cancers. In its late, full-blown state it can be as disfiguring as leprosy or smallpox. Conditions of poverty, especially in the third world, seem every bit as conducive to its spread as tuberculosis, with which it is opportunistically linked. And AIDS in sub-Saharan Africa seems to be operating under the same victim dynamic as the influenza pandemic of 1918, in that it mainly targets people in the prime and most productive part of their lives while leaving the very young and the very old relatively unscathed. AIDS at times inspires fitful efforts at quarantine or ostracization, contact tracing, and other public health measures that conflict with individual liberties and that likewise were tried with plague, cholera, tuberculosis, and syphilis.

The late author Susan Sontag drew upon a rich array of these historical analogies in her famous book AIDS and Its Metaphors, but the counterintuitive lesson she took from it was that AIDS and other comparable diseases like cancer should be divorced from their social context and ideally approached in biological isolation in order to strip away their debilitating stigmas.⁹² The problem is we have already seen how apparently biologically neutral statements about hetero­sexual transmission or epidemiological origins of AIDS can nonetheless be charged with their own political and social agendas. From the very beginning, it was nearly impossible to disentangle the social construction of AIDS from what­ever independently objective, biological reality it had. Its name and even very existence has been a matter of some debate and dissidence, while its origins, transmission, and spread are deeply rooted in our society's variable trends and behaviors, on both a communal and a personal level.⁹³ And yet, while AIDS does act as a kind of grand summation of all the diseases of the past, it also possesses some unique and distinctive qualities of its own. AIDS is less easily spread than other latent diseases such as tuberculosis and syphilis (although this can change depending on various cofactors), and this fact can affect how urgently measures to protect the public welfare should be implemented. Meanwhile, AIDS is per­haps more asymptomatic or else more easily masked by opportunistic infections than these other diseases during its long, slowly progressing incubation and dor­mant periods, allowing it to silently worm its way into a target population until it becomes endemic, despite the difficulty with which it is transmitted. It is a disease of the blood as well as of seminal fluids, and blood has always had a singular fascination for society as the precious bodily fluid of life. At least ini­tially, AIDS was intimately associated with a particular subgroup of society, the gay community, that until then had not received much attention in disease his­tory, or for that matter in human history in general. The timing of AIDS came right after the sexual revolution of the 1960s and 1970s, mixing sex and death in a particularly potent and frightening combination. Above all, AIDS forever changed the way historians view the history of disease, coming as it did right after victory had been declared against major infectious diseases like smallpox and as the medical community began to shift its focus toward more chronic conditions like cancer and heart disease. Even though AIDS at last seems to be joining the ranks of these latter, chronic diseases, the damage has already been done and historians can now never go back to the assumptions of the past: that human society will inevitably triumph over and find a cure for its ills, especially when concurrently or fast in AIDS' wake has come other, exotic diseases like Ebola, bovine spongiform encephalopathy (“mad cow disease”), and hantavirus pulmonary syndrome. AIDS indeed changed the very definition of what a dis­ease is, forcing recent historians to take a much more relativist approach to dis­ease history. For teachers, it has likewise proved very useful for posing all sorts of questions with respect to disease, even as it has withheld all its answers, since its mysteries are still unfolding. AIDS has thus been a boon for people morbidly fascinated with disease like me. But even so, I fervently wish it had never come among us.