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Following on from this year’s Clinical Placement Competition, asking medical students “What does being a doctor mean to you?” – we are hoping to broaden our understanding of the medical profession, and appreciate exactly what being a doctor means in practice. What stories of highlights, difficulties, and uncensored advice can current doctors pass on, and how can we help those starting out?

The post What does being a doctor mean to you? appeared first on OUPblog.

Following on from this year’s Clinical Placement Competition, asking medical students “What does being a doctor mean to you?” – we are hoping to broaden our understanding of the medical profession, and appreciate exactly what being a doctor means in practice. What stories of highlights, difficulties, and uncensored advice can current doctors pass on, and how can we help those starting out?

The post What does being a doctor mean to you? appeared first on OUPblog.

When I was in the eighth grade I wrote a story about a vampire. He was young, roughly my age, entering puberty, entering vampirism. He ached to touch, to kiss, to drink in the loveliness of what he hungered for, but to do so was to admit his monstrosity and to kill what he loved. He feared himself and hated himself.

I don’t remember anything else about that story except how terrified I was to show it to anyone, lest they notice what I was saying about desire between the lines.

But I did show it to my English teacher. She had been sensitive and supportive of the stories I’d written, no matter how weird and violent. We talked about the story for a while. Now, more than 25 years later, all I remember is that she spoke—casually and not in any way judgmentally, without lingering—about the vampire’s desires being a powerful element of the story because they could also be read as sexual desires.

“No,” I replied quickly, lip trembling, “he’s just a vampire. Vampires have to drink blood or they die.”

She smiled and nodded. “Of course, of course,” she said.

You may have heard about the recent Pew Research Center study that shows millennials (born roughly between 1980 and 1995) fleeing Christian churches to occupy the ranks of the “nones,” those professing no religious affiliation. But how much do you know about the decade that gave birth to the millennial generation?

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World AIDS Day is a global campaign that raises awareness and funds for the estimated 34 million people living with HIV, and also commemorates the 35 million people who have died of the virus. The first one was held in 1988 and, as such, it is the longest running health day. Despite many medical advances, HIV remains one of the most devastating epidemics in human history. The search for a cure or vaccine for HIV continues, with new discoveries being published all the time. We’ve created a reading list of journal articles and books so that you can read some of the latest, cutting-edge texts on the subject:

‘Diagnosing acute and prevalent HIV-1 infection in young African adults seeking care for fever: a systematic review and audit of current practice‘, published in International Health
This article investigates the extent to which HIV-1 infection is considered in the diagnostic evaluation of febrile adults in sub-Saharan Africa (SSA) through a systematic review of published literature and guidelines in the period 2003–2014.

‘Delivering TB/HIV services in Ghana: a comparative study of service delivery models‘, published in Transactions of the Royal Society of Tropical Medicine & Hygiene
Three hospitals with different delivery models were identified and a survey of TB cases registered between June 2007 and December 2008 conducted.

‘HIV and HIV treatment: effects on fats, glucose and lipids‘, published in British Medical Bulletin
This review provides a brief summary of our current understanding of the epidemiology, clinical presentation and therapeutic approaches of what is termed ‘the HIV-associated lipodystrophy syndrome’ and of HIV-associated lipid and glucose metabolic abnormalities.

‘Increased Morbidity in Early Childhood Among HIV-exposed Uninfected Children in Uganda is Associated with Breastfeeding Duration’, published in Journal of Tropical Pediatrics
Studies in Sub-Saharan Africa have shown that HIV-exposed uninfected children (HEU) have an increased risk of morbidity and mortality compared with HIV-unexposed uninfected children (HUU). This article looks at how breastfeeding affects the relationship between HIV-exposure and morbidity and mortality.

‘Randomized community-level HIV prevention intervention trial for men who drink in South African alcohol-serving venues’, published in European Journal of Public Health
South African alcohol-serving establishments (i.e., shebeens) offer unique opportunities to reduce HIV risks among men who drink. Read the study in full

‘Primary Effusion Lymphoma (PEL) in the absence of HIV infection – Clinical presentation and management’, published in QJM
To clarify treatment issues in HIV-negative PEL patients, this report looks at two such patients who represent two opposing ends in the spectrum of treatment and review the literature regarding treatment options and patient outcomes.

‘Early diagnosis and treatment of HIV infection: magnitude of benefit on short-term mortality is greatest in older adults’, published in Age and Ageing
The number and proportion of adults diagnosed with HIV infection aged 50 years and older has risen. This study compares the effect of CD4 counts and anti-retroviral therapy (ART) on mortality rates among adults diagnosed aged ≥50 with those diagnosed at a younger age.

‘Attitudes about providing HIV care: voices from publicly funded clinics in California’, published in Family Practice
As the enactment of health care reform becomes a reality in the USA, it has been widely predicted that HIV+ patients will increasingly be cared for by primary care physicians (PCPs), many of whom lack the experience to deliver full-spectrum HIV care.

‘Community-based family-style group homes for children orphaned by AIDS in rural China: an ethnographic investigation’, published in Health Policy and Planning
As the number of children orphaned by AIDS (Acquired Immunodeficiency Syndrome) has reached 17.3 million, most living in resource-poor settings, interest has grown in identifying and evaluating appropriate care arrangements for them.

‘Physician communication behaviors from the perspective of adult HIV patients in Kenya’, published in International Journal for Quality in Health Care
This study looks at the perceived physician communication behaviors and its association with adherence to care, among HIV patients in Kenya.

‘Glycodendrimers prevent HIV transmission via DC-SIGN on dendritic cells’, published in International Immunology
The authors design molecules that bind dendritic cells and block HIV-1 binding, thereby stopping transport to CD4+ T cells and preventing virus transmission.

‘Clinical Outcomes of AIDS-related Burkitt Lymphoma: A Multi-institution Retrospective Survey in Japan’, published in Japanese Journal of Clinical Oncology
Highly intensive chemotherapy would bring a high remission rate and prolonged overall survival for patients with AIDS-related Burkitt lymphoma.

‘Interview with Dr. Deborah Cotton about HIV Treatment and the Early Years of the Epidemic’, published in Open Forum Infectious Diseases
In this podcast, Editor-in-Chief Paul Sax, MD, speaks with colleague Deborah Cotton, MD, MPH, about the recent OFID article “A Glimpse of the Early Years of the Human Immunodeficiency Virus Epidemic: A Fellow’s Experience in 2014.” Drs. Sax and Cotton compare their experiences in Boston with those of the authors at Atlanta’s Grady Hospital, which still cares for a large number of patients with untreated HIV

‘Improvements in HIV Care Engagement and Viral Load Suppression Following Enrollment in a Comprehensive HIV Care Coordination Program’, published in Clinical Infectious Diseases
Gaps in the HIV care continuum jeopardize the success of the National HIV/AIDS Strategy. A pre-post analysis of 1-year outcomes among New York City Ryan White Care Coordination clients demonstrated improvements in HIV care engagement and viral suppression.

‘Frailty in People Aging With Human Immunodeficiency Virus (HIV) Infection’, published in The Journal of Infectious Diseases
The increasing life spans of people infected with HIV reflect enormous treatment successes and present new challenges related to aging. This review explains how frailty has been conceptualized and measured in the general population, critically reviews emerging data on frailty in people with HIV infection, and explores how the concept of frailty might inform HIV research and care.

‘Factors Associated With Retention Among Non–Perinatally HIV-Infected Youth in the HIV Research Network’, published in Journal of the Pediatric Infectious Diseases Society
The transmission of HIV among youth through high-risk behaviors continues to increase. Retention in care is associated with positive clinical outcomes and a decrease in HIV transmission risk behaviors, but this retrospective analysis shows alarmingly high proportions of newly enrolled non-perinatally HIV-infected youth were not retained.

‘Sex differences in atazanavir pharmacokinetics and associations with time to clinical events: AIDS Clinical Trials Group Study A5202′, published in Journal of Antimicrobial Chemotherapy
This new research from the Journal of Antimicrobial Chemotherapy examines whether HIV-1 antiretroviral exposure and clinical response varies between males and females. The study of 786 participants revealed that average atazanavir clearance was slower in females than males.

Oxford Textbook of Medicine, edited by David A. Warrell, Timothy M. Cox, and John D. Firth
Giving an unparalleled integration of HIV/AIDS basic science and clinical practice, this chapter is taken from the Oxford Textbook of Medicine, the most comprehensive, authoritative, and international medical textbook available.

Oxford Handbook of Genitourinary Medicine, HIV, and Sexual Health, edited by Richard Pattman, Nathan Sankar, Babiker Elawad, Pauline Handy, and David Ashley Price
Taken from the Oxford Handbook of Genitourinary Medicine, HIV, and Sexual Health, this chapter provides evidence based, practical information on HIV/AIDS and details the pathogenesis of HIV infection.

Fitness For Work, edited by Keith T Palmer, Ian Brown, and John Hobson
Comprehensive coverage of occupational health issues relating to HIV. While antiretroviral treatment (ART) has increased survival, many HIV-infected people remain symptomatic, either through drug side effects, HIV-related illnesses, or the psychological morbidity associated with the diagnosis and disease. All of these factors can have a significant effect on an individual’s ability to find, and remain in, work.

Oxford Handbook of Tropical Medicine, edited by Andrew Brent, Robert Davidson, and Anna Seale
This guide to HIV is from the Oxford Handbook of Tropical Medicine, a definitive resource for medical problems in tropical regions, and low-resource countries. Covering diagnosis and associated diseases, through to treatment and prevention strategies, this chapter is a comprehensive guide to clinical practice.

Challenging Concepts in Infectious Disease, edited by Amber Arnold and George Griffin
Part of a compendium of challenging cases, this chapter examines prevention of mother-to-child HIV transmission in a case where a 26-year-old Nigerian lady presented with a week-long history of worsening fever, cough, and shortness of breath. She was 28 weeks into her first pregnancy, which had otherwise been uneventful and had included a negative routine antenatal test for HIV at 12 weeks’ gestation.

Virus Hunt, by Dorothy H. Crawford
The hunt for the origin of the AIDS virus began over twenty years ago. It was a journey that went around the world and involved painstaking research to unravel how, when, and where the virus first infected humans.

The Aids Generation, by Perry Halkitis
Perry Halkitis narrates a story of HIV survival, based on his interviews with the AIDS Generation, those gay men who came of age at the onset of the epidemic, prior to any effective treatments. This chapter provides a historical and epidemiological background of the HIV/AIDS epidemic as it has manifested itself over the last three decades.

African Health Leaders, edited by Francis Omaswa and Nigel Crisp
Written by Africans, who have themselves led improvements in their own countries, the book discusses the creativity, innovation and leadership that has been involved tackling everything from HIV/AIDs, to maternal, and child mortality and neglected tropical diseases.

Featured image credit: World AIDS Day, White House, by tedeytan. CC-BY-SA-2.0 via Flickr.

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By Perry N. Halkitis

On 25 May 2014 and nearly 30 years after first appearing on the stage, Larry Kramer’s The Normal Heart will be aired as a film on HBO. This project, which has evolved over the course of the last three decades, documents those first few harrowing years of the AIDS epidemic in New York City. The Normal Heart debuts at a time when much attention is being cast upon the early days of AIDS and the lives of gay men, who survived the physical and emotional onslaught of this disease in a society that often shunned us because we were gay and because we were afflicted with this disease.

Now a generation of gay men, my generation—the AIDS Generation—stands proudly as testament to our individual and collective resilience which has brought us all into middle age. Certainly there have been huge hurdles along the way—too many deaths to enumerate, the havoc that the complications of this disease wreaked on our bodies, the lack of support. Even today, darkness and disrespect lurks in every corner, and no one is immune. For some in our society, identifying what is wrong with us as gay men comes to easily. We are reminded of it daily as right wing zealots fight against marriage equality, as young boys take their lives. Despite these conditions, despite the inaction of our national and local politicians, and despite a large yet ever-shrinking segment of our society that continues to view us as weak and sick, we stand together as a testament to the fortitude of our bodies, minds, and spirits.

The theme of resistance or resilience permeates the words, the thoughts, and the actions of the protagonists in The Normal Heart and many depictions of the AIDS epidemic.

Taylor Kitsch as GMHC President President Burce Niles in HBO’s The Normal Heart. (c) HBO via thenormalheart.hbo.com

Behavioral and psychological literature has attempted to delineate sources of resilience. Dr. Gail Wagnild posits that social supports in the form of families and communities foster resilience in individuals. I also adhere to this idea. Although the sources of resilience are still debated in the literature, there is general agreement that resilience is a means of maintaining or regaining mental health in response to adversity the ability to respond to and/or cope with stressful situations such as trauma, conditions that characterize the life of the men of the AIDS Generation.

For many of the men of the AIDs Generation, grappling with their sexuality was closely tied to the development of their resilience. In other words, resilience developed in their childhoods as young men grappling with their sexuality as stated by Christopher: “I also think that wrestling with my own sexuality and trying to navigate through that in my teenage years taught me how to just ‘keep pushing’ and to do what needed to be done.” Some, including myself, found support among our families. Even if parents were loving and supportive, this did not ameliorate the burdens experienced being raised in a heteronormative and often-discriminatory world in which men were portrayed as weak, effeminate, and sickly.

As we watch The Normal Heart, we will be reminded of those dark, confusing early days of the epidemic. And while we must celebrate the resilience of a generation of gay men to fight this disease, we must also be reminded of our obligation to create a better world for a new generation of gay men, who despite our social and medical advances, need the love and support of their community of elders as the navigate the course of their lives.

Perry N. Halkitis, PhD, MS, MPH is Professor of Applied Psychology and Public Health (Steinhardt School), and Population Health (Langone School of Medicine), Director of the Center for Health, Identity, Behavior & Prevention Studies, and Associate Dean (Global Institute of Public Health) at New York University. Dr. Halkitis’ program of research examines the intersection between the HIV epidemic, drug abuse, and mental health burden in LGBT populations, and he is well known as one of the nation’s leading experts on substance use and HIV behavioral research. He is the author of The AIDS Generation: Stories of Survival and Resilience. Follow him on Twitter @DrPNHalkitis.

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By Chandra Ford

The seventh of February will mark the thirteenth National Black HIV/AIDS Awareness Day. Despite the fact that blacks make up only 14% of the US population, the CDC reports that blacks accounted for 44% of all newly reported HIV infections in 2009, the HIV infection rate among Latinos was nearly three times as high as that of whites, and 1 in 4 persons living with HIV/AIDS in the USA is an older adult (50+ years old).

The CDC reported that 1,600 White, 450 Black, and 300 Latino men aged 50 or older acquired HIV in 2009 through unprotected sex with other men. In other research conducted among senior-housing residents, investigators learned that 42% of residents had been sexually active within the previous six months. One third of the sexually active residents reported two or more partners during that period, but only 20% had regularly used condoms.

Alarmingly, older adults are prone to be disproportionately diagnosed in the late stages of HIV disease. Many older Americans who seek services in public health venues do not undergo testing for HIV infection, some due to mistrust in the government. Researchers in a recent study found among the 226 participants, 30% reported belief in AIDS conspiracy theories, 72% reported government mistrust, and 45% reported not undergoing HIV testing within the past 12 months.

Among African Americans, endorsements of AIDS conspiracy theories stem from historical experiences with racism and medical discrimination, although knowledge of African Americans’ experiences may lead members of other racial/ethnic groups to endorse such theories.

Making HIV testing routine in public health venues may be an efficient way to improve early diagnosis among at-risk older adults. Alternative possibilities include expanding HIV testing in nonpublic health venues. Finally, identifying particular sources of misinformation and mistrust would appear useful for appropriate targeting of HIV testing strategies in the future.

Key calendar dates:
7 February 2013               National Black HIV/AIDS Awareness Day
19 May 2013                       Asian Pacific Islander HIV/AIDS Awareness Day
27 June 2013                     National HIV Testing Day
15 October 2013               National Latino HIV/AIDS Awareness Day
1 December 2013              World AIDS Day

For further reading:

• AIDS.gov
• CDC on HIV/AIDS
• “Belief in AIDS-Related Conspiracy Theories and Mistrust in the Government” by Chandra L. Ford et al. in The Gerontologist

Dr. Chandra Ford is an assistant professor in the Department of Community Health Sciences at UCLA. Her areas of expertise are in the social determinants of HIV/AIDS disparities, the health of sexual minority populations and Critical Race Theory. Ford has received several competitive awards, including the Ruth L. Kirschstein National Research Services Award (an individual dissertation grant) from the National Institutes of Health and a North Carolina Impact Award for her research contributions to North Carolinians. Her most recent research, “Belief in AIDS-Related Conspiracy Theories and Mistrust in the Government” in The Gerontologist, is available to read for free for a limited time.

The Gerontologist, published since 1961, is a bimonthly journal (first issue in February) of The Gerontological Society of America that provides a multidisciplinary perspective on human aging through the publication of research and analysis in gerontology, including social policy, program development, and service delivery. It reflects and informs the broad community of disciplines and professions involved in understanding the aging process and providing service to older people.

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The post HIV/AIDS testing: suspicion and mistrust among Baby Boomers appeared first on OUPblog.

By Chandra Ford

February 7th will mark the thirteenth National Black HIV/AIDS Awareness Day.  Despite the fact that blacks make up only 14% of the US population, the CDC reports that blacks accounted for 44% of all newly reported HIV infections in 2009, the HIV infection rate among Latinos was nearly three times as high as that of whites, and 1 in 4 persons living with HIV/AIDS in the USA is an older adult (50+ years old).

The CDC reported that 1,600 White, 450 Black, and 300 Latino men aged 50 or older acquired HIV in 2009 through unprotected sex with other men.   In other research conducted among senior-housing residents, investigators learned that 42% of residents had been sexually active within the previous six months. One third of the sexually active residents reported two or more partners during that period, but only 20% had regularly used condoms.

Alarmingly, older adults are prone to be disproportionately diagnosed in the late stages of HIV disease.  Many older Americans who seek services in public health venues do not undergo testing for HIV infection, some due to mistrust in the government. Researchers in a recent study found among the 226 participants, 30% reported belief in AIDS conspiracy theories, 72% reported government mistrust, and 45% reported not undergoing HIV testing within the past 12 months.

Among African Americans, endorsements of AIDS conspiracy theories stem from historical experiences with U.S. racism and medical discrimination.  Although knowledge of African Americans’ experiences may lead members of other racial/ethnic groups to endorse such theories.

Making HIV testing routine in public health venues may be an efficient way to improve early diagnosis among at-risk older adults. Alternative possibilities include expanding HIV testing in nonpublic health venues. Finally, identifying particular sources of misinformation and mistrust would appear useful for appropriate targeting of HIV testing strategies in the future.

Key calendar dates:

February 7, 2013National Black HIV/AIDS Awareness Day

May 19, 2013                      Asian Pacific Islander HIV/AIDS Awareness Day

June 27, 2013                    National HIV Testing Day

October 15, 2013              National Latino HIV/AIDS Awareness Day

December 1, 2013            World AIDS Day

For further reading:

AIDS.gov

CDC on HIV/AIDS

The Gerontologist: Belief in AIDS-Related Conspiracy Theories and Mistrust in the Government by Chandra L. Ford et al.

Preventative Medicine: Do blacks believe that HIV/AIDS is a government conspiracy against them? (Klonoff EA, Landrine H).

Journal of Acquired Immune Deficiency Syndromes: Individual, contextual, and social network factors affecting exposure to HIV/AIDS risk among older residents living in low-income senior housing complexes (Schensul JJ, Levy JA, Disch WB).

Dr. Chandra Ford is an assistant professor in the Department of Community Health Sciences at UCLA. Her areas of expertise are in the social determinants of HIV/AIDS disparities, the health of sexual minority populations and Critical Race Theory. Ford has received several competitive awards, including the Ruth L. Kirschstein National Research Services Award (an individual dissertation grant) from the National Institutes of Health and a North Carolina Impact Award for her research contributions to North Carolinians.  Her most recent research, “Belief in AIDS-Related Conspiracy Theories and Mistrust in the Government” in The Gerontologist, can be accessed here.

The Gerontologist, published since 1961, is a bimonthly journal (first issue in February) of The Gerontological Society of America that provides a multidisciplinary perspective on human aging through the publication of research and analysis in gerontology, including social policy, program development, and service delivery. It reflects and informs the broad community of disciplines and professions involved in understanding the aging process and providing service to older people.

 

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1 December is World AIDS Day. Here Kenneth Mayer, MD, explains what makes the 2012 observance different from all those before – and, hopefully, those to come. Dr. Mayer is Co-Editor of Clinical Issues in HIV Medicine, Co-Chair of the HIVMA/IDSA Center for Global Health Policy’s Scientific Advisory Committee, founding Medical Research Director of Fenway Health, a visiting professor at Harvard Medical School, and an attending physician and director of HIV Prevention Research at Beth Israel Deaconess Hospital in Boston.

By Kenneth Mayer

Last year, on World AIDS Day, U.S. President Barack Obama set ambitious goals to reach more people with treatment and fundamental prevention. Echoing U.S. Secretary of State Hillary Clinton’s call for an “AIDS-free generation,” he envisioned a tipping point in a 30-year battle to subdue the world’s costliest epidemic.

This World AIDS Day, the administration’s release of a global AIDS roadmap takes the vision into practice. Outlining the U.S. government’s commitment to apply research to reality, with the efforts of affected countries and other donors, it is as much a promise as a challenge.

The plan serves as a solid indication that three decades into a struggle that began without direction, and that sometimes seemed futile, the U.S. has set a course to continue the pace it has achieved in the last year, while giving partners encouragement and reason to match those efforts. It underscores, at a time of worldwide economic challenges and competing concerns, that this investment will yield gains, this is a battle that can be won, and this is not the time to stand still.

The global health community and its researchers, policy makers, donors, field workers, and affected populations know what to do to begin to end this epidemic, and now need to do it. To realize the magnitude of this opportunity, compare where we are now to where we were 31 years ago when fear, ignorance, and prejudice stymied responses while AIDS’ death toll multiplied exponentially as it circled the world. With little clue as to how the virus was transmitted from 1981 to 1985 rumors and mistrust also spread. Through epidemiological research we overcame the terror of those years, understanding that without blood exchange or intimate sexual contact the virus was not readily transmitted. Researchers’ discovery in the mid-1990s that combinations of antiretroviral drugs could arrest the virus changed it from a death sentence into a manageable disease, for many. Shamefully, the cost of those drugs kept the benefit of that breakthrough from being shared in the poor countries where relief was most needed. Finally, in the last decade, with the importation of generic medicines, the establishment of The Global Fund to Fight AIDS, Tuberculosis and Malaria, and the President’s Emergency Plan for AIDS Relief, work to confront the epidemic emerged from laboratories and wealthy countries, to what are now some of the most formidable front lines.

Yet we continue to fall short. We know that injection drugs are a major vector for HIV transmission, but many countries punish users of those drugs rather treat them with opioid substitution therapy and protect them with needle exchange programs. Homophobia and criminalization of gay sex threaten efforts to even count the toll in countries where HIV is most prevalent. Programs to prevent transmission of the virus from mothers to infants are hobbled by constraints on family planning commodities. Sex workers are marginalized by efforts that exclude their input. Treatment and prevention programs fail to reach people with physical and mental disabilities. While tuberculosis is the primary killer of people living with HIV, screening and treatment for the two diseases remain unlinked. While donors have imported some of the means to fight the epidemic, too often they have imported answers as well, failing to allow for the diversity of needs and affected populations in different countries.

With a plan that includes the needs of all affected populations, the tools we have now will be powerful. The study known as HPTN 052 showed that early initiation of antiretroviral therapy could decrease the transmission of HIV in couples in which only one partner was HIV-positive by 96 percent. The use of an antiretroviral drug as pre-exposure prophylaxis in combination with other risk-reduction measures, was shown to be effective in protecting men who have sex with men, and heterosexual men and women from acquiring the virus.

These discoveries will be useless, however, if people who need medicine to save their lives don’t get it. While eight million people are getting treatment, 34 million are living with the virus. Maintaining the momentum of treatment coverage that the U.S. has achieved in the last year in Africa is imperative to meet the original humanitarian mission of the response as well as to continued progress.

Then, with shared responsibility and political will, the next World AIDS Day can be one on which we can see the end of the road, far ahead but certain, when we can stop the further spread of HIV.

To raise awareness of World AIDS Day, Dr. Mayer and Daniel Kuritzkes, MD (Co-Editor of Clinical Issues in HIV Medicine) have selected recent, topical articles, which have been made freely available for a limited time by  The Journal of Infectious Diseases and Clinical Infectious Diseases. Both journals are publications of the HIV Medicine Association and the Infectious Diseases Society of America.

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Image credits: World AIDS Day press images via worldaidsday.org media centre.

On World AIDS Day 2011, we speak with Dr Martin S. Hirsch, MD, FIDSA to find out the latest news on the global fight against AIDS. Dr. Hirsch is editor-in-chief of The Journal of Infectious Diseases, professor of medicine at Harvard Medical School, professor of infectious diseases and immunology at the Harvard School of Public Health, and a physician at Massachusetts General Hospital. – Nicola

Q: Thirty years after the first reports of AIDS, why is HIV/AIDS research still important?
A: Although we have made enormous progress in developing effective combination antiretroviral therapies to control HIV infection, we have been far less successful in preventing infection. Thus, in the US, as well as in the rest of the world, there are more people living with HIV infection today than ever before; worldwide, this number is over 30 million. Many individuals who are infected do not know that they are and, thus, they continue to spread virus to contacts by sexual contact, needle sharing, or mother-to-child transmission. We are not near having an effective preventative HIV vaccine, nor is a cure for those already infected on the immediate horizon. The risk of emerging drug-resistant viruses is also always with us. For all these reasons and more, it is essential that research efforts continue until we can say that HIV has been eradicated or is no longer a public health problem in the world.

Q: What notable important discoveries or research findings have there been in the field recently?
A: In my view, the most notable research advances in the field recently have been in efforts to prevent new HIV infections by using treatment as prevention and pre-exposure prophylaxis. Studies published this year by Myron Cohen and colleagues have shown in placebo-controlled studies that by treating HIV-infected members of discordant couples (one infected, one not), new infections can be reduced by up to 96 percent. This emphasizes the need for early recognition of infections and early treatment. It has also been established that pre-exposure prophylaxis with antiretroviral drugs can reduce transmission in high-risk populations, whether they be heterosexual or men who have sex with men. Pre-exposure prophylactic regimens have taken the form of oral therapy or topical administration of vaginal microbicides. The challenge now is to find ways to implement these strategies worldwide to prevent new infections in cost-effective ways.

Q: What should the public take away from these findings?
A: The public should be aware that only by early recognition of infection can we reduce the scourge of continued HIV transmission and disease. The US Centers for Disease Control and Prevention and other organizations have indicated the need for more routine testing of all populations who enter medical care in the US, and gradually our states and other public health authorities are implementing these suggestions. Nevertheless, there are still thousands of individuals in the US and millions in the world who do not know they are infected and who continue to spread virus. The public should insist on more HIV testing with appropriate measures to protect confidentiality among those tested. It is also critical that efforts to make effective therapies available to those in need not be curtailed in these times of budget stringency. Cuts at this time would reap bitter harvests in years to come.

Q: What do you see as the priority areas for future HIV/AIDS research? Where will the next great advances be?
A: There are several priority areas for HIV research in the years ahead. These include:

- Continued efforts to develop safe and effective prophylacti

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By Justyna Zajac and Michelle Rafferty

“Growth of Overt homosexuality in City Provokes Wide Concern”

-New York Times (headline in 1963)

The world recoiled when the gay community started receiving credit for its influence in fashion and culture, but at least, according to Christopher Reed, they were being acknowledged. In his new book Art and Homosexuality: A History of Ideas, Reed argues that for some time the professional art world plain ignored the gay presence.

We had the chance to speak with Reed recently at his Williams Club talk, where he laid out the tumultuous relationship between art and activism. Below we present a few of the controversial things we learned.

1.) Art that didn’t get a chance…

During the most formative years of the gay rights movement in the 70s and on through the late 80s, arts publications and professionals, and even museums like the Museum of Modern Art, ignored imagery associated with gay and lesbian identity. Imagery like the graffiti pictured below which emerged in urban areas during the 70s:

Grafitti on “The Rocks,” Lincoln Park, Chicago, mid-1990s.

According to Reed, “These sites of visual history were destroyed with no organized documentation when rising property values prompted local governments to reclaim these areas.”

2.) Censorship…

Is right for people to ban art today? Even if it’s in the imaginary town of Pawnee, Indiana? Reed surprised us with his answer, making us consider that there’s actually a worse kind of censorship. Listen below to hear what he said.

Transcript:

Censorship is an interesting question because there are overt examples of censorship like what just happened with the Hide/Seek show and the David Wojnarowicz piece, where particular politicians make a statement to their constituency by removing something that’s on exhibition. And then the kind of thing that you’re talking about where institutions simply don’t show things or don’t buy things – in the case of libraries – or don’t do things or don’t let particular people in, which often doesn’t read as censorship because people never realize what they could be seeing or could be reading, or could be going on, because the institution has already created a kind of logic in which that kind of thing doesn’t exist.

And so in a lot of ways I actually think that’s the most dangerous kind of censorship because people aren’t aware of it and they can’t make a

I'll admit it - my youthful competition for the Travelocity Travel for Good scholarship is beating the pants off me. HEEEEELPPPPP! I need lots of people voting daily so that I can win the opportunity to help babies, elders and people with HIV/AIDS in Salvador, Brazil. You can vote here via the link, but even better would be to join my daily email list. How it works: I send you an email with the voting link every morning, you click twice and you're done. It takes TEN SECONDS (I clocked it).

Here's the link: Send Andi to Brazil. Or, just shoot me a quick email and I'll put you on the daily email. My email is [email protected]

Thank you so much, or, as they say in Brazil, muito obrigada.
Gratefully,
Andi

Josh Sides is the Whitsett Professor of California History and the Director of the Center for Southern California Studies at California State University, Northridge.  His most recent book, Erotic City: Sexual Revolutions and the Making of Modern San Francisco, looks at America’s capital of sexual libertinism and a potent symbol in its culture wars.  In the excerpt below Sides introduces the history of AIDS in San Francisco.

Selma Dritz was the last person you would expect to be an expert on the outlandish gay sex scene South of Market.  Born in Chicago to Russian parents in 1917, Dritz finished medical school in 1941 and became the chief resident of the Cook County Contagious Disease Hospital before retiring in 1947 to raise her three children.  She and her family moved to San Francisco in 1949, where they bought a house in the sleepy southwestern edge of the outer Sunset District, and Dritz became a stay-at-home mom for almost two decades.  Once her kids were grown, she got a master’s degree in public health at Berkeley in 1967 and quickly accepted a post as assistant director of disease control for the SFDPH.  As a doctor and a mother, she already knew the terrain well.  “At first,” she later recalled, the work “was the usual standard chasing down of measles, mumps, whooping cough, making sure that children in school had their proper immunizations.”

Very little in Dritz’s daily work routine changed during her first decade at the SFDPH.  To be sure, rates of syphilis and gonorrhea increased, “but that didn’t bother anybody; one shot of penicillin and you were cured.”  But by the end of 1977, Dritz remembered, there was a “complete change”: the number of enteric diseases, typically associated with the fecal contamination of food, escalated dramatically.  Because virtually all of the patients were men, she knew that “these cases weren’t coming from eating establishments.”  Instead, she came to learn, they had been transmitted through the exotic sex taking place in South of Market bathhouses and sex clubs.  When she followed up her observations with close research, the findings were alarming: between 1974 and 1979, the annual number of amebiasis cases in San Francisco had risen from 10 to 250; annual cases of giardiasis had risen from fewer than 2 to 85; annual shigelosis and hepatitis A cases had doubled, and hepatitis B cases had trebled.  By 1980, she estimated that 70-80% of all the patients at the SFDPH Veneral Disease Clinic were homosexual men.  Dritz’s findings paled in comparison to those of Edward Markell, a doctor who conducted research among a sample of Castro District residents in 1982.  Almost 60% of the subjects in Markell’s study tested positive for intestinal parasites.

“Too much is being transmitted,” Dritz warned a group of San Francisco physicians in 1980.  “We’ve got all of these diseases going unchecked.  There are so many opportunities for transmission that, if something new gets loose here, we’re going to have hell to pay.”  Dritz was no scold; she was a consummate professional, and she never indulged in moralistic hand-wringing.  Instead, she immediately reached out to the city’s prominent gay political clubs, gay business associations, and gay physicians to warn them about the threat.  Her professionalism immediately earned her the trust of the gay community, and that of gay physicians in particular.  In her early sixties and nearing retirement, Dritz had unwittingly become – as her children joked – “sex queen of San Fr

Professor Alan Whiteside is an AIDS researcher and author. He is Professor of Economics and Director of the Health Economics and HIV/AIDS Research Division at the University of KwaZulu-Natal, South Africa, and is a member of the Governing Council of the International AIDS Society. He has written several books on HIV and AIDS, including HIV/AIDS: A Very Short Introduction. In this original post below, Professor Whiteside discusses the recent encouraging results of HIV vaccine trials in Thailand.

The human immunodeficiency virus the cause of AIDS, is fortunately not easily transmitted. When it first appeared in 1981, there were fears of a global epidemic, some thought it would be on the scale of the impending Swine flu (H1N1) outbreak. This has not and will not happened. However those who are infected will eventually develop AIDS and in the absence of treatment will die.

There are an estimated 33 million people living with HIV in the world. The majority are in sub-Saharan Africa and more women than men infected. Most HIV transmission takes place through unprotected sexual intercourse. Some people are infected through drug abuse – sharing contaminated needles. If a woman is HIV positive and pregnant then there is a chance that her child will be born with the virus or infected while breast feeding (vertical transmission).

HIV transmission can be prevented. In injecting drug using populations provision of clean needles will halt the epidemic – as was done in a number of western cities. It is rare for vertical transmission to occur in the rich world, pregnant women will be given drugs and babies formula feed, in the poor world one dose of nevirapine will greatly reduce risk. New interventions are being developed and tried and it is likely that this form of transmission can be further reduced.

Preventing sexual transmission requires behavior change. Clearly not being sexually active will ensure a person remains HIV negative. This is not an option for humankind or most individuals. Having only one partner (who is faithful) will be effective but again, human nature being what it is, this is not a realistic goal despite what many faith-based organizations would have us believe. Condoms are generally effective provided they are used consistently and correctly. Unfortunately this too is not always an option. In some settings they are not available or are discouraged by religious leaders. Women may not be empowered to insist or even ask their partners to use them. And of course there are many who just don’t like them.

I believe that halting the HIV epidemic requires a mix of behaviour change and science. With regard to behaviour the key is developing respect. People should not enter sexual relations without respecting each other. If they do then they will either be faithful or they will want to protect their partner(s) by knowing their HIV status and/or using condoms.

Science has brought us drugs that keep people alive albeit at price. It is too science that we look in the area of prevention, here there are a few possibilities. Male circumcision provides a degree of protection for men. A microbicide, a substance that could be inserted into the vagina prior to intercourse that would kill viruses and bacteria would be female controlled and highly beneficial. A number are being tried. But the first prize would be an effective vaccine.

In 1983 when the virus was first isolated the then US Secretary of Health and Human Services announced confidently that a vaccine was imminent. This proved to be widely optimistic and in my book I said: “Despite rapid scientific advances there are no simple solutions. There will almost certainly not be a vaccine available by 2015 the date the Millennium Development Goals were to be met”. At the time of writing there were just four pharmaceutical companies with vaccines in trials; only one candidate had gone through all trials and it was not effective.

The news over the past week of developments in Thailand is extremely significant. The US Military HIV Research Programme and Thai Ministry of Health announced that a ‘combination of two vaccine candidates’ is at least partially effective in preventing HIV transmission. It was reported that the combination is 31% effective at preventing infection with HIV. Clearly this is not were we need to be but it is a breakthrough. More information will be given on 20th October this year at an AIDS vaccine meeting in Paris.

At this point those of us working in the field of HIV/AIDS are encouraged. It is in the words of the International AIDS Vaccine Initiative’s Chief Executive “a significant scientific achievement. It is the first demonstration that a candidate AIDS vaccine provides benefits in humans”. It will lead to new investment and energy in the development of vaccines.

Although an effective vaccine is still some years off, there is at last good news on this front.

Today I am delighted to be able to bring you another VSI column. This month Véronique Mottier has kindly answered a few questions for OUPblog about her latest book Sexuality: A Very Short Introduction. Véronique Mottier is Fellow and Director of Studies in Social and Political Sciences at Jesus College since 1999, and part-time Professor in Sociology at the University of Lausanne since 2006.

OUP: Have sexuality and politics always been as closely aligned as they seem to be today?

VÉRONIQUE MOTTIER: In antiquity already, sex was important to political life, but in different ways from the present. For example, in ancient Athens, it was perfectly acceptable for free men to have sex with women, slaves, or young men. However, men who prostituted themselves were seen to lower themselves to the level of women and slaves by accepting the role of sexual object, and could be stripped of their political citizenship rights. Accusations of sexual impropriety were frequently used weapons against political opponents in public debate in the ancient world and could have devastating consequences. It is difficult to think of any society where the sexual was not political, though how the political and sexual spheres were understood has varied enormously throughout history. What is different today is the pervasive role of the modern state, which intervenes in the sex lives of its citizens through education, legislation, and healthcare. Another important change is that modern citizens demand political rights based on their sexual orientation. In the classical world, the idea of classifying people according to the gender of the person they have sex with would have seemed downright bizarre!

OUP: You talk about the impact of HIV/AIDS in your book. With the rate of new infections still rising in the Western world, what do you think governments need to do to help slow the epidemic?

MOTTIER: There is certainly no room for complacency. While anti-viral drugs have been highly successful in extending the lives of people living with AIDS, the battle has by no means won. Campaigns promoting sexual abstinence have been largely unsuccessful in reducing unsafe sex, while prevention strategies which focused primarily on providing information and condoms have implicitly assumed that citizens are rational beings who will abandon their risky practices once they’ve been informed of the risks. Continuing new infections demonstrate that the provision of information and condoms continues to be crucial; however, it is not enough. Sex does not constitute the most rational area of most individuals’ lives. Today, Western governments are increasingly aware that prevention campaigns need to try to take into account the emotional and irrational aspects of people’s sex lives.

OUP: You say in the book that sexuality has been an issue that has deeply divided feminists over the years. Could you briefly explain to the OUPblog readers in what ways this has happened?

MOTTIER: Many feminists initially embraced the sexual revolution of the 1960s with great enthusiasm, seeing sexual liberation as crucial for women’s liberation generally. Pretty rapidly however, feminist critiques emerged which rejected sexual liberation rhetoric for mainly serving the sexual interests of men while continuing to exploit women. Separatist lesbian groups argued that women who slept with men were ‘collaborating with the enemy’, a stance which hardly endeared them to heterosexual feminists at the time and created great controversy within the women’s movement. Further deep splits over the links between sexuality and women’s oppression occurred in the 1980s and 1990s, when prominent voices such as Catherine MacKinnon and Andrea Dworkin argued that pornography and prostitution were forms of violence against women, and that sexual violence was the foundation of male domination over women generally. In contrast, feminists such as Lynne Segal or Carol Queen began to define themselves as ‘sex-positive’, rejecting the ‘depressing’ views of sexuality that reduce female sexual pleasure from intercourse to the effects of male brainwashing.

OUP: With so much controversy over sex education, when do you think is the optimum age to start sex education in schools, and why?

MOTTIER: Perhaps we should less worry about the age at which sex education should start (since different cultures have such different ideas about sexual adulthood this that a general reply would make little sense), and more about its contents. It strikes me that much sex education today aims to inform children of the mechanics of sex, as well as of its risks and dangers such as unwanted pregnancies or sexually transmissible diseases. These are extremely important matters; what gets a bit lost in the process is the issue of sexual pleasure. If we want to produce citizens who are able to express and negotiate their sexual needs, and to respect partners’ personal boundaries, sex education needs to address issues of communication and consent perhaps more explicitly than it has done in the past.

OUP: Once people have read your VSI, which five books would you recommend them for further reading?

MOTTIER: Jeffrey Weeks’ Sexuality is an excellent and well-written general introduction (Routledge, 2003). David Halperin’s One Hundred Years of Homosexuality and Other Essays on Greek Love (Routledge, 1990) is a scholarly analysis revealing the enormous gap that separates modern understandings of sexuality from those of the ancient world. The series of reports by Shere Hite, in particular her Hite Report on Female Sexuality, first published in 1976 (Dell Books), remain fascinating, both in terms of offering insights into people’s everyday experiences of sexuality in 1970s America, and as prominent contributions to the feminist critiques of sexuality which followed the sexual revolution. Angus McLaren’s Impotence: A Cultural History (2007) on the cultural consequences of male sexual ‘failure’ is riveting. The influential History of Sexuality (especially Volume 1: an introduction) by the French philosopher Michel Foucault (Penguin 1990) transformed current thinking about sex when it first came out in 1976.

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Earlier today we excerpted from With Pleasure: Thoughts on the Nature of Human Sexuality which argues that human sexuality cannot be understood if its significance is limited to reproduction alone.  Below is a second excerpt, which explores why having safe sex can be so difficult.

Probably the most influential reason that many people choose to forgo safe sex is that they believe it to be less pleasurable than the riskier alternatives. This is particularly true of condoms, the use of which has been unflatteringly compared to taking a shower in a raincoat. The primary complaint of men is that condoms decrease penile sensitivity, hence pleasure; some women also complain of a loss of sensation. (As one eighteenth-century rake brags, “I picked up a fresh agreeable girl called Alice Gibbs. We went down a lane to a snug place, and I took out my armor, but she begged that I might not put it on, as the sport was much pleasanter without it.”) Both men and women further dislike condoms for the related reason that they form an artificial barrier against intimate contact. Many people also believe that condoms decrease sexual spontaneity and therefore romance.

These are, for the most part, valid complaints. Condoms could certainly be made thinner to increase sensitivity and enjoyment. In 1995 a British company began marketing a thinner plastic condom, which it claimed is more comfortable and pleasurable than comparable latex condoms. And, as noted previously, the receptive partner’s pleasure could further be enhanced by thoughtfully designed condoms.

However, even if condoms were vastly improved, there would probably still be people who would refuse to use them. Some men claim to be unable to perform while wearing a condom. Others simply dislike them because they decrease sensitivity and pleasure; so much so that some men are willing to pay male or female prostitutes extra for unprotected sex. Although this practice increases the prostitute’s risk of becoming infected with HIV or some other STD, a skillful prostitute can slip a condom onto a customer -without him ever knowing it (or so we’ve been told). This trick requires the prostitute to hide a rolled-up condom in his or her cheek and then nimbly slip it onto the customer during oral sex, just prior to vaginal insertion. The fact that some men are unable to discern that they’ve been protected against their will suggests that whatever loss of sensitivity condom use entails cannot be that great. A slight loss of sensitivity might even be desirable in some instances because it helps stave off ejaculation, prolonging the pleasures of intercourse (some prostitutes dislike condoms for exactly this reason).

Inventing novel ways to put on condoms could also be a playful way for couples to eroticize condom usage. More generally, simply incorporating condoms into erotic foreplay can have measurably positive effects on how condom use is perceived and even on how much pleasure is experienced during protected intercourse. Furthermore, the power of sexual reward suggests that positive experiences with condoms should be self reinforcing. Perhaps, with enough practice, even couples that initially detested condoms could grow to love (or at least tolerate) them.

The adoption of behaviors, such as always using condoms, that reduce HIV risks is liable to be gradual at best. People must decide on a situation by- situation basis whether or not to take risks. Positive experiences with safer sex practices tend to reinforce protective behaviors, whereas negative experiences reduce the likelihood of these behaviors being repeated. But individuals do not make sexual decisions in a vacuum—it takes two to tango. Ideally, HIV-prevention decisions should be made jointly by the partners involved. In practice, however, the male half of a heterosexual couple often has the final say in whether or not condoms are used. (Not surprisingly, condoms are more likely to be utilized by couples who communicate freely about sexual issues.) This is especially true in traditional cultures. In parts of Africa, for example, some married women are at high risk of becoming infected with HIV as a result of having sex with their husbands, many of whom frequent prostitutes. Knowledge about HIV/ AIDS and specifically about the effectiveness of condoms in preventing HIV transmission is generally poor in Africa. Moreover, when women do attempt to protect themselves by suggesting that their husbands wear condoms, their suggestions are viewed with distrust, or worse, as a sign that the wife has been unfaithful. As a result, condoms are seldom used in marital relations, and millions of African women have become infected with a catastrophic, yet preventable, disease.

Social influences play an important role in shaping how safer sex practices are viewed. For example, some men refuse to wear condoms because they believe condoms are for boys, not for men. Others insist that “real men don’t wear condoms.” Furthermore, as a consequence of past “social hygiene” campaigns, condoms are inextricably linked with prostitution in many people’s minds.

However, the remarkable success of safer sex campaigns in the gay communities of large urban areas throughout the United States and Europe suggests that the social norms that regulate sexual behavior are at least somewhat malleable. By the early to mid-1990s the use of condoms had already been incorporated into socially accepted sexual scripts in many gay communities. Of course, gay sexual practice has always embraced a wide range of activities, many of which are completely safe. According to Donald Crimp, “We [gay men] were able to invent safe sex because we have always known that sex is not, in an epidemic or not, limited to penetrative sex.” Indeed, many gay men do not participate in anal intercourse at all, while others prefer only the relatively safer insertive role.

Despite the widespread (though sometimes grudging) acceptance of safer sex by many gay men, as therapies for treating HIV improved in the late 1990s, disturbing signs of complacency began to appear. As the twentieth century came to a close, incidence rates for many sexually transmitted diseases began to climb among some groups of men who have sex with men, and several studies of the behavior of these men documented increases in sexual risk taking, such as having unprotected anal sex. This apparent trend toward unsafe behaviors by some gay men reflects many factors, including “condom burn out” (dissatisfaction with the continued need for condoms more than a decade after the start of the epidemic) and a persistent desire for the pleasures of unprotected intercourse. It may also be related to the availability of effective therapies, which slow the progression of HIV disease in infected persons. These “combination therapies” consist of multiple antiretroviral drugs, which, when taken in large doses, can help keep the virus from proliferating, resulting in improved health and greater longevity for HIV patients. (These drugs do not work for everyone, however, and they are very toxic, causing myriad side effects that range from nausea to the development of anomalous fatty deposits, including so-called buffalo humps.) In short, the outlook for many—but not all—people living with HIV is much brighter than ever before…

As a result, having sex with a potentially infected partner is now perceived as being less risky than it was ten years ago, provided that the sex partner is receiving combination antiretroviral therapy…

A number of other factors can also influence “whether or not people decide to engage in particular sex acts and whether condoms are used in these activities. Adolescents, in particular, may have different reasons for having unprotected sex.

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Paul R. Abramson is one of the world’s most eminent scientists in the field of human sexuality. He is Professor of Psychology at the University of California, Los Angeles and a former editor of the Journal of Sex Research . He has been a technical advisor to the World Health Organization’s Global Program on AIDS and is the author of six books, including Sexual Nature, Sexual Culture and Sarah: A Sexual Biography . Steven D. Pinkerton recently received a doctorate in psychology from the University of California, Los Angeles. Dr. Pinkerton has written extensively in the areas of human sexuality and AIDS prevention and is presently pursuing a broad research agenda in psychology and the behavioral sciences as a post-doctoral fellow at UCLA. Together they are the authors of With Pleasure: Thoughts on the Nature of Human Sexuality which argues that human sexuality cannot be understood if its significance is limited to reproduction alone. The authors posit that in humans reproduction itself occurs as a byproduct of pleasure–not the other way around–and that it is the strong drive for pleasure that makes people overcome many obstacles–and even life-threatening dangers such as AIDS–to have sex. In the excerpt below we learn how “sexual pleasure” is defined.

What is sexual pleasure? Unfortunately, the concept denoted here by “sexual pleasure” is a rather slippery creature, weighted down by considerable pop psychological baggage, and subject to cross-cultural and
cross-historical variation. Nevertheless, it is desirable to have some definition of this concept, however inexact, to provide an anchor for subsequent discussions. With this in mind, we offer the following very simple (and regrettably vague) definition: Sexual pleasure consists of those positively valued feelings induced by sexual stimuli. Notice that this conceptualization encompasses a broad range of sexual pleasures, from the soothing sensations of sensual massage, to the explosion of feeling that accompanies orgasm.

Although the positive sensations we are calling sexual pleasure can be evoked, to some extent, by erotic thoughts, fantasies, and direct neural stimulation, we assume here for the sake of simplicity that stimulation of the genitals, breasts, or other relevant body parts (i.e., the erogenous zones) is necessary to initiate these feelings. According to this simplified model, the experience of sexual pleasure begins when the skin receptors in one or more erogenous zones are stimulated, and ends with a positive evaluation within the brain that the sensations experienced are indeed both pleasurable and sexual in nature. The interpretive function of the brain in the experience of sexual pleasure cannot be overemphasized. The sensory signals arriving at the brain following stimulation of an erogenous zone are not inherently pleasurable, or even inherently sexual. Instead, interpretation of these signals by the brain is required for the impinging sensations to be recognized as sexually pleasurable. It is this interpretive stage that admits the profound influences of culture and context in the experience of sexual pleasure. With regard to context, it is often claimed that sex isn’t really sex for a prostitute plying her trade; sex with a lover, however, is an entirely different matter.

A rather extreme example of the pervasive influence of culture is provided by the Manus, a pre-World War II society in Papua New Guinea. Among the sex-negative Manus: Intercourse between husband and wife was considered to be sinful or degrading, and was undertaken only in strict secrecy. Women considered coitus to be an abomination which they had to endure, even painfully, until they produced a child.

Unfortunately, the definition of sexual pleasure provided here neglects several of its more salient aspects, including the pleasure of giving pleasure. For example, in the butch/femme lesbian culture of the 1940s and 1950s, the butch partner often derived her greatest erotic satisfaction from pleasuring her femme counterpart, “if I could give her satisfaction to the highest, that’s what gave me satisfaction”; in such stereotyped role playing it was neither expected nor desired that the femme should reciprocate. This does not mean, however, that the butch’s pleasure necessarily lacked a physical component. According to Elizabeth Lapovsky Kennedy and Madeline Davis: Many butches were and remain spontaneously orgasmic. Their excitement level peaks to orgasm when they make love orally or digitally to a woman. The nature of this orgasm is unclear. Some describe it as physical, while others think it is mental.

The popular 1993 film, The Crying Game,18 can be used to illustrate one of the main aspects of our conception of sexual pleasure—namely, the interpretive role of the mind. Politics and mayhem notwithstanding, this Academy Award-winning film’s plot follows the basic modern love story, up to a point. Thus, boy meets girl, boy falls in love with girl, boy and girl decide to have sex. But then, in the pivotal sex scene, the boy discovers—much to his dismay—that the girl is really a guy, penis and all. The boy responds by vomiting uncontrollably. Why? Wasn’t the boy in love (or at least in lust)? And wasn’t he also highly aroused sexually? So what triggered his disgust? Presumably, his reaction sprang from his brain rather than his heart. Despite his intense attraction and physiological arousal, this encounter was no longer interpreted as heterosex, but was instead homosex. Even with love and lust, the circumstances were no longer acceptable, and, therefore, no longer arousing to him.

As conceptualized here, sexual pleasure encompasses a loosely defined collection of physiological and psychological responses. Physiologically, it appears that the capacity for sexual pleasure is “hardwired” in the sense that it constitutes an innate and universal aspect of human sexual anatomy. However, like any intrinsic characteristic, sexual pleasure is moderated by and unfolds within a particular physical and cultural milieu. It is therefore subject to the cultural vagaries of permissibility and restriction that influence both the overt expression and subjective experience of sexual pleasure.

Even if the capacity for sexual pleasure is innate, and in some sense “basic” for the human species, one might argue that pleasure is secondary to procreation (or reproduction). This is certainly true for the
“lower” species of mammals, which, if they experience pleasure at all, are nonetheless restricted sexually to the reproductively fertile estrus periods of the female. For these animals, sexual pleasure (if it exists) is clearly subservient to reproduction. With the primates, however, one begins to see a bifurcation in the functional meaning of sex. Although the reproductive cycle of many nonhuman primates remains at least
partially bound to hormones, sexuality is no longer entirely restricted by the female cycle.

In humans the divergence of the reproductive and the nonreproductive is even more striking. Essentially free of the hormonal regulation of sexual desire, women can—and do—engage in sex at any time in their cycle, irrespective of fertility status. For men and women, pleasure is not dependent on fecundity. Sexual desire is evident in postmenopausal women and in prepubescent children of both sexes. Furthermore, human sexual anatomy is specialized for pleasure no less than procreation. The sole function of the clitoris, for example, is the generation of pleasure. Pleasure, not reproduction, also provides the most parsimonious explanation of the presence of numerous nonobvious erogenous zones, such as ears, toes, and the backs of kneecaps. Similarly, the wide variation in sexual practices observed across cultures, and even within cultures, is largely inexplicable within a reproductively oriented explanatory framework. Psychologically, pleasure drives the human desire for sex, and also provides the foundation for ancillary sexual functions, such as emotional bonding. In sum, the evidence suggests that the pleasurable and procreative aspects of human sexuality are conceptually, anatomically, and psychologically distinct.

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Dorothy H. Crawford is a Professor of Medical Microbiology and Assistant Principle for the Public Understanding of Medicine at the University of Edinburgh. Her most recent book, Deadly Companions: How Microbes Shaped Our History, takes us back in time to follow the interlinked history of microbes and man, impressing upon us how a world free of dangerous microbes is an illusion.  In an excerpt this morning we looked at SARS.  The excerpt below looks at the effect of poverty on disease.

It is glaringly obvious from a glance at the figures that poverty is the major cause of microbe-related deaths. On a worldwide scale microbes are still major killers, accounting for one in three of all deaths. But the huge discrepancy in the death rates between rich and poor nations reveals the stark reality. Whereas only 1–2 per cent of all deaths in the West are caused by microbes, this figure rises to over 50 per cent in the poorest nations of the world, and it is in these highly microbe-infected areas where over 95 per cent of the global deaths from infections occur. Most of the 17 million killed by microbes each year are children in developing countries where the link with poverty is clear. It is the poor who are malnourished, live in filthy, overcrowded urban slums and go without clean drinking water or sewage disposal, and therefore they are the ones who fall prey to the killer microbes: HIV, malaria, TB, respiratory infections and diarrhea diseases like cholera, typhoid and rotavirus; all eminently preventable and treatable given the resources.

The spread of HIV is an excellent example of how microbes exploit the poor, striking at the most disadvantaged in the community. The virus emerged in Central Africa and spread silently throughout the continent in the 1970s, given a head start by its long silent incubation period, and aided by despotic leaders, corrupt governments, civil wars, tribal conflicts, droughts and famines. Carried by undisciplined armies and terrorists, the virus infiltrated city slums, infected commercial sex workers, was picked up by migrant workers and passed on to their wives and families. While malnutrition accelerated the onset of AIDs, breakdown of health-care services in the political turmoil of Africa excluded any possibility of medical support for the millions in need.

Now we are living through the worst pandemic the world has ever known, with 40 million living with HIV, 25 million already dead and around 10,000 dying daily—the equivalent of over three 9/11disasters every twenty-four hours. A third of people living in sub-Saharan African cities are HIV-infected, and while highly active antiretroviral therapy (HAART) has converted this lethal disease into a manageable chronic infection in the West, presently only a tiny proportion of Africans living with HIV receive this treatment; for most there is no hope of obtaining the drugs vital for keeping them alive.

The dynamics of HIV in Africa reflects its mode of spread. As the virus is sexually transmitted gender inequalities mean that women are particularly vulnerable. In general they are poorer and less well educated than their male counterparts, and are often powerless to choose or restrict their sexual partners, or to insist on condom use. Indeed many are forced to exchange sex for essentials like food, shelter and schooling. Now one in four African women are HIV-infected by the age of twenty-two years (compared to one in fourteen men of the same age), and women account for 60 per cent of all those living with HIV.

Over 90 per cent of HIV-positive women in Africa are mothers, and the virus has created 15 million orphans worldwide, 12 million of them in sub-Saharan Africa. These children are bearing the burden of the HIV pandemic; they miss school to care for their sick mothers or to earn the family income; the virus has not only deprived them of their parents but their childhood and their education as well.

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Gerald M. Oppenheimer and Ronald Bayer are the authors of Shattered Dreams?: An Oral History of the South African AIDS Epidemic which uses interviews to tell the story of how physicians and nurses in South Africa struggled to ride the tiger of the world’s most catastrophic AIDS epidemic. They wrote such a compelling piece for World AIDS Day that I thought it would be nice to delve deeper into their book. The excerpt below looks at how doctors responded to the AIDS epidemic in South Africa.

Coming to AIDS (more…)

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Saturday is World Aids Day. We asked authors Gerald M. Oppenheimer and Ronald Bayer to help us commemorate this important holiday, to help us remember why AIDS research, awareness and education is so very important to our society. Oppenheimer and Bayer are the authors of Shattered Dreams: An Oral History of the South African AIDS Epidemic which uses interviews to tell the story of how physicians and nurses in South Africa struggled to ride the tiger of the world’s most catastrophic AIDS epidemic. In the original article below they reflect on the progress made and work still to be accomplished.

Once again it is almost World AIDS Day and in cities and communities around the world, there will be commemorations marking the date, December 1. But this year may be different. Some will begin to say, as they did in the United States, “Enough!” Too much energy, too many resources, have been devoted to an epidemic whose dimensions may have been exaggerated. They will point to a recent report from the United Nations suggesting that the global burden of HIV have been overestimated. Instead of the approximately 39 million people, as the world body previously reported, it is now thought that the numbers are closer to 33 million individuals. The number of newly infected, said the report, is declining where it is not leveling off. Seizing on these numbers, we will be urged to breathe a collective sigh of relief. (more…)

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Earlier today, Mary Ann Cohen, co-editor of the Comprehensive Textbook of AIDS Psychiatry helped us better understand the AIDS epidemic in young American men. Cohen’s book (with Jack M. Gorman), navigates the ample evidence supporting the fact that psychiatric treatment can decrease transmission, diminish suffering, improve adherence, and decrease morbidity and mortality in AIDS patients. In the excerpt below, Jimmie Holland, MD the Wayne E. Chapman Chair in Psychiatric Oncology at Memorial Sloan Kettering Cancer Center and a Professor of Psychiatry at the Weill Medical College of Cornell University provides a forward which puts the Comprehensive Textbook of AIDS Psychiatry into historical perspective.

The publication of the Comprehensive Textbook of AIDS Psychiatry, edited by two psychiatrists who have ‘‘been there’’ since the beginning of the epidemic, is a benchmark for the field —it has come of age. (more…)

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A little while back someone in the office pointed out this interesting piece about the rise of AIDS among young men in NYC. I started wondering what could be done and I took my query to Mary Ann Cohen a clinical professor in the Department of Psychiatry at The Mount Sinai School of Medicine, and the co-editor of the Comprehensive Textbook of AIDS Psychiatry. Cohen wrote me back with the following illuminating response.

During a century when rapid advances in medicine led to near eradication of infectious diseases throughout much of the world, the emergence of HIV infection in 1981 led to an unexpected crisis in health care that has not yet resolved. (more…)

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Ellis does an excellent job of bringing the children's stories together with clear information about the problems of AIDS, child labour, poverty, and women's rights. Although this book packs a mighty emotional wallop for complacent Canadians, Ellis also manages to find hope, and her conclusion is a rousing call to action. Royalties from the sale of the book will be donated to Unicef. A must-have for all libraries, and a must-read for everyone.