AIDS and HIV

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AIDS and HIV

This entry contains the following:

I. OVERVIEW
Maureen Lauder

II. HISTORY
Maureen Lauder

III. EFFECTS ON POPULATION
Maureen Lauder

IV. TREATMENTS AND PREVENTION
Maureen Lauder

V. SOCIAL AND POLITICAL RESPONSES
Maureen Lauder

I. OVERVIEW

AIDS (acquired immunodeficiency syndrome) presents as a variety of diseases and illnesses, all of which result from infection by the human immunodeficiency virus (HIV). HIV attacks the human immune system, weakening the response of the body to infection and disease and rendering a patient susceptible to various illnesses. HIV causes few symptoms, and an infected person may appear and feel healthy for years after contracting the virus. Once the virus has weakened the immune system sufficiently, the disease progresses to full-blown AIDS, which is marked by a variety of illnesses from which the patient has increasing difficulty in recovering. Death from AIDS results from the effects of secondary illnesses.

HIV/AIDS is believed to have arisen in western and central Africa in the mid-twentieth century. The virus is transmitted through bodily fluids such as blood, semen, and vaginal secretions. It is communicated primarily through sexual contact but also can be transmitted from mother to child (prenatally, during delivery, or during breast-feeding), through the sharing of contaminated needles by intravenous drug users, through the use of infected blood in medical procedures, and by other means of blood contamination (needle punctures, contamination of open wounds, etc.).

HIV is a retrovirus capable of rapid mutation that produces a latent infection that develops over a long period. To infect a human, HIV must attach to specific host cells known as CD4 cells, which are responsible for regulating the immune system. Once it has occupied a host cell, the virus copies the DNA of the cell, rendering it invisible to the body's defense system. The virus replicates itself within the cells, producing numerous virus particles that bud from the surface of the cell, destroying the cell and moving on to attach to another CD4 cell. For several weeks or months after initial infection the patient is highly infectious, although HIV testing will not reveal the patient's positive status. After this initial period, which is known as the window period, the virus incubates, destroying many CD4 cells but being fended off by the immune system. Some two million CD4 cells are destroyed each day by some ten billion newly produced virus particles. The incubation period for HIV is quite long, averaging around ten years. Once the balance between CD4 cells and virus particles shifts in favor of HIV, however, symptoms begin to appear.

In the United States the diagnosis of AIDS is tied to CD4 counts as well as to secondary symptoms. When an HIV-positive individual's CD4 counts falls below 200 (a healthy person's count appears to range from 500 to 1,600) or when that person is determined to have any one of twenty-six opportunistic infections, a diagnosis of AIDS is made. In less developed or poorer countries, however, means for testing CD4 counts are often unavailable or prohibitively expensive. In such cases doctors rely on clinical examination of the patient to make the diagnosis. Certain infections, including tuberculosis and meningitis, are particularly common in HIV-positive individuals.

see also Sexually Transmitted Diseases.

BIBLIOGRAPHY

Barnett, Tony, and Alan Whiteside. 2006. AIDS in the Twenty-First Century: Disease and Globalization. 2nd edition. New York: Palgrave Macmillan.

Maureen Lauder

II. HISTORY

AIDS (acquired immunodeficiency syndrome) appears to have originated in Africa at some time in the twentieth century. The human immunodeficiency virus (HIV) is assumed to be a variant of a simian immunodeficiency virus (SIV) that became capable of crossing the species barrier. It is unclear how that crossover first occurred, although scholars have posited contamination in the slaughter of bush meat or contamination of an oral polio vaccine cultured on chimpanzee kidneys that was administered widely in parts of Africa. In either case it appears that HIV and AIDS were present in the human population long before they were recognized.

Scholars have identified isolated deaths in European countries as early as the 1950s that now appear to be the result of AIDS and HIV, and analysis in the 1980s of blood samples originally drawn from African subjects in 1959 turned up one sample contaminated by HIV. It is possible that isolated individuals or communities experienced AIDS outbreaks earlier in the century, but political and social upheaval in Africa after World War II, coupled with widespread vaccination campaigns in regions that often could not afford to use disposable needles, provided an environment in which HIV was readily transmissible.

AIDS first came to public attention in the United States in 1979 and 1980, when doctors in New York and Los Angeles began noticing an increased incidence of fatalities resulting from extremely rare and normally benign diseases. In Los Angeles doctors were seeing multiple cases of a deadly form of pneumonia caused by Pneumocystis carinii, a generally harmless and extremely common protozoan that rarely induces illness and almost never causes death. In New York physicians were also seeing Pneumocystis carinii pneumonia as well as cases of Kaposi's sarcoma, an extremely rare and benign skin cancer that normally afflicted (though seldom killed) elderly men of Jewish and Mediterranean origin. In New York, however, Kaposi's sarcoma suddenly was making fairly young men extremely ill and, often coupled with other opportunistic infections, leading to rapid deterioration and death. All those early cases of AIDS involved homosexual men.

The gay rights movement of the 1970s had been invested in the importance of sexual freedom. If mainstream America deemed gay sexuality distasteful and shameful, there seemed no better way to confront and overturn those prejudices than by celebrating gay sex. In the early 1970s sexual promiscuity not only was accepted but was considered politically and socially desirable, a means of forging a new kind of community that resisted heteronormative ideals of partnership, family, and sexual practice.

By the late 1970s bathhouses designed expressly to facilitate fast, anonymous sex were a common feature of gay life in some urban centers, notably New York and San Francisco. The first victims of AIDS had in common frequent bathhouse attendance and a promiscuous lifestyle that included lifetime sexual contacts that numbered in the thousands and sometimes in the tens of thousands. Because of their numerous sexual partners, those early victims were an ideal vector for the disease, and because of the long incubation period that preceded the symptoms, HIV was well established in urban centers in the United States before anyone knew it existed. By the time people became aware of it, gay men in other areas of the country—men who were not part of the San Francisco or New York gay scenes but who may have slept with someone who was or once had been—had been infected.

In the second half of 1981 reports began to surface of AIDS infections in the heterosexual population. Drug addicts who used intravenous drugs became sick in noticeable numbers, infant children of drug addicts fell ill shortly after birth, and hemophiliacs and those who had received blood transfusions started to develop symptoms. Intense political pressure surrounding the disease, however, stymied the attempts of doctors, health officials, and activists to mobilize a defense. Many doctors and health officials were reluctant to accept evidence that the epidemic was not limited to the homosexual population, and the testing of blood donors for HIV was instituted much too late to stem the progression of the disease.

The gay press often considered claims of the prevalence and severity of the disease to be hysterical, overly alarmist, and indicative of widespread homophobia, whereas the mainstream press largely refused to touch an issue that involved primarily gay sexuality. Only when evidence that AIDS could strike heterosexuals became overwhelming did the major news organs begin to run stories about HIV and AIDS, and even then there were relatively few compared with earlier, much smaller epidemics. The Reagan administration provided little leadership or research funding, and the response of the National Institutes of Health (NIH) was slow and was accompanied by inadequate funding. Ultimately, AIDS research and prevention in the first decade after the emergence of the disease were driven by local groups and individual doctors, activists, health officials, and politicians, usually with insufficient resources and funding. Thus, by the time the U.S. government gave HIV and AIDS substantive attention, the virus was well entrenched and spreading rapidly in U.S. society and throughout the world.

BIBLIOGRAPHY

Barnett, Tony, and Alan Whiteside. 2006. AIDS in the Twenty-First Century: Disease and Globalization. 2nd edition. New York: Palgrave Macmillan.

Hooper, Edward. 1999. The River: A Journey to the Source of HIV and AIDS. Boston: Little, Brown.

Shilts, Randy. 1988. And the Band Played On: Politics, People, and the AIDS Epidemic. New York: St. Martin's.

Maureen Lauder

III. EFFECTS ON POPULATION

In most countries human immunodeficiency virus (HIV) infection initially spreads primarily through a group of core transmitters who are at particular risk. Sex between men may have a transmission rate as high as one in ten, depending on sexual practices. Transmission rates among intravenous drug users are high because a contaminated needle can introduce HIV directly into the bloodstream. Sex workers also have an elevated risk of contracting and transmitting HIV. HIV/AIDS (acquired immunodeficiency syndrome) often establishes itself in those high-risk groups before moving into the general population. As the mode of transmission shifts from sex between men and the sharing of needles by intravenous drug users, the rate of HIV diagnosis among women often increases dramatically, leading to greater numbers of children being born with HIV or orphaned by AIDS. HIV is most likely to be a generalized epidemic in poorer countries, which may lack the infrastructure, money, and political stability for effective wide-scale treatment and prevention.

THE UNITED STATES

In the United States HIV/AIDS first became widespread among populations of homosexual men, which suffered widespread fatalities in the early years of the epidemic. As a result AIDS long was considered a "gay" disease, and there is still a lingering perception that AIDS victims are most likely to be homosexual men. In later years, however, the nature of the epidemic changed noticeably. More than 50 percent of new HIV diagnoses have been among African Americans, and some three-quarters of women diagnosed with HIV are African American. The wide availability of antiretroviral therapy has led to a substantial decrease in AIDS deaths; African Americans, however, have substantially lower survival rates than does the white population. In 2002 the death rate of African Americans with AIDS was twice that of whites.

AFRICA

Sub-Saharan Africa bears a disproportionate burden from the AIDS epidemic; it is home to about 10 percent of world population but contains 60 percent of HIV cases worldwide. In Africa the epidemic is widespread and generalized, with most transmission occurring through heterosexual sex.

Widespread poverty, lack of infrastructure, inconsistent or ineffective prevention programs, expensive or unavailable treatment, and social and political upheaval have contributed to the spread of infection in many countries in that region. As a result the areas hardest hit by HIV/AIDS are often the least able to respond effectively. Because AIDS is most likely to kill people in the prime of life, local and national productivity has been affected seriously. Households with one or more AIDS victims often are strained by the loss of income and the need to provide care and treatment to the afflicted member; young children and the elderly often end up shouldering much of the burden. Local communities also are strained by AIDS deaths because extended families and elderly grandparents with limited resources often take in children orphaned by AIDS.

EASTERN EUROPE AND ASIA

In many countries in Eastern Europe and Asia, HIV infections have been on the rise. The Ukraine experienced a tremendous upsurge in HIV diagnoses after 2000, with a significant incidence in women and the heterosexual population. Russia also has seen an increase in HIV cases, apparently linked to widespread intravenous drug use in its population. In several other countries in Eastern Europe, AIDS is spreading rapidly through intravenous drug users. The epidemic is expected to become more generalized as drug users begin transmitting the virus to their partners.

In many East Asian countries most new infections are transmitted by sex workers, who often cannot insist on condom use. In Thailand, however, a government mandate requiring universal condom use among sex workers has slowed the advance of HIV/AIDS dramatically. Because of the sheer size of many Asian nations, the raw number of HIV-infected individuals in that region is expected by some to overtake that of sub-Saharan Africa.

WOMEN

As HIV infection becomes increasingly generalized in a population, women tend to be affected disproportionately. Of the estimated 39.4 million HIV cases worldwide at the end of 2004, some 17.6 million were women. Almost 75 percent of those women lived in sub-Saharan Africa, where women accounted for 57 percent of HIV infections. Among young women in that region, the gap between male and female infections has been even more striking: It has been estimated that some thirty-six women between the ages of fifteen and twenty-four are infected for every ten men in the same age group.

The increased infection rates among women may be in part biological—evidence suggests that it may be easier for men to transmit HIV to women than vice versa—but it is often also a reflection of the relative status and power of women in a society. Researchers in sub-Saharan Africa, for example, have noted that HIV transmission among women is accelerated in societies in which large numbers of women are not in a position to refuse sex or to insist on safe sex, for example, when they are physically or economically dependent on a male head of household's earnings, gifts from a lover, or earnings from prostitution. In countries stricken by warfare increases in the number of rapes also help spread infection. In societies in which the economic and social status of women has risen, researchers have found that transmission rates tend to drop.

CHILDREN

As of the end of 2004 some 2.2 million children were infected with HIV. Although many children are infected by their mothers, several countries have seen a marked increase in early sexual activity among children, making that population more vulnerable to HIV infection. Additionally, some children are infected in the course of sexual molestation and abuse by adults. In addition to those directly infected by HIV, millions of children worldwide have been orphaned by AIDS. It appears that some 11 million children or more are AIDS orphans; that number was projected to more than triple by 2020.

Societies that have large numbers of orphans are also those which have few institutional structures to help care for them. In sub-Saharan Africa, which is home to some 12 percent of orphans worldwide, extended families traditionally have shouldered the burden of caring for the children of deceased relatives, often straining already tight resources. Members of families that have taken in orphans are more likely to be malnourished and their children and foster children are more likely to be stunted. Orphans often have increased responsibilities at home, are less likely to attend school, and are more likely to do poorly when they do attend. Lack of resources to care for orphaned children probably will affect a region or nation over the long term as malnourished and uneducated children grow into an unskilled adult population with a variety of health problems.

BIBLIOGRAPHY

Barnett, Tony, and Alan Whitehead. 2006. AIDS in the Twenty-First Century: Disease and Globalization. 2nd edition. New York: Palgrave Macmillan.

Maureen Lauder

IV. TREATMENTS AND PREVENTION

Treatment and prevention measures for human immunodeficiency syndrome (AIDS) vary widely from country to country and region to region. The availability of treatment for human immunodeficiency virus (HIV) infection and AIDS is highly variable and largely dependent on national wealth and medical infrastructure. Prevention programs also differ greatly between countries, and in places where the epidemic has been stemmed, that often has been the result of a number of complex and interrelated factors rather than a single prevention strategy.

TREATMENT

In wealthy societies with a strong medical infrastructure and widespread public or private health insurance coverage, treatment of HIV/AIDS often begins shortly after a patient is diagnosed with HIV. In the early stages of the infection, when HIV is present but CD4 counts are high, it is recommended that individuals engage in generally healthy practices: eating well, avoiding exposure to other diseases or infections, and refraining from behaviors, such as smoking, that might weaken the body's immune response. As the CD4 count begins to drop, doctors may begin prophylactic treatment designed to prevent common opportunistic infections. In later stages of the disease antiretroviral (ARV) drug therapy is instituted.

A number of antiretroviral drugs may be used singly or in combination. Single-drug therapy is the least expensive but tends to provoke rapid mutation of the virus. Dual therapy is cheaper than triple therapy but works more slowly and may not be as effective over the long term. Triple therapy is considered a HAART (highly active antiretroviral therapy) regimen, which means that it is capable of reducing the viral load in a significant number of people and remains effective for many years. Triple therapy is able to reduce viral loads quickly to almost undetectable levels. Early HAART treatment reduces the risk of bodily damage during extended periods of high viral load but leaves few options if the patient later develops resistance to the drugs. As a result some doctors choose to begin with single-drug therapy and gradually increase the treatment level.

The cost of antiretroviral drugs is substantial and for many people and nations prohibitive. In wealthier nations AIDS drug therapy can range from $10,000 to $20,000 per patient per year or even more. Political pressure and competition from generics have resulted in substantially lower drug costs in many underdeveloped countries; some ARV triple-drug therapies are available for less than $200 per year. In most instances, however, those prices are still prohibitive for residents of many countries; researchers have estimated that drug costs have to be lowered by at least two-thirds. Moreover, drug therapy requires regular consultations and follow-up visits as well as routine testing of CD4 levels and often tests for drug resistance.

In many developing countries such care is often inaccessible, unavailable, or unaffordable. Poverty tends to make adherence to a drug regimen difficult, and when adherence drops too low, viral resistance develops. ARV drugs provided without adequate funding and support thus may increase mutation and drug resistance in HIV strands. Additionally, patients in poorer regions are far more likely to have secondary infections before ARV treatment begins; treatment for secondary conditions such as tuberculosis and meningitis is often unavailable or unaffordable.

PREVENTION

AIDS prevention programs take two primary tacks: biomedical intervention and behavioral modification. Recommended biomedical interventions include securing the safety of blood and blood products, usually through the screening of donors; treating other sexually transmitted diseases that may increase the risk of HIV infection; and treating HIV-infected pregnant women with ARVs to reduce the risk of transmission to their children. A number of researchers are working to develop an AIDS vaccine, though that task is complicated by the rapid mutation of the virus and appears to be a number of years off. Another possible biomedical intervention would be the development of a microbicide—an agent capable of killing bacteria and viruses—that could be applied vaginally before sexual activity. Microbicides might have an advantage over condoms because they would allow women to assert greater control over their sexual safety, but their development has been given relatively little attention.

Behavioral intervention is used to modify the behaviors and practices of people to reduce the likelihood of transmission. Most behavioral interventions follow the ABC model: abstain, be faithful, use condoms. Prevention programs thus encourage people to wait longer to become sexually active, have fewer partners, and use condoms if they have multiple partners.

The success of those programs has been highly variable. In societies in which resistance to or embarrassment about discussing sexual matters is common, it is difficult to improve knowledge and change attitudes on a wide scale and even more difficult to affect behavior substantially. Condoms are often unavailable or too expensive, and even in places where their use is fairly common, it appears to be highly inconsistent. Moreover, in extremely poor regions where expectations for future standards of living are low there may be little incentive to avoid AIDS. Although those populations may have sufficient knowledge about HIV/AIDS and its transmission, daily concern about finding enough to eat may override any impetus to change a behavior that has only long-term consequences.

Many countries have contained the spread of HIV by altering behaviors and through a biomedical response early in the course of the epidemic. Countries that moved quickly to institute screening of their blood supplies shut down a major vector by which HIV moves from a group of core transmitters to the general population. Targeting core transmitters for particular kinds of interventions also has been successful when done early enough. Gay men in the United States, for example, shifted their behaviors rapidly in the first decade of the epidemic, moving from a culture of free love and promiscuity to one that valued safe sexual practice. Needle exchange programs in several countries have reduced transmission between intravenous drug users significantly, and the Thai government reduced transmission rates by mandating condom use among sex workers.

Countries with fewer resources and more generalized epidemics typically have had more difficulties. Uganda is one of the few that have made great strides; many people credit that success to that nation's multilateral, open response to the issue. The government and its leader instituted conversations on multiple levels and among various agencies, sparking a nationwide awareness of and response to the problem. In Uganda first sexual contact among young people has been delayed, and couples are more likely to be in a monogamous relationship. The example of Uganda has demonstrated that behavioral interventions can work, but that success has been fairly unusual among developing countries.

BIBLIOGRAPHY

Barnett, Tony, and Alan Whiteside. 2006. Aids in the Twenty-First Century: Disease and Globalization. 2nd edition. New York: Palgrave Macmillan.

Green, Edward C. 2003. Rethinking AIDS Prevention: Learning from Successes in Developing Countries. Westport, CT: Praeger.

Usdin, Shereen. 2003. The No-Nonsense Guide to HIV/AIDS. London: Verso.

Maureen Lauder

V. SOCIAL AND POLITICAL RESPONSES

AIDS research, drug development, and treatment and prevention strategies have been advanced, shaped, and sometimes stymied by a complex interaction among social responses, political activism, governmental policy, business interests, and artistic and cultural interventions.

GOVERNMENT POLICY

In the United States the early governmental response to the AIDS crisis is considered by many people to have been deplorable. Despite quick action on the part of the Centers for Disease Control (CDC) to determine the causes and modes of transmission of AIDS, its investigations were crippled by underfunding and inadequate staffing. The National Institutes of Health (NIH) moved at what many considered a maddeningly slow pace in opening up the grant process for funding AIDS research, and most early federal funding was forced on the Department of Health and Human Services by congressional appropriations bills. The Reagan administration was silent on the question of AIDS; Reagan did not give a speech on AIDS until 1987, six years after the CDC began work on tracking and controlling the epidemic and after more than twenty thousand Americans had died of the disease.

Although federal funding increased dramatically, it was often too little too late. Moreover, AIDS prevention and education programs were hampered by guidelines written by and resistance from right-wing members of Congress and the administration. Many public health officials had argued for the importance of large-scale HIV testing, but when the federal government began to move toward the articulation of a national prevention policy, discussions often were stymied by right-wing insistence on mandatory testing coupled with a refusal to agree to anonymous testing or guarantee nondiscrimination toward those who tested positive. Moreover, the administration was deeply resistant to AIDS prevention programs that provided education on safe sex. Believing that such programs advocated promiscuity and homosexual behaviors, the Reagan administration advocated prevention programs that emphasized abstinence and moral behavior.

In 1987 Congress passed legislation banning federal funding for educational materials that indirectly or directly promoted homosexual activity. As late as 1988 most federal AIDS policy came from Congress, which continued to push through ever-larger spending bills and challenge the lack of direction provided by the nation's health agencies.

The 1990s saw increased federal involvement in and funding of the AIDS crisis, including the Ryan White CARE (Comprehensive AIDS Resources Emergency) Act, which provided federal funds for organizations providing community-based treatment. Steps were taken to prevent discrimination against HIV-positive individuals, and a federal court struck down the 1988 restrictions on AIDS educational materials. In 1993 the Clinton administration established the White House Office of National AIDS Policy, which was designed to provide federal leadership and guidance in the national response to AIDS, and in 1999 it established the LIFE (Leadership and Investment in Fighting an Epidemic) initiative to address the global AIDS epidemic. Funding for AIDS research, treatment, and education—both nationally and globally—increased throughout the 1990s, and by 2000 both Congress and the Clinton administration had earmarked significant funding for the HIV response and had created a number of agencies and commissions to help develop and implement future AIDS policies.

In 2003 President Bush announced the President's Emergency Plan for AIDS Relief (PEPFAR), a five-year, $15 billion plan to fight AIDS globally. Although Bush was credited for making AIDS a significant part of his foreign policy, his administration was criticized for endorsing abstinence-only prevention programs. One-third of PEPFAR funding was reserved for agencies promoting abstinence programs. In 2004 new CDC regulations, which had to be followed by any organization receiving federal money for HIV prevention programs, required that educational materials include information on the lack of effectiveness of condom use and prohibit sexually suggestive content; in 1993 the CDC had issued a statement with the NIH and the U.S. Food and Drug Administration (FDA) declaring that condom use was highly effective in curtailing HIV transmission.

After 2000 the United Nations and the World Health Organization took the lead in organizing global treatment and prevention programs. Such undertakings, however, were underfunded and often fell short of their goals.

POLITICAL ACTIVISM

In the face of lackluster U.S. government leadership in the AIDS epidemic, members of the gay community, particularly in urban centers that had been hard hit by HIV, became active participants in the political, medical, and social processes by which research funding was generated and treatment and prevention methods were developed. In the early 1980s much of that effort was at a local level: Gay leaders and activists raised funds, recruited help from local politicians, and set up community treatment centers that pooled resources for and information about treating AIDS patients.

In mid-1980s, frustrated by the slow pace of AIDS research and the inaccessibility of effective treatment methods—particularly drug therapies—to many AIDS patients, gay activists and their supporters began to organize in greater numbers. In 1985 Project Inform was created to provide treatment information and advocacy to members of the San Francisco community, and amfAR (American Foundation for AIDS Research) was organized to fund and promote AIDS research and prevention. In 1986 the AIDS Treatment News was founded as a clearinghouse for new information about experimental and standard treatments. Project Inform and AIDS Treatment News were crucial to the dissemination of new and emerging medical information to AIDS patients and their caregivers and helped create a community with substantial medical and clinical knowledge. The technical expertise of AIDS advocacy groups was a key factor in their intervention in the development, pricing, and accessibility of drug treatments.

In 1987 members of the gay and lesbian community in New York formed ACT UP, the AIDS Coalition to Unleash Power, as a mechanism for forcing change in the social and political response to AIDS. Insisting on the importance of access to clinical trials for people with AIDS, ACT UP and other organizations took aim at the slow drug approval process and restrictive guidelines for clinical trials followed by the FDA. In the late 1980s and early 1990s ACT UP staged demonstrations in a variety of venues, including on Wall Street to protest the exorbitant price of the new antiviral drug AZT (azidothymidine), at the post office on the day tax returns were due to gain increased media coverage and raise awareness of the AIDS crisis, at St. Patrick's Cathedral to protest the stand of the Catholic Church on contraceptive use, and at the offices of the Hearst Corporation, whose publication Cosmopolitan in 1988 had published an article suggesting that women were not at risk of AIDS transmission during heterosexual sex.

As the nature of the AIDS epidemic changed in the 1990s, so too did the kind of activism it inspired. As activism, advocacy, and the availability of antiretroviral drugs and triple therapy began paying off in the form of a decreased death rate among the most severely affected population, homosexual men, the center of political and social activism shifted to other groups that were experiencing increased infection rates. As a result of the increased prevalence of HIV among African-Americans, activist groups became more likely to focus on improving education, treatment, and access to drugs and clinical trials among minority and low-income groups.

The growing dimensions of the AIDS crisis in developing nations, particularly in sub-Saharan Africa, engendered an increased emphasis on global aspects of AIDS treatment and prevention. Some organizations, such as Health GAP (Global Access Project), formed in 1999, and the Global AIDS Alliance, founded in 2001, were created specifically to deal with AIDS on a global level and generally advocated full funding of the United Nations' Global Fund to Fight AIDS, TB, and Malaria; debt cancellation for third-world nations; better trade policies; improved accessed to treatment; and the development of more effective prevention mechanisms. Such groups often formed coalitions with global trade activists, public health organizations, and domestic AIDS organizations, including ACT UP.

DRUG DEVELOPMENT

The activism of the gay community and the technological savvy of many of its organizations were instrumental in reforming the FDA's approval process and policies on clinical trials. Doctors, AIDS patients, and supporters in the 1980s had regarded the long and slow approval process of the FDA, which averaged eight years in the early 1980s, with increasing frustration. The few drug treatments that were available were limited to clinical trials, in which scientific principles demanded double-blind studies in which half the participants in a trial were given placebos. Additionally, policies designed to protect trial participants severely limited the eligibility of many AIDS patients. Because of the rapid progression of the disease, many doctors and patients felt that the only hope lay in access to experimental drugs. AIDS activist organizations became increasingly vocal about the need to speed both drug development and the approval process, and networks of activists, scientists, doctors, and AIDS patients began to work through alternative channels, exchanging drugs, expertise, and anecdotal evidence about new treatment possibilities.

Activists vocally challenged drug companies and scientists to explore new therapies and means of testing and distributing them while applying increased pressure on the FDA to take charge of the response to the epidemic. Agitation against the FDA sparked congressional hearings in 1987. In 1988, when the FDA commissioner announced that only two drugs could be approved before 1991, networks of AIDS activist amassed enough information to challenge that assertion. A protest at the FDA headquarters by twelve hundred demonstrators received extensive media coverage and initiated a substantial loosening of FDA regulations, including approval of the importation of unapproved drugs for those with life-threatening illnesses.

From the beginning drug prices were exceedingly high and generated a great deal of concern among activists, which was exacerbated by secrecy surrounding development costs. The first antiviral drug to be approved by the FDA, Zidovudine (AZT), cost between $8,000 and $10,000 per patient per year, a price that seemed exorbitant to many, particularly in light of the fact that AZT originally had been developed as a cancer therapy with federal funding. Activists protested against the drug's maker, Burroughs-Wellcome, on Wall Street, and the company was lobbied by a large coalition of activists and legislators. In response, the company reduced its pricing by 20 percent.

Drug companies were criticized for inflating prices and restricting the access of poorer countries to cheaper generic drugs. International pressure and global health initiatives led to significantly decreased drug pricing and wider access to drug therapy in developing nations, though most researchers continued to believe that the price of drugs was far too high to allow widespread access in poorer countries.

SOCIAL AND CULTURAL REACTIONS

In the first half of the 1980s, while AIDS was ravishing homosexual men, the rest of the population of the United States took little note. The desire to believe that AIDS was a gay disease was strong and resulted in minimal media coverage of AIDS outside the gay community. In 1985, however, when Rock Hudson's diagnosis of AIDS became public, the nation was electrified. Almost overnight AIDS became a widespread point of concern for gay and straight populations alike. The illness of Ryan White, a young boy who had been infected with HIV as an infant, generated further mainstream public concern.

HIV and AIDS engendered a great deal of artistic and cultural output after that time. In 1985 An Early Frost represented the first major network broadcast of a film dealing with AIDS. That film was followed by a number of mainstream films and television movies that dealt with AIDS and HIV, including Parting Glances (1986), The Ryan White Story (1986), Longtime Companion (1990), and Philadelphia (1993). A 1989 Bob Huff mockumentary, Rockville Is Burning, chronicled AIDS activism, and in the 1990s a number of playwrights wrote plays that later were turned into general-release and cable films, including Love! Valour! Compassion! by Terrance McNally, Jeffrey by Paul Rudnick, and Angels in America by Tony Kushner. Randy Shilts's And the Band Played On (1988), which depicted the early years of the AIDS epidemic, became an HBO movie in 1993. In 1996 the musical Rent broke barriers by featuring the controversial subjects of AIDS and sexuality on Broadway.

In 2003 Daniel Bort premiered a short film called Bugchaser at the Austin Gay and Lesbian Film Festival; the short appeared with a documentary by Louise Hogarth titled The Gift. Both films concerned a practice known as bugchasing, in which gay men attempt to contract HIV from HIV-positive men. The phenomenon appears to be quite rare, though it has generated some mainstream attention. Psychological reasons for bugchasing may involve survivor's guilt, a belief that sharing the virus creates intimacy, the excitement generated by the danger of infection, and a general relief of anxiety at having one's HIV status definitively established.