HIST 234: Epidemics in Western Society Since 1600

Lecture 22

 - AIDS (I)


The global AIDS pandemic furnishes a case study for many of the themes addressed throughout the course. While in the developed West the disease largely afflicts concentrated high-risk groups such as intravenous drug users and the sexually promiscuous, in Southern Africa it is much more a generalized disease of poverty. In countries such as Botswana and Swaziland, the economic and social consequences of the disease have created a vicious circle, whereby the devastation wrought by AIDS severely impedes public health efforts and prepares the way for further infection. One important lesson that has been drawn from the past decades of struggle against the epidemic is therefore to take account of the specific, local characteristics of each affected area, making provision for the social as well as purely biological factors of transmission.

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Epidemics in Western Society Since 1600

HIST 234 - Lecture 22 - AIDS (I)

Chapter 1. AIDS: Background [00:00:00]

Professor Frank Snowden: Our subject this morning, and next time, is the AIDS pandemic, and I’ll start this morning dealing — in a sense by popular demand, because I know from visiting sections that people were particularly concerned with bringing this study up to date and talking about where we are at the moment. So, I’ll be concentrating largely on the global pandemic and where we are today. Then next time we’ll look more conventionally at the history of the AIDS epidemic, focusing on this country and the experience of the United States — is how I’m proposing to do it.

We’ll start with the sort of run through of things that you probably know very well, but that we really ought to discuss a bit as background — the nature of the disease, its course in the body and its symptoms — and then we’ll move on to the epidemiology of where the pandemic is today, and some of both the worrying aspects about this pandemic, and also a couple of the rays of hope, that of progress that has been made, especially in the last couple of years. So, that’s where we’re headed this morning. First of all, in terms of the disease — you know already, because we’ve talked about viruses — in this case a retrovirus.

Here we have a slide, a schematic picture of the HIV virus. You know about it; that it’s a core containing two strands of genetic material, RNA, encased in a membrane, with two glycoproteins on the surface. The glycoproteins, particularly this one, 120, is crucial for allowing the virus to target certain cells. In the case of this virus, it targets the T4 cells in the body, which are the ones that regulate antibodies and are the regulators of the body’s immune system. Well, once attached to the T4 cell, the RNA penetrates the host cell, and for a time it’s inactive, even for years. There then occurs a trigger, or detonator, which may be — this is a little speculative — an infection that activates the T4 cells, and then the RNA is converted into DNA that penetrates the chromosomes of the host cell and turns it into a factory for the reproduction of the virus and the killing of the cell.

So, the retrovirus is an absolute parasite. It takes over the controls of living T cells and turns them into factories to reproduce virus. Now, this we can see also in a picture. This is a slide of an infected T cell, and this is an image of a cell reproducing HIV. And finally let me show you, this is a picture of an HIV particle budding from an infected T cell. This is how the — part of the mechanism of the disease. And let’s talk about what happens to the body in terms of symptoms.

First there’s an incubation period of some six to eight weeks, after which there occurs the primary infection. Symptoms at that stage, in the majority of cases, are flu-like; that is to say fever, night sweats, muscular aches and pains, fatigue, swollen lymph nodes, headache, sore throat, sometimes diarrhea, sometimes a rash. Then the symptoms disappear after a few weeks, and in many cases there’s a prolonged period that’s entirely asymptomatic. This is a period of latency, which can last months, and has been known to last even as long as ten years or more, the time being entirely unpredictable. But during this period, the virus continues to multiply and destroy the cells of the immune system.

Then there comes the period of active AIDS, where there are direct lesions caused by the retrovirus, carried in some cases to the brain. Sometimes there’s neurological damage, known as AIDS dementia, or loss of motor control, memory, sometimes reasoning power. But the characteristic, as you know, of AIDS, different from most infections, is that it’s not the symptoms that it causes itself, but rather its ability to give rise to opportunistic infections by switching off the body’s immune system, making it vulnerable to an exotic variety of infections that the body is unable to fight. This is immunosuppression.

Later in the disease, the victim experiences weight loss, lethargy, recurrent yeast infections, rashes or sores, fevers and night sweats. Active AIDS develops when a patient has fewer, with HIV, than 200 T cells per micro liter of blood. The normal count is 800 to 1200. From this point, the average untreated — and I stress untreated — AIDS patient has about two or three years to live. Sometimes other symptoms develop: difficulty swallowing, loss of memory, cough, shortness of breath, sometimes seizure, nausea or impaired vision. But death is usually caused by a whole array of opportunistic infections, with names familiar to you, like candidiasis, pneumocystis carinii pneumonia, Kaposi’s sarcoma, cytomegalovirus, cryptococcal meningitis; but above all tuberculosis, which is the most important of the opportunistic infections of AIDS, and globally, at least, the most common immediate cause of death.

Note this characteristic of AIDS. Its course is not just the direct result of the virus itself on the body, but those pathologies which are substratum are combined with those of a series of other diseases superimposed on the AIDS virus, because of the progressive destruction of the immune system. And note how well adapted the virus is to its ecological niche in the human population. It’s a lethal disease, but one that avoids killing its host too quickly. A major evolutionary advantage begins with a lengthy asymptomatic latent period, as HIV, when it’s contagious, but the infective patient almost certainly doesn’t know that he or she harbors the virus in his or her body. And then full-blown AIDS can last for long years, while again the patient remains infective.

Chapter 2. Transmission [00:09:06]

Well, what about transmission? Transmission can occur in a variety of ways. As you know, it’s transmitted sexually. Everyone knows that. We need to remember there was a myth about AIDS, in the outset in this country in the ’80s, that it was a gay plague, that it spread homosexually. And you all know about the Moral Majority and Reverend Jerry Falwell, who welcomed AIDS as God’s sword to destroy homosexuality.

Apart from blasphemy, and the arrogance of a claim to know God’s will, what’s most striking about Falwell’s comment is his complete ignorance of the facts of epidemiology. The virus is present in bodily fluids: blood, semen, vaginal secretions, breast milk. So, one means is certainly sexual intercourse; especially intercourse involving an infected partner where there are lesions that allow the virus to penetrate the skin and enter the bloodstream. Hence sex, heterosexual or homosexual, where there’s a pre-existing venereal infection such as herpes, is particularly dangerous, or sex that causes abrasions, such as anal intercourse.

The risk factor is not homosexuality but promiscuity, by which I would define as sex outside the context of a loving relationship, whether heterosexual or homosexual. In Africa today, it has been established epidemiologically that multiple partner sex behaviors account for two-thirds of all new infections. But AIDS can be transmitted in other ways, despite what Jerry Falwell said. It can be transmitted through the blood by shared needles and syringes, for example, needles that haven’t been sterilized but are shared. One thinks of injecting drug users. One can think also of patients in resource poor health systems, in which needles are scarce and not routinely sterilized. One can think also of unsafe blood supplies; blood that isn’t screened, and is supplied to people by people who are remunerated, thereby making every transfusion a risk for HIV transmission, for patients who have surgery, or for hemophiliacs.

Another factor, of course, is the sex industry, where the disease spreads rampantly among sex workers and their clients. And then there’s vertical transmission, a real shock to Jerry Falwell. The disease can be transmitted transplacentally from mother to fetus, or from mother to infant via breast milk. This is one of the drivers of the present day pandemic. In 2008, the latest statistics, children constituted just under twenty percent of all new infections, and nearly the same percentage of AIDS-related mortality.

Chapter 3. Scale of the Pandemic [00:12:55]

Well what about the epidemiology of this pandemic? We’re now a quarter of a century into the global AIDS epidemic. And I would argue that AIDS is a good example of one of the themes with which we began our course: whether epidemic diseases are part of the big picture of history.

I would argue that you wouldn’t be able, in the future, to write the history of the late-twentieth and twenty-first centuries without devoting an ample space to the AIDS pandemic and its consequences. From the standpoint of the industrial world — Western Europe, North America — some people have a comforting illusion that the emergency has been controlled; for a couple of reasons. One is the fact that the number of cases in the developed world has leveled off; except that in the last few years there have been some troubling signs, including right here in the United States. And secondly, there’s been the development of expensive drug cocktails that have reduced mortality significantly, with many patients experiencing the disease as a chronic illness. But we need to be very careful about complacency.

There are only seven countries in the world that have more cases of HIV infection than the United States. In 2006, there were 1.2 million people living with HIV in the United States, and the number is not declining at all. Furthermore, we need to remember that living with HIV as a chronic disease is itself enormously problematic. It means an expensive and complicated regimen of pills, and the medication itself is toxic and has unpleasant side-effects. The evidence seems to suggest too that patients with HIV-AIDS, under treatment, experience nevertheless a significantly higher incidence of other diseases, and that they die at a significantly lower age. And then very disturbingly, since 2004 there’s been a real spike in HIV infections among men who have sex with men.

Meanwhile, worldwide the pandemic continues. In the words of the UNAIDS Report for 2008, it was continuing at a staggering level. At the end of 2007, the World Health Organization reported globally that 33 million people were affected by HIV/AIDS; that there were 4.5 million new infections during that year, and during that dreadful year nearly 3 million AIDS deaths. That’s something like 8,200 people a day. 2006 also witnessed 4.3 million new infections. In 2007 and ‘08, the number of deaths decreased, and that was partly due to the increased access to therapy, antiretroviral therapy, that lowered mortality.

In 2010, for the first time, UNAIDS suggested some reasons for optimism, but optimism of a strictly limited kind. Not that progress was being made to controlling and decreasing the epidemic, but that it seemed to have leveled off. That was one of the hopeful stories of the UN Report of this year. It remains true though that most people in resource-poor countries who need retroviral therapy still don’t receive it. But let’s look at some of the graphs.

This was HIV at the end of 2005, and it shows the total of 40.3 million people with HIV/AIDS, and below that it shows the numbers of newly infected people and the number of AIDS deaths for 2005. And this gives you some idea of the dramatic inequality of the burden of HIV/AIDS, that it’s enormously a burden in Sub-Saharan Africa, which has more than half of the total number of AIDS people in the world. Or let’s look at this picture, which just gives a clear indication of where the epicenter of the AIDS is, which is in Southern Africa; countries such as Botswana, Lesotho, Swaziland, Namibia, South Africa, Zimbabwe, Angola, Mozambique. There the WHO reported in 2006, and again in 2008, that the epidemic was still rampant, that the trend still offers no comfort. And in the sub-region as a whole, life expectancy has actually declined, because of AIDS, to below fifty; plunging to levels not seen indeed since the 1950s.

Swaziland and Botswana have the unhappy distinction of having the world’s highest prevalence of HIV/AIDS. And here you see the worst-case scenario. Twenty-six percent of people are infected with HIV, the highest levels ever recorded, as are twenty percent of pregnant women. Those are rates of prevalence that the Center for Disease Control once thought to be impossible, and life expectancy at birth dropped below forty years in several countries in the region. With nearly 6 million people living with HIV, in 2008, South Africa has the sad record of possessing the largest HIV epidemic in the world in absolute numbers, not though per capita.

Chapter 4. Epidemiology [00:20:09]

Now, epidemiologically it now seems that there are two great divergent patterns in this terrible epidemic. In the industrial world, it’s primarily an affliction of high-risk groups. We’ll talk about them in a moment: men who have sex with men; sex workers; injecting drug users. This is what the World Health Organization calls “concentrated epidemics,” in which the pandemic is confined, above overwhelmingly, to certain high-risk groups. But there’s a second and more devastating pattern, clearly evident in southern Africa, where HIV/AIDS is a leading cause of death, and where transmission among high-risk groups certainly occurs, but it’s overwhelmed by transmission in the general population. There transmission is primarily through heterosexual sex, and significantly more women are infected than men. And it’s also true, as I’ve said, that transmission occurs on a large scale, vertically from mother to unborn child, so that significant numbers of children are born with congenital AIDS.

Why women? And this is again one of the themes of our course, and I’ll be dealing in part here with poverty, and not just poverty but inequality. Women, in part, because of biology. The disease is more easily transmitted from men to women than vice-versa. It’s also true, clearly true in Sub-Saharan Africa, that sexual activity tends to start earlier for women. Young women in many parts of Sub-Saharan Africa also frequently have sex with much older partners. Sexual inequality also fuels the sex industry, as does — the epidemic is primed also by violence against women, and often the inability of women in many situations to negotiate safe sex practices. In many parts of the world girls are simply severely discriminated against in terms of education, and therefore do not acquire sex education and knowledge necessary to take effective measures to protect themselves and control their reproduction.

Girls who have not received primary school education are twice as likely to be infected with HIV as those with higher educational attainments. And as I said, violence against women is a major factor in the epidemic. It’s also true that we need to mention cultural norms in these areas where notions of masculinity are important determinants of male behavior patterns that increase the risk of AIDS; the idea that it’s meritorious to have multiple partners, and unmanly to use condoms.

Well, this is an epidemic that can serve also as a review for some of the themes of our course. We see this epidemic being primed by a number of factors that by now are familiar to you, in comparative discourse. There’s a clear link with poverty. The countries with uncontrolled epidemics are among the poorest nations in the world, and poverty is directly linked with the epidemiology of HIV/AIDS. Poverty prevents national governments from building effective public health structures, or educational infrastructures. And studies of sectors most at risk from the epidemic in southern Africa — that is, sexually active young people in the fifteen to twenty-five age group — those studies reveal that large numbers of people of that age group still do not have an accurate understanding of the mechanisms of AIDS transmission.

Local studies also show in some places the disturbingly large numbers of sexually active young people — twenty-five percent have been discovered in places — still have no idea of what a condom is. Poverty prevents people from having access to means to defend themselves: education, medical care and treatment for those already infected. It drives recruitment into the sex industry, another major driver of the pandemic. It leads to unemployment, demoralization and alienation; all of which fuel high-risk behavior, including intravenous drug use, and that in turn leads to further unsafe sex practices. Then there’s the social and economic impact, which is maximized by the age profile of the victims themselves; that is, young men and women in the prime of life, who should be the mainstays of families and their economies.

In some places poverty even destroys the effects of sex education itself. In Uganda, for example, the newspaper theUganda Monitor, reported two years ago that condoms remained so far beyond the means of many people that a widespread practice was to boil them after use and reuse them. Then another theme in our course. We’ve talked about urbanization and its role with certain diseases; not all, malaria was clearly very different. But it’s no coincidence that southern Africa, where the pandemic is rampant, is also rapidly, rapidly urbanizing, and that indeed twenty percent of the global burden of HIV/AIDS falls on fifteen cities in southern Africa.

Another theme of our course is represented by AIDS, and that’s the impact of conflict and war. The movement of troops once again has proved to be ideal for sexually transmitted diseases, and for prostitution. And the spread of other STDs — syphilis, gonorrhea and herpes — actually furthers the spread of AIDS. The lesions that they cause, like genital ulcers, provide ideal portals for entry of HIV into the body.

Trade and modern means of transport have been important. One can’t understand the AIDS epidemic without roads, railroads, the airplane. Societal neglect is a theme we’ve talked about, and national governments, in some cases nations that are poor and under-developed and have virtual status as almost failed states, have been incapable of taking major initiatives on their own, in terms of improving the health of their populations. But in some cases they also have other priorities.

There’s the siren song of military spending. There’s corruption. Or let’s take the case of the former president of South Africa, Mbeki, who refused to take science seriously, and rejected the idea that the HIV virus causes AIDS. He called on people not to use condoms, but simply to drink a mixture of olive oil and garlic as a prophylactic of choice. So, there’s been a current of AIDS dissidents who reject the link between the virus and the disease. Fortunately, that situation has changed.

Then there’s stigmatization, which is a cause of the spread of the epidemic. It causes people at risk not to seek medical attention, and that in turn undermines surveillance and active understanding of the epidemiology of the disease. And the inequality of women who are stigmatized has a number of structural consequences: that is, in terms of inheritance laws that disenfranchise them; unequal jobs in the economy; violence; early sexual debut; and large-spread practices of what UNAIDS calls “transactional sex.” In Kenya, for example, teenage girls are three times more likely to be infected with HIV than boys of the same age, and the differential, instead of decreasing, increases with age.

There’s also the displacement of people, and HIV/AIDS thrives on migrant labor, on disrupted families, on refugee status. And in industries where migrants live, for example, among miners, in compounds at vast distances from their homes and families, a situation that leads to the thriving of commercial sex. Mobile populations are at high risk of infection. And then one of the vicious factors of HIV/AIDS is the burden of the disease itself, which causes the burden of poverty to increase, and poverty furthers the epidemic. AIDS then leads to a vicious downward spiral in which poverty creates favorable conditions for AIDS. AIDS breeds poverty, and so on.

In the words of the UNAIDS Report for 2008: “HIV causes a greater loss of productivity than any other disease, and is likely to push an additional 6 million households into poverty by 2015. HIV has inflicted the single greatest reversal in human development in modern history.” That was the UN Report. And then there is super-infection; that is, multiple infections with different strains of AIDS. And one of the most tragic factors of all is the phenomenon of AIDS orphans. The WHO reports staggering numbers of them. It terms it “a crisis of gargantuan proportions.” Already in Sub-Saharan Africa, 11 million children under fifteen are orphans; a number that’s expected, given current and projected prevalence of HIV infection, to reach the staggering figure of 25 million in a few years. In the worst infected cases, it could be, if this actually materializes, that one child in five could be an AIDS orphan.

Chapter 5. Societal Effects [00:33:14]

What are the effects of this dreadful pandemic on societies? Again we see that this functions almost as a review of themes of our course. Clearly no one would be able to write the history of the present moment in southern Africa without giving a central place to HIV/AIDS. HIV/AIDS prevents education and literacy. At the heart of the epidemic in Botswana is the fact that the disease kills teachers more rapidly than they can be replaced; that poor families, with a member ill from AIDS, can’t afford to send children to school. The fact that it destroys healthcare systems. In many countries in southern Africa fifty percent of all hospitalizations are due to HIV/AIDS, and nearly all other healthcare interventions and programs have therefore been erased or radically downscaled.

It destroys productivity and creates a crippling burden of disease, destroys families and communities, thereby trapping whole countries in underdevelopment and international dependency. It destroys civil society and undermines democracy. It’s the substratum for a lethal epidemic that follows in its wake, the reemergence of tuberculosis, the classic opportunistic infection complicating HIV/AIDS. And TB is rising at a rate of six percent per annum in southern Africa, where 2 million cases of TB are diagnosed a year. Businesses find that they’re crippled. There are high rates of absenteeism. There’s a real shortage of skilled workers available. There are high rates of turnover, and it’s extremely expensive to train new workers. And, of course, the rocketing healthcare expenses that they face.

There’s a major cultural impact on societies. Clearly this undermines any confident sense that a society is protecting one. There’s a demographic impact. We’ve already seen the way in which HIV/AIDS is altering the age structure of whole populations and transforming life expectancy. And there’s even the possibility of failed states as a direct result of disease, with enormous implications for security, political stability and democracy. But this last fact paradoxically has also opened a ray of hope. The realization that I last mentioned affected the national security estimate of our own government, which reckoned that in fact HIV/AIDS was a major threat to the security of the United States; the first time that disease was recognized by the CIA and the security community as a threat to our country. And this was reinforced by studies by, for example, the RAND Corporation.

The result of this realization, that we are indeed a global community, and that what’s happening in Southern Africa and other places is of enormous impact throughout the world, led to a massive investment of funds. And I’d most like to mention PEPFAR, the President’s Emergency Plan for AIDS Relief, that was established by President Bush in 2004. It now targets fifteen countries, has been extended under President Obama, and those countries are primarily, though not exclusively, in southern Africa. Initially it was fifteen billion dollars over several years, and has been renewed since, and it became the largest commitment of funding to an international health effort ever recorded.

This has led with the — there’s also funds through the Gates Foundation particularly directed at research, and through the Global Fund for HIV/AIDS, Malaria and Tuberculosis. One of the conclusions is that there’s been — that we could reach — is that in the last years, under this massive new investment of effort and funding, that the world health community is developing much more sophisticated strategies for dealing with this epidemic, that it has much more data and information, and that it’s learned a number of important, indeed vital, lessons.

Chapter 6. Public Health Strategies [00:38:59]

What are some of the conclusions that provide us with at least a measure of hope? One of them is that in campaigns against this disease, one size definitely does not fit all. And here we see another theme of our course, that information, hard data, is absolutely crucial to any effective public health strategy. Public health needs to be based on a solid basis of information, and in this case we see a rapid up-scaling of testing and surveillance as one of the key components of the global effort to combat the disease. That’s necessary because it establishes the clear idea that the epidemiology of this disease in each society is distinctive, and that in turn enables the campaign to concentrate resources, to change tactics, depending on the actual results of the interventions so far.

So, you need to be able to, in order to have sound public health, scientifically to assess what you’ve done to date, and to change course if it’s not working properly. One of the hopeful signs in the AIDS pandemic is that the campaign has become more sophisticated and focused. It has been realized that strategies that fit one phase in the history of the epidemic may not be effective at another stage. And, so, the response has continually to be updated and adapted.

The priority now is to clearly identify high burden areas as a priority, and to saturate them with prevention efforts. The slogan of PEPFAR, for this reason, is “Know Your Epidemic.” In the past, for example, anti-AIDS programs failed to target married couples, and people in long-term relationships, couples in which one partner in particular is HIV-positive while the other is not; in the jargon of the World Health Organization, “discordant couples.” Another lesson, that the commitment cannot be short-term; that it must be sustained. That short-term interventions that are then scaled back can be useless and counter-productive.

A good illustration is Uganda, which a few years ago was one of the bright spots in Africa. When the government invested heavily in sex education, in the provision of condoms, and the fostering of new and healthy sexual behaviors, the results were highly successful, until funding was scaled back in favor of other priorities. And since then, the epidemic in Uganda has resurged with a vengeance. And one could say something similar about Thailand. There are also new strategies.

Let me give you a couple of examples. One is the need to abolish the distinction, in this pandemic, between prevention and treatment as a false dichotomy. Because treatment with antiretroviral therapy is in fact a valid and essential preventive strategy. In particular, antiretroviral therapy radically lowers the incidence of vertical transmission from mother to child. It’s also true that antiretroviral treatment lowers the viral load, and therefore reduces transmission. Antiretroviral therapy is a prophylactic because it prolongs the life of parents, thereby decreasing the number of orphans and vulnerable children; the very people who fuel the sex industry and are most likely to indulge in unsafe sex practices because they lack education, resources and access to medical care.

PEPFAR has concentrated recently on making generic antiretroviral therapies available in focused countries, at an affordable price, and the FDA, in this country, has established fast-track approval to allow antiretrovirals to be rapidly reviewed and cleared. By the end of 2008, antiretroviral therapy had been extended to 10 million people with HIV/AIDS, and especially to pregnant women who are HIV-positive. Another hopeful sign. At first, PEPFAR was ideologically motivated, and stipulated that one-third of its funding had to go to abstinence-only education. But this has been demonstrated by results to be counterproductive and so has largely been dropped, and funding has been redirected toward other aspects of the program.

Another stress has been on gender inequality. And here I want to stress that it’s not only poverty but inequality that drives this epidemic forward. Let me give you the example of Swaziland, which is at the epicenter of this pandemic. One third of women in the eighteen-to-twenty-four age group were found to have experienced sexual violence, as had one quarter of girls under fifteen. So, providing education and re-education, stressing the dangers of power differentials in intimate relationships, has been important in demonstrating the devastating consequences of sexual entitlement, and also offering adolescent women vocational training so that they would have the skills necessary in the marketplace, and hence the economic independence that was a major determinant of public health.

Until recent years, HIV/AIDS programs avoided what might be called socioeconomic and cultural determinants of the pandemic, concentrating on generic awareness, but not confronting the specifics of local situations that fuel the epidemic. Let me give you an example of targeting specific high-burden groups and areas. One of them has been in recent years the targeting of intravenous drug users, and removing ideological blinkers, and simply talking in terms of epidemiology and hard science, leading to such innovations as needle exchange programs to make blood safe, and indeed in a couple of countries to opioid substitution treatments to remove, or at least to downscale, heroin addiction, thereby once again lowering the rates of transmission.

Another major intervention has been on establishing safe blood supplies, combating what we might call the medical transmission of HIV/AIDS, through the establishment of laboratories, when with them the screening of all blood and the recruitment of donors from low-risk sectors of the population on a non-remunerated basis. Or there’s been the awareness of the utility of male circumcision as a prophylactic measure in this pandemic. Let me then just contrast the situation in Sub-Saharan Africa, where the epidemic is, in the population, the general population, with a couple of other worrying places in the world — and I’ll end then on a slightly more somber note — some places that are currently sources of concern, outside of Africa.

There’s Eastern Europe, and the former areas of the Soviet Union, where UNAIDS has talked about an emerging epidemic, unlike that of Southern Africa. The epidemic has a different profile. It’s a concentrated epidemic, showing prevalence among high-risk groups, like intravenous drug users. In Saint Petersburg, thirty percent of intravenous drug users are under nineteen-years-of-age, and the sharing of needles is the norm. And it’s also driven by the sex industry, and by the collapse of the healthcare system, and fueled also by some religious attitudes which scorn sex education and the use of condoms, or devote resources to a practice of abstinence education, which has demonstrably not worked. Or there’s East Asia and the Pacific; again, injecting drug use, sex industry, low condom use and sexual tourism, all of these being risk factors that are cumulative.

I’ll conclude just with a couple of worrying points about our own country. The outbreak began in the ’80s, as far as we know, peaked around 1993, and then declined steeply until approximately the year 2001, since which time there’s been an upturn; and a surprising degree of misinformation has abounded. New infections, we can see, demonstrate that the epidemic has been transformed, and the epidemic in the United States is totally unlike what’s happening in Southern Africa. New infections are overwhelmingly among men; 718,000 males affected and 160,000 women. And it tends to be among concentrated groups: men who have sex with men; drug users; and ethnic minorities — African-Americans, who have half of the new cases in the last few years, and Hispanics.

A transformation occurred. AIDS in the 1980s was primarily a disease among the white population. It has since declined among whites, and spread disturbingly among minorities; African-Americans, Hispanics and Asians. So, at that point I’ll refer you to Wednesday, when we’ll talk about the United States in greater detail. And I’ll just conclude, since I’ve run out of time, by saying that the pandemic at the moment is extremely active. The most hopeful thing I could say to you is not that it’s being controlled, but that it seems to be globally stabilized; but there are a number of really worrying places in the world, and some very worrying developments.

[end of transcript]

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