J Hist Med Allied Sci 2014 Kazanjian 351 82

The AIDS Pandemic in Historic
Perspective
POWEL KAZANJIAN
University of Michigan, 1500 E. Medical Center Drive, 3119 Taubman Center, Ann Arbor,
Michigan 48109-5378. Email: [email protected]
ABSTRACT. Potent antiretroviral drugs (ART) have changed the nature of
AIDS, a once deadly disease, into a manageable illness and offer the promise
of reducing the spread of HIV. But the pandemic continues to expand and
cause signicant morbidity and devastation to families and nations as ART
cannot be distributed worldwide to all who need the drugs to treat their
infections, prevent HIV transmission, or serve as prophylaxis. Furthermore,
conventional behavioral prevention efforts based on theories that individuals
can be taught to modify risky behaviors if they have the knowledge to do so
have been ineffective. Noting behavioral strategies targeting individuals fail
to address broader social and political structures that create environments vul-
nerable to HIV spread, social scientists and public health ofcials insist that
HIV policies must be comprehensive and also target a variety of structures at
the population and environmental level. Nineteenth-century public health
programs that targeted environmental susceptibility are the historical analogues
to todays comprehensive biomedical and structural strategies to handle AIDS.
Current AIDS policies underscore that those ghting HIV using scientic
advances in virology and molecular biology cannot isolate HIV from its broader
environment and social context any more than their nineteenth-century prede-
cessors who were driven by the lth theory of disease. KEYWORDS: AIDS, vac-
cine, antiretroviral, prevention, structural programs, history.
I NTRODUCTI ON
H
ISTORIANS and physicians have addressed how several facets of
AIDS have changed since its inception in 1981. Most obvi-
ously, the victim and the locale have changed; this disease rst
JOURNAL OF THE HISTORY OF MEDICINE AND ALLIED SCIENCES, Volume 69, Number 3
#The Author 2012. Published by Oxford University Press. All rights reserved.
For permissions, please e-mail: [email protected]
Advance Access publication on October 22, 2012 doi:10.1093/jhmas/jrs061
[ 351 ]

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appeared in gay men and intravenous drug users (IVDUs) living in
urban locales in developed nations and is now a global epidemic spread
most commonly through heterosexual contact.
1
What was almost always
a deadly disease has become a manageable illness due to the remarkable
discoveries of potent antiretroviral therapy (ART).
2
The fear once asso-
ciated with a fatal pestilence has been replaced by one of complacency
toward a chronic disease.
3
During the early phase of the epidemic, when AIDS was a fatal
disease, historians rst placed AIDS in historic perspective. They
used the idiom of pestilence to underscore the dangers caused by
blame and fear of the maligned sufferers. Historians have not, how-
ever, attempted to trace the historic roots of AIDS now that it has
evolved into a chronic disease. In this article, I rst describe AIDS as
a chronic disease and then analyze how this characterization changes
how historians should view its history.
I argue that the focus of current biomedical and public health
efforts to handle AIDS as a chronic disease has expanded beyond the
individual to include the population and environment. ART has
been proposed as a strategy to benet the infected individual, prevent
spread to the population, and end the epidemic if used early by all
infected people and prophylactically by at-risk uninfected individuals.
4
Despite these predictions, several pragmatic issues, including how to
afford the drugs and ensure they will be taken regularly, threaten these
goals. Given these problems, as well as limitations of traditional behav-
ioral prevention programs that target individuals, policy makers have
implemented structural interventions at the population and social
level to target environmental vulnerabilities to accompany biomedical
approaches.
I then trace the historic roots for the comprehensive policies used
to handle the AIDS epidemic. Late nineteenth-century public health
efforts were directed at rectifying vulnerable environments to reduce
1. Helen Epstein, The Invisible Cure: Africa, the West and the Fight against AIDS
(New York: Farrar, Straus and Giroux, 2007), xi xix.
2. Carl Dieffenbach and Anthony Fauci, Thirty Years of HIV and AIDS: Future
Challenges and Opportunities, Ann. Intern. Med., 2011, 154, 76671.
3. Stephen Lewis, Race against Time: Searching for Hope in AIDS-Ravaged Africa (Berkeley:
House of Anansi Press, 2005), 136.
4. Hillary Rodham Clinton, Remarks on Creating an AIDS-Free Generation,
National Institutes of Health, Masur Auditorium, Bethesda, Maryland, 8 November 2011,
http://www.state.gov/secretary/rm/2011/11/176810.htm (accessed 17 August 2012).
Journal of the History of Medicine : Vol. 69, July 2014 352

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the spread of contagion. Following the introduction of practices target-
ing particular microbes by public health departments, reliable means to
handle infections by case nding and tailoring measures accordingly
replaced deemphasized broad-scale sanitation measures. Despite pre-
sent biomedical advancesARTas treatment and prevention, and pre-
exposure prophylaxis (PrEP), the course of AIDS has demonstrated
that there is no inexpensive, efcient way to handle the epidemic that
is divorced from broader social and moral considerations. The AIDS
epidemic underscores that public health efforts that take into consider-
ation social issues and environmental considerations remain as impor-
tant as they did in the nineteenth-century pregerm era, even if a
therapeutic cure or an effective vaccine is on the horizon.
BACKGROUND
The Idiom of Pestilence (198195)
In 1981, physicians and society at large struggled to understand why
an unexpected array of perilous infections and unusual tumors began
to appear in an otherwise young healthy population; as the common
factor appeared to be a steep decline in immune function, the disease
was ultimately dubbed AIDS, for acquired immune deciency syn-
drome.
5
Due to the recent accomplishments of science yielding antibi-
otics and vaccines, there was a widely held belief that major epidemics
had receded into the past in developed countries.
6
As AIDS aficted a
marginalized group of people whose behavior some individuals consid-
ered deviantgay men and those who used illegal intravenous drugs
the disease was viewed within a moralistic framework.
7
AIDS patholo-
gized those seen by many as morally repugnant.
8
Some individuals saw
AIDS as a disease that struck those they considered guilty for engaging
in deplorable behavior.
9
For them, AIDS legitimated stigmatization of
5. Jean L. Marx, New Disease Bafes Medical Community, Science, 1982, 217, 618. See
also: Robert C. Gallo and Luc Montagnier, AIDS in 1988, Sci. Am., 1988, 259, 4144.
6. Rene Dubos, Mirage of Health: Utopias, Progress, and Biological Change (Garden City,
New York: Anchor Books, 1959), 11381.
7. Harvey V. Fineberg, The Social Dimensions of AIDS, Sci. Am., 1988, 259, 11121.
8. Paul Farmer and Arthur Kleinman, Politics in the First Part of AIDS Pandemic:
AIDS as Human Suffering, Daedalus, 1989, 118, 13560.
9. Jerry Falwell, Jerry Falwell Quotes, Think Exist, 2010, http://thinkexist.com/
quotes/jerry_falwell/ (accessed 1 August 2011). See also: Patrick Buchanan, Editorial,
Seattle Times, 31 July 1993.
Kazanjian : AIDS Pandemic 353

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gay men and drug users by claiming their behavior was not only devi-
ant, it was also dangerous.
Scientists expressed hope that biomedicine could handle the dis-
ease after the virus causing AIDS was discovered in 1983.
10
Margaret
Heckler, then secretary of health and human resources, accompanied
by Robert Gallo, virologist at the National Institute of Health and
co-discoverer of the virus, hoped that a vaccine for AIDS could be
forthcoming within two years.
11
Gallo acknowledged that historically,
identifying a virus was a key step in producing an effective vaccine.
12
The identication of viral protein components enabled a diagnostic
test to be developed by 1985.
13
This test, together with a measurement
of depleted CD4 lymphocytes, enabled researchers to show that indi-
viduals remained healthy for a decade before their immune system
deteriorated to the point where they developed AIDS-related dis-
eases.
14
They could engage in permissive behaviors without limita-
tions, as their bodies functioned properly and showed no evidence of
being diseased.
15
In the process, they could unknowingly transmit the
virus to others.
16
The diagnostic HIV blood test had profound social and ethical
implications as it could determine if an individual was a carrier of a
lethal virus for which there was no treatment. As health policy expert
Ronald Bayer maintained, the test signied social divisions between
the innocent and the dangerous.
17
Some alarmed citizens called for
10. R. C. Gallo, S. Z. Salahuddin, M. Popovic, et al., Frequent Detection and Isolation
of Cytopathic Retroviruses (HTLV-III) from Patients with AIDS and at Risk for AIDS,
Science, 1984, 224, 5003.
11. Jon Cohen, Shots in the Dark: The Wayward Search for an AIDS Vaccine (New York:
W.W. Norton & Company, 2001), 315, 11.
12. Robert C. Gallo, Virus Hunting: AIDS, Cancer, and the Human Retrovirus: A Story of
Scientic Discovery (New York: Basic Books, 1991), 44162.
13. Jonathon N. Weber and Robin A. Weiss, HIV Infection: The Cellular Picture, Sci.
Am., 1988, 259, 1009.
14. William A. Haseltine and Flossie Wong-Staal, The Molecular Biology of the AIDS
Virus, Sci. Am., 1988, 259, 5262.
15. Weber and Weiss, HIV Infection: The Cellular Picture, 128. See also: J. A. Levy,
Human Immunodeciency Viruses and the Pathogenesis of AIDS, J. Am. Med. Assoc.,
1989, 261, 2997.
16. William L. Heyward and James Curran, The Epidemiology of AIDS in the U.S.,
Sci. Am., 1988, 259, 41. See also: J. M. Mann, J. Chin, P. Piot et al., The International
Epidemiology of AIDS, Sci. Am., 1988, 259, 8289.
17. Ronald Bayer, Private Acts, Social Consequences: AIDS and the Politics of Public Health
(New York: Free Press, 1989), 10136.

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the exclusion of all who tested positive from social interactions.
18
Gay activists, however, struck back at attempts to limit their civil lib-
erties. They argued that the HIV test could be used for discrimination
in housing, employment, or obtaining insurance benets.
19
They also
assured there was no need to force screening as gay males would seek
testing voluntarily and would take personal responsibility to modify
their behavior and therefore not pose risk to others.
20
Leaders of the
gay community saw it as their obligation to take social responsibility
for protecting the health of the individual and survival of the commu-
nity through a normative process of dening standards of safe behavior
through peer messages.
21
An anonymous voluntary testing policy
without mandatory partner notication was subsequently enacted.
22
By the mid-1980s, the HIV epidemic posed new fears when it
expanded beyond those deemed guilty to groups perceived as
innocent. Children of HIV-infected mothers or adults receiving
treatments for hemophilia, tainted blood transfusions, or receiving
dental care could now acquire infection through no fault of their
own.
23
Not only had the epidemic reied a distinction between
these innocent victims and, by implication, the guilty persons
with AIDS, the potential for the epidemic to breach existing bound-
aries and cause widespread deaths among the entire population exac-
erbated existing anxieties.
24
Although the idiom of pestilence as just
punishment for sinners remained applicable, to some, the idea that
the disease would decimate exclusively those who behaved sinfully
no longer seemed to apply. An anguished William Buckley, for
example, feared a dismal scenario of mass deaths due to pervasive
18. Anon., LaRouche Initiative Stopped Dead, New York Native, 17 November 1986.
Lyndon LaRouche, a conservative political activist, proposed quarantine for those who
tested positive for HIV.
19. Randy Shilts, And the Band Played On (New York: St. Martins Press, 1987), 3490.
20. Ibid., 3495.
21. Mitchell H. Katz, The Public Health Response to HIV: What Have We Learned?,
in Kenneth H. Mayer and H. F. Pizer, eds., The AIDS Pandemic: Impact on Science and Society,
(San Diego: Elsevier Academic Press, 2005), 91109. This peer message established norms
from within the community for the survival of the community.
22. Thomas J. Coates, What Is to Be Done?, AIDS, 2008, 22, 107988.
23. Elizabeth Fee and Daniel M. Fox, AIDS: The Burdens of History (Berkeley and Los
Angeles: University of California Press, 1988), 1266. See also: Bruce Lambert, Kimberly
Bergalis Is Dead at 23, New York Times, 9 December 1991, D9.
24. Farmer and Kleinman, Politics in the First Part of AIDS Pandemic, 13560.

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infection.
25
As sociologist Susan Chambre noted, AIDS activists
exploited the heightened concern about the spread of AIDS among
the general population.
26
Concomitantly, funding for AIDS research
increased markedly.
27
With a heightened fear of the spread of AIDS, sufferers were
excluded from social interaction. According to Ronald Bayer and
Gerald Oppenheimer, some healthcare workers refused to provide
care for AIDS victims.
28
In addition, anxious customers avoided res-
taurants for fear that gay waiters would spread the virus.
29
Despite
evidence from scientic authorities stating that HIV could not be
spread by day-to-day social family contact, some people remained
unconvinced that the virus could not be transmitted casually and
chose not to alter their exclusionary practices.
30
AIDS sufferers were
avoided by those who feared becoming infected via handshakes,
utensils, and toilet seats, even though medical evidence told them
otherwise.
31
The distress of being shunned in the domestic and pub-
lic spheres, along with fears of discrimination in the workplace, led
some to conceal their HIV status from their family and co-workers.
Unable to receive the social support they needed, patients were at
risk from a terminal medical disease and social attitudes that encour-
aged discrimination and isolation.
In the 1980s, historians Elizabeth Fee, Daniel Fox, Virginia Ber-
ridge, and others attempted to situate the AIDS epidemic in the
25. William F. Buckley, Jr., Identify All the Carriers, New York Times, 18 March 1986.
Buckley warned that there is no guarantee that the disease will remain largely conned to
groups at special risk.
26. Susan Maizel Chambre, Fighting for Our Lives: New Yorks AIDS Community and the
Politics of Disease, Critical Issues in Health and Medicine (New Brunswick, New Jersey:
Rutgers University Press, 2006), 57110.
27. In 1986, Reagan allocated 213 million dollars to AIDS research; in 1984, he asked
Congress for 33 million dollars. Ofce of Technology Assessment (U.S. Congress),
Review of the Public Health Services Response to AIDS: A Technical Memorandum,
Washington, DC, February 1985.
28. Ronald Bayer and Gerald M. Oppenheimer, AIDS Doctors: Voices from the Epidemic
(Oxford: Oxford University Press, 2000), 63118.
29. Powel Kazanjian, personal interviews with HIV-infected persons (Ann Arbor, Mich-
igan, 2011).
30. Anon., AFRAIDS, The New Republic, 1985, 192, 79. In a 1985 New York
Times/CBS poll, 47 percent of Americans believed that AIDS could be transmitted by a
shared drinking glass. Thirty-four percent of those polled believed it unsafe to associate
with an AIDS person even when no physical contact was involved.
31. Nancy Tomes, The Gospel of Germs: Men, Women and the Microbe in American Life
(Cambridge, Massachusetts: Harvard University Press, 1998), 25667.

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context of the history of other epidemic diseases.
32
At a time when
AIDS was almost always fatal and involved mainly gay men who lived
in urban locales in developed nations, historians addressed the disease
in a moralistic framework of exclusion and derision of the stigma-
tized sufferers.
33
They used the idiom of pestilence with its associated
fear to make the point that historically, greater suffering had been
caused by blame, isolation, and repression of the feared sufferers than by
microorganisms themselves.
34
Moreover, Mirko Grmek argued that
AIDS became a metaphor for a culture that spawned major social ills
(e.g., illicit drugs, promiscuity) that like HIV, spread through society.
35
By the late 1980s, federally funded studies had identied drugs
demonstrating activity against the causative virus.
36
A six-month
analysis of a planned one-year 1986 study showed that azidothymi-
dine (AZT), a nucleoside agent, reduced mortality.
37
AIDS activists
achieved a streamlined process for licensing AZT in 1987 on the
basis that victims were dying while the drug was awaiting approval.
38
But survival was not extended beyond twelve months because the
virus soon developed resistance to AZT.
39
AIDS activists responded
by demanding that the FDA make alternatives available to patients
taking AZT.
40
However, none of four FDA-approved alternative
nucleoside agents could alter the terminal nature of HIV.
41
The wait
for effective treatments seemed far too long for physicians whose
patients were dying from AIDS.
42
Gavin McLeod, a physician, said
32. Fee and Fox, AIDS: The Burdens of History, 111. See also: Virginia Berridge and
Philip Strong, AIDS and Contemporary History (New York: Cambridge University Press,
1993), 114.
33. Brandt, No Magic Bullet, 97146.
34. Ibid., 14771.
35. Mirko D. Grmek, History of AIDS: Emergence and Origin of a Modern Pandemic
(Princeton, New Jersey: Princeton University Press, 1990), 2279.
36. Weber and Weiss, HIV Infection: The Cellular Picture, 128.
37. Victoria Harden, AIDS at 30: A History (Washington, DC: Potomac Books, 2012),
12557.
38. Amy Sue Bix, Diseases Chasing Money and Power: Breast Cancer and AIDS Activ-
ism Challenging Authority, J. Policy Hist., 1997, 9, 532. See also: Chambre, Fighting for
Our Lives, 57110.
39. Martin Hirsch, Azidothymidine, J. Infect. Dis., 1988, 157, 42731.
40. David J. Rothman and Harold Edgar, AIDS, Activism, and Ethics, in Lawrence
Corey, ed., AIDS Problems and Prospects (New York: Norton Medical Books, 1993), 145
55.
41. Deborah J. Cotton, Disappointing Assessment of Current Antiretrovirals, AIDS
Clin. Care, 1993, 5, 5153.
42. Bayer and Oppenheimer, AIDS Doctors: Voices from the Epidemic, 11970.

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resignedly in 1993, Some progress is being made, but not at a pace
equal to the death and devastation inicted by HIV.
43
1996 Potent ART
In 1996, protease inhibitor (PI) drugs were developed. When used
together with nucleoside agents, PI drugs were substantially more
potent than AZT.
44
Combination ART that included a PI agent
maximally reduced viral load (VL) to levels undetected by a serum
VL test, a marker that replaced clinical outcomes in trials and
became the therapeutic goal.
45
ARTrestored CD4 cell depletion and
reduced mortality, thereby turning AIDS from a death sentence into
a manageable disease.
46
The success of ARTreinforced the scientists
faith in the ability of science to understand basic mechanisms of dis-
ease and the power of biomedicine to deliver effective treatments.
47
Likewise, practitioners and citizens no longer viewed AIDS as an
invincible killer. Chapters on preparing AIDS patients for death were
no longer included in medical textbooks.
48
The last public display of
the AIDS Quilt was held in 1996, marking the end of an era where the
ritual of collective grief of deceased victims was visibly enacted on a
national stage. The once prevalent trope of wasting and dying from
AIDS now seemed remote.
The accomplishments of ART shifted the framework for viewing
the epidemic. The idiom of pestilence, with its fear and repression,
was yielding to a virologic framework of viewing the disease. Some
HIV-infected persons on ART, in fact, began to dene themselves
by their HIV VL measurement.
49
As new agents turned AIDS from
43. Gavin X. McLeod and Scott M. Hammer, Zidovudine: Five Years Later, Ann.
Intern. Med., 1992, 117, 48486, 486.
44. Emilio A. Emini, Protease Inhibitors, in XCI International AIDS Conference
(Vancouver, Canada, 1996).
45. Roy M. Gulick, John W. Mellors, et al., Treatment with Indinavir, Zidovudine and
Lamivudine in Adults with HIV, N. Engl. J. Med., 1997, 337, 73439.
46. F. J. Palella Jr., K. M. Delaney, A. C. Moorman, et al., Declining Morbidity and
Mortality among Patients with Advanced HIV Infection, N. Engl. J. Med., 1998, 338,
85360.
47. H. Varmus, Science and the Control of AIDS, Science, 1998, 280, 1815.
48. Merle A. Sande and Paul A. Volberding, The Medical Management of AIDS (Philadel-
phia: W.B. Saunders, 1992), 1186. See also: Merle Sande and Paul Volberding, The Medical
Management of AIDS, 6th ed. (Philadelphia: W.B. Saunders, 1999). Only the former version
contains a chapter on treatment of terminal illness.
49. Susan Best, Anthony Gust, Elizabeth Johnson, et al., Quality of HIV Viral Load
Testing in Australia, J. Clin. Microbiol., 2000, 38, 401520.

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a deadly disease to a chronic one, the fear of a deadly scourge
evolved into a mood of complacency.
50
The fear of widespread dis-
ease permeating into the general population causing massive deaths
was receding from public memory.
During this period of optimism, bold predictions emerged from
several sectors of society about the capacity of biomedicine to resolve
the epidemic. President Clinton predicted in 1998 that America
would have an effective vaccine within the next ten years. Clinton
channeled federal funds for a dedicated AIDS vaccine institute at the
National Institutes of Health (NIH), where a new laboratory facility
was constructed and staffed by top-level scientists recruited from aca-
demia.
51
Scientists speculated whether ART used early in infection
when immune function had not begun to wane could eradicate HIV
altogether, and designed and initiated studies to test for a therapeutic
cure.
52
CHRONI C HI V I NFECTI ON
Problems Posed by Chronic Infection (1996today)
The optimism in biomedicine to resolve the epidemic became tem-
pered when scientists learned that HIV has emerged as a chronic dis-
ease with its own set of medical problems. Studies to determine if
ART could eradicate HIV showed that treatment could not provide
a cure because the virus persists in reservoirs of latently infected rest-
ing CD4 cells that can reactivate and release virus whenever ART is
discontinued.
53
This meant that patients needed to take ART for
life. But a problem with taking ART indenitely is that a sizeable
proportion of patients cannot maintain such a regimen, due to cost
or behavioral factors.
54
Viral resistance and treatment failure ensue in
50. Harold Jaffe, Whatever Happened to the U.S. AIDS Epidemic?, Science, 2004, 305,
124344.
51. Seth Berkley, An AIDS Vaccine for All the World, AIDS Clin. Care, 1999, 11, 55.
See also: AVAC, Introduction, in An Agenda for Action for an HIV Vaccine (San Francisco:
AIDS Vaccine Advocacy Coalition, 1998), 911.
52. Eric Rosenberg, Marcus Altfeld, Samuel Poon, et al., Immune Control of HIV-1
after Early Treatment of Acute Infection, Nature, 2000, 407, 52326.
53. T. W. Chun, L. Carruth, and D. Finzi, Quantication of Latent Tissue Reservoirs
and Total Body Viral Load in HIV Infection, Nature, 1997, 387, 18388.
54. M. A. Chesney, The Elusive Gold Standard. Future Perspectives for HIVAdherence
Assessment and Intervention, J. Acquir. Immune Dec. Syndr., 2006, 43, Suppl 1, S14955.

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this circumstance.
55
Despite multiple new drugs acting at novel sites
against resistant viruses, the capacity of the virus to develop resistance
has outpaced the rate of development of these new drugs.
56
Conse-
quently, there is a growing number of patients with multiresistant
HIV viruses for whom there are no remaining active agents.
57
More-
over, chronic treatment with HIV drugs can cause long-term toxici-
ties including the accumulation of fat around the back of the neck,
wasting of the extremities and face as well as lipid abnormalities.
58
Physicians have also identied an array of troublesome medical
problems in patients whose HIV infection is well suppressed by
ART.
59
Inammation resulting from low-level, prolonged viral repli-
cation places people receiving long-term ART at increased risk for
coronary artery disease, heart attacks earlier in life, kidney failure, loss
of bone integrity and bone fractures, and even subtle HIV-related cog-
nitive changes.
60
Taken together, these complications underscore that
although HIV is not an automatic death sentence as it was in the early
phase of the epidemic, it still remains a dangerous disease.
61
Compared
with an uninfected person, in fact, the lifespan of an HIV-infected
person is shorter by approximately ten years on average.
62
ART has
transformed HIV into a chronic disease that is not necessarily an easy
one to live with.
55. Brendan Larder, Mechanisms of HIV-1 Drug Resistance, AIDS, 2001, 15, S27
S34.
56. M. A. Thompson, J. A. Aberg, J. F. Hoy, et al., Antiretroviral Treatment of Adult
HIV Infection: 2012 Recommendations of the International Antiviral Society-USA Panel,
J. Am. Med. Assoc., 2012, 308, 387402.
57. Department of Health and Human Services, Guidelines for the Use of Antiretrovi-
ral Agents in HIV-1-Infected Adults and Adolescents, http://www.who.int/hiv/pub/arv/
adult2010/en/index.html (accessed 30 July 2012).
58. Andrew Carr, Toxicity of Antiretroviral Therapy and Implications for Drug Devel-
opment, Nat. Rev. Drug Discov., 2003, 2, 62434.
59. Tim Schakler, Chronic Inammation in HIV Disease, in 18th Conference on Ret-
roviruses and Opportunistic Infections (Boston, Massachusetts: CROI, 2011), 96.
60. Z. H. Tseng, E. A. Secemsky, D. Dowdy, et al., Sudden Cardiac Death in Patients
with Human Immunodeciency Virus Infection, J. Am. Coll. Cardiol., 2012, 59, 189196.
See also: Schakler, Chronic Inammation in HIV Disease, 96. See also: I. Ofotokun,
E. McIntosh, and M. N. Weitzmann, HIV: Inammation and Bone, Curr. HIV/AIDS
Rep., 2012, 9, 1625, and T. D. Ruel, M. J. Boivin, H. E. Boal, et al., Neurocognitive and
Motor Decits in HIV-Infected Ugandan Children with High Cd4 Cell Counts, Clin.
Infect. Dis., 2012, 54, 10019.
61. Schakler, Chronic Inammation in HIV Disease, 96.
62. J. S. Currier and D. V. Havlir, Complications of HIV Disease and Antiretroviral
Therapy, Top. HIV Med., 2009, 17, 5767.

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The need for indenite ARTalso poses problems in the economic
and ethical spheres. The cost of drugs and the tests needed to monitor
their efcacy divides HIV patients into those with access to this
expensive care, and those who lack insurance or other means (espe-
cially in resource-poor countries) to afford this life-saving course of
treatment.
63
In fact, the trend in industrial countries of reducing
deaths from AIDS is not representative of the developing world where
90 percent of the people with HIV now live.
64
By 1998, Jonathan
Mann, former director of the World Health Organization (WHO)
Global Program on AIDS, objected to the fact that people of eco-
nomic disadvantage were discriminated against because they were
denied life-saving treatment.
65
In 2004, Greg Behrman, Policy Advi-
sor at the U.S. Department of State, pointed out the inherent injustice
that human beings with identical medical conditions are enabled to
liveor condemned to diebecause of their income.
66
A year later,
Steven Lewis, UN Secretary General for HIV in Africa argued that
nonaccess to effective AIDS prevention and treatment violated the
basic human rights of millions of people in the developing world.
67
The moral framework in which AIDS has resided since its incep-
tion has persisted in the ART era. Before ART became available,
moral issues centered around protecting the civil rights of an individ-
ual from discrimination.
68
These issues have never vanished, as gay
men, drug users, and female sex workers who live in conservative
societies today may avoid HIV testing in fear of discrimination
should their test return positive, or lack the stature to participate in
needle exchange programs or to request their male customers to use
condoms.
69
But today, ARTallows for benets associated with HIV
63. Milt Freudenheim, Price of Success in AIDS Treatment, New York Times, 7 June
2001.
64. Paul Farmer, Pathologies of Power: Health, Human Rights and the New War on the Poor
(Berkeley: University of California Press, 2005), 128.
65. Jonathan M. Mann and Daniel J. M. Tarantola, HIV 1998: The Global Picture,
Sci. Am., 1998, 279, 8284.
66. Greg Behrman, The Invisible People: How the U.S. Has Slept through the Global AIDS
Pandemic, the Greatest Humanitarian Catastrophe of Our Time (New York: The Free Press,
2004), 16778.
67. Lewis, Race against Time, 14590.
68. Bayer, Private Acts, Social Consequences, 120.
69. United Nations, World AIDS Day Report, 2011. http://www.unAIDS.org/en/
media/unAIDS/contentassets/documents/unAIDSpublication/2011/JC2216_WorldAIDS
day_report_2011_en.pdf (accessed 17 August 2012).

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diagnosis and brings to light a humanitarian obligation to the popu-
lation at large in addition to an individuals civil rights.
70
ART
brought a human injustice into focusthose who could not afford
treatment had no less right to live than people who could afford
treatment.
71
Just as activists sought to protect the civil liberties of
predominantly gay men in urban, industrialized regions in the early
part of the epidemic, policy makers took action to correct the basic
human injustice of denying ART to HIV-infected persons through-
out the world who were ill or transmitting the disease to others
because they could not afford ART.
In response to pleas to address this human injustice, the WHO
and the U.S. Presidents Emergency Plan for AIDS Relief (PEPFAR)
committed funding to distribute ART to those in need who lived in
developing nations.
72
As a result of their efforts, the number of HIV-
infected people worldwide who receive ART has markedly increased
from ve hundred thousand people in 2002, to over 6.6 million in
2010.
73
The distribution of HIV drugs has been accompanied by
improvements in healthcare delivery services in low-income coun-
tries that, according to John Iliffe, underscore how medical moder-
nity became common within Africa.
74
However, declining contributions from donor nations because of
the global recession means that UNAIDS is unlikely to reach their
target goal of providing universal ART access to all HIV people by
2015.
75
The total amount of money presently provided by donor
nations, fteen billion dollars per year, is well below the amount
estimated to achieve and maintain universal access to ART, twenty-
70. Ronald Bayer and Gerald Oppenheimer, Routine HIV ScreeningWhat Counts
in Evidence-Based Policy?, N. Engl. J. Med., 2011, 14, 126568.
71. Dale Bourke, The Skeptics Guide to the Global AIDS Crisis (Colorado Springs:
Authentic Media, 2004), 183.
72. Jim Yong Kim and Paul Farmer, AIDS in 2006Moving toward One World, One
Hope?, N. Engl. J. Med., 2006, 355, 64547.
73. Patrick L. Osewe, Yvonne K. Nkrumah, and Emmanuel K. Sackey, Improving Access
to HIV/AIDS Medicines in Africa; Trade-Related Aspects of Intellectual Property Rights Flexibili-
ties (Washington, DC: The International Bank for Reconstruction and Development/The
World Bank, 2008), 157.
74. John Iliffe, The African AIDS Epidemic: A History (Athens: Ohio University Press,
2006), 12659.
75. Anon., Opinion/Editorial, The Wavering War on AIDS, New York Times, 14 May
2010.

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four billion dollars per year.
76
Furthermore, resource-poor countries
cannot contribute the remaining amount, as discounted prices of
drugs remain above their per capita incomes.
77
Consequently, the
people currently being treated represent half of the fteen million
people ill enough or whose immune system is sufciently depleted
to require treatment according to 2010 WHO recommendations
(CD4 ,350 cells/mm
3
).
78
The gure falls even shorter of reaching
2012 recommendations by the International Antiviral Society to treat
all HIV-infected people, in which case all thirty-four million
infected people globally would require treatment.
79
As donor nations and aficted countries cannot afford the life-
prolonging drugs for those who need them, global death rates from
AIDS remain high.
80
Indeed, mortality from AIDS is lower in PEP-
FAR-funded African countries than in nonsupported countries.
81
The
socioeconomic ramications of the two million deaths per year from
AIDS yearly are far-reaching. AIDS strikes predominantly young, sex-
ually active people in the most productive years of their lifethe pop-
ulation responsible for vital functions of society, including food
procurement for their families.
82
Consequently, family infrastructure
has been collapsing with over ten million orphans receiving care from
relatives and severe economic damage has been inicted on societies in
affected countries.
83
Plummeting numbers of teachers, medical staff,
and farmers and closing of schools have been documented in the some
countries.
84
As the number of productive individuals decreases, and the
76. Donald McNeil, Jr., New Cases of AIDS Hit Plateau, New York Times, 21 Novem-
ber 2011.
77. Anon., Opinion/Editorial, Advances on the AIDS Front, New York Times, 3 De-
cember 2010.
78. Department of Health and Human Services, Guidelines for the Use of Antiretrovi-
ral Agents in HIV-1-Infected Adults and Adolescents.
79. Thompson, Aberg, Hoy, et al., Antiretroviral Treatment of Adult HIV Infection:
2012, 387402.
80. Vitoria Marco, Getting the Most from Global HIV Scale Up, in 18th Annual
Conference on Retroviruses and Opportunistic Infections (Boston, Massachusetts, 2011),
110.
81. E. Bendavid, C. B. Holmes, J. Bhattacharya, et al., HIV Development Assistance
and Adult Mortality in Africa, J. Am. Med. Assoc., 2012, 307, 206067.
82. Douglas Feldman and Julia Wang Miller, The AIDS Crisis (Westport, Connecticut:
Greenwood Press, 1998), 3052.
83. Epstein, The Invisible Cure. See also: Alexander Irwin, Joyce Millen, and Dorothy Fallows,
Global AIDS: Myths and Facts (Cambridge, Massachusetts: South End Press, 2003), 59133.
84. Tony Barnett and Alan Whiteside, AIDS in the Twenty-First Century: Disease and
Globalization (New York: Palgrave MacMillan, 2002), 31646.

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amount of land under cultivation dwindles, regions with high HIV
prevalence have confronted chronic food crises.
85
Thus, AIDS is a
health problem and catastrophe that has affected social and economic
dimensions of many societies.
86
New Biomedical Strategies
As the HIV pandemic still rages globally, new biomedical strategies,
including treatment as prevention, have been proposed to control its
spread. This strategy is based on a principle recognized early in the
epidemicthat even people who have no symptoms remain trans-
mitters of HIV.
87
The strategy assumes that ART could reduce the
infectiousness of an infected individual, even those without CD4
cell depletion, by reducing the amount of virus in the blood and in
bodily secretions.
88
In discordant couples, ART indeed reduced the
rate of transmission to the negative partner by 96 percent and also
slowed disease progression in the HIV-treated patient.
89
The study
veried that treatment of all infected people, regardless of their stage
of infection, provided benet to the individual and also reduced the
spread of infection to others.
90
HIV treatment now takes into account the wellbeing of the indi-
vidual and the general population. To be effective, this strategy must
identify all infected people, including the 20 percent of HIV-infected
individuals who are unaware of their diagnosis, and engage this seg-
ment into care.
91
Home-based testing has been proposed as a means
to accomplish enrolling persons into care and providing timely access
to ART.
92
To monitor the success of such test and treat strategies,
studies now use community viral load (CVL), the mean measure
85. Ibid., See also: Anon., Advances on the AIDS Front, New York Times.
86. Farmer, Pathologies of Power, 21346.
87. WHO, PMTCT Strategic Vision 20102015. http://www.who.int/HIV/pub/
mtct/strategic_vision/en/index.html (accessed 29 June 2011).
88. Anon., Editorial, HIV Treatment as Prevention; It Works, Lancet, 2011, 377, 1719.
89. M. S. Cohen, Y. Q. Chen, M. McCauley, et al., Prevention of HIV-1 Infection
with Early Antiretroviral Therapy, N. Engl. J. Med., 2011, 365, 49395.
90. Ibid., 494.
91. S. M. Hammer, Antiretroviral Treatment as Prevention, N. Engl. J. Med., 2011,
365, 56162.
92. E. J. Mills and N. Ford, Home-Based HIV Counseling and Testing as a Gateway to
Earlier Initiation of Antiretroviral Therapy, Clin. Infect. Dis., 2012, 54, 28284.

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of the individual VLs in a given population, to dene the HIV status
of a population in the same way it does for a person.
93
Communities
with high ARTuse have been shown to have reduced CVL in associa-
tion with lower rates of new infections.
94
Test and treat strategies,
along with methods to monitor their efcacy, indicate the increasing
emphasis placed on protecting the population at large. With the dove-
tailing of individual and public health benets of ART, the distinction
between treatment and prevention has become blurred.
Secretary of State Hillary Rodham Clinton laid out a goal of using
promising test and treat strategies to achieve an AIDS-free Genera-
tion.
95
The optimism for this strategy is based on a mathematical
modeling study predicting that universal voluntary HIV testing com-
bined with immediate ART for those found to be positive would
reduce HIV prevalence to 1 percent within fty years.
96
Others,
however, have pointed out mistaken expectations of this prediction
that would emerge in real settings. In fact, the expectation that when
there is life-saving medicine, people will take them properly has not
been born out. In one study, for example, 40 percent of people tak-
ing ART had detectable VL and were able to transmit HIV to others
because they did not take their pills regularly.
97
In addition, the
expectation that once tested, people will initiate care, and once treat-
ment has begun, patients will remain in care has also not been con-
rmed.
98
Consequently, Joep Lange, professor at the Institute for
Global Health and Development in Amsterdam, maintains it is unlikely
93. M. Das, P. L. Chu, G. M. Santos, et al., Decreases in Community Viral Load Are
Accompanied by Reductions in New HIV Infections in San Francisco, PLoS One, 2010, 5,
e11068.
94. J. S. Montaner, V. D. Lima, and R. Barrios, Association of Highly Active Antiretro-
viral Therapy Coverage, Population Viral Load, and Yearly New HIV Diagnoses in British
Columbia, Canada: A Population-Based Study, Lancet, 2010, 376, 53239.
95. Clinton, Remarks on Creating an AIDS-Free Generation.
96. R. M. Granich, C. F. Gilks, C. Dye, et al., Universal Voluntary HIV Testing with
Immediate Antiretroviral Therapy as a Strategy for Elimination of HIV Transmission:
A Mathematical Model, Lancet, 2009, 373, 4857.
97. E. M. Gardner, M. P. McLees, J. F. Steiner, et al., The Spectrum of Engagement in
HIV Care and Its Relevance to Test-and-Treat Strategies for Prevention of HIV Infection,
Clin. Infect. Dis., 2011, 52, 793800.
98. J. M. Tassie, K. Malateste, M. Pujades-Rodriguez, et al., Evaluation of Three Sampling
Methods to Monitor Outcomes of Antiretroviral Treatment Programmes in Low and Middle
Income Countries, PLoS One, 2010, 5, e13899. See also: E. Bendavid, M. L. Brandeau,
R. Wood, et al., Comparative Effectiveness of HIV Testing and Treatment in Highly Endemic
Regions, Arch. Intern. Med., 2010, 170, 134754.

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that test and treat strategies by themselves even if vigorously pursued
by efforts to retain patients in care can end the epidemic.
99
There are also ethical concerns about allocation of scant global
resources to fund the expanded role of ART. Given the shortfall that
exists in access to ART for the millions of people in need of treat-
ment with symptoms or depleted immunity who now go without it,
some have asked: how can it be ethical to provide ARTas prevention
to asymptomatic people with preserved immune function?
100
Health
policy expert Ezekiel Emanuel argues that expanding funding to
provide ART for all HIV-infected people could crowd out resources
and attention from other health priorities, possibly worsening overall
health outcomes.
101
At present, global health programs that improve
the health of poor people worldwide, including malaria and neglected
tropical diseases, receive markedly less funding than PEPFAR.
102
Em-
anuel argues that reallocating existing funds to support these programs
rather than expanded ART could do more good in terms of saving
lives and improving health.
Another biomedical approach, PrEP using ART in at-risk nonin-
fected persons, magnies these ethical concerns.
103
PrEP is 44 per-
cent effective in reducing HIVacquisition if one pill a day is given to
gay men not infected with HIV, but only if taken faithfully.
104
Because the same drugs used for treatment are also a valuable tool to
prevent infections, concerns have arisen about whether it is just to
provide medications to uninfected individuals in developed nations
when poor people elsewhere with AIDS receive none.
105
Given the
global recession, it may be unethical to nd additional money to
treat millions more people to slow the spread of HIV.
106
There are
99. J. M. Lange, Test and Treat: Is It Enough?, Clin. Infect. Dis., 2012, 52, 8012.
100. Anon., Treatment as Prevention for HIV, Lancet, 2011, 11, 65152.
101. E. J. Emanuel, PEPFAR and Maximizing the Effects of Global Health Assistance,
J. Am. Med. Assoc., 2012, 307, 2097100.
102. P. J. Hotez, E. Dumonteil, L. Woc-Colburn, et al., Chagas Disease: The New HIV/
AIDS of the Americas, PLoS Negl. Trop. Dis., 2012, 6, e1498.
103. K. H. Mayer and D. Krakower, Antiretroviral Medication and HIV Prevention:
New Steps Forward and New Questions, Ann. Intern. Med., 2012, 156, 31214.
104. R. M. Grant, J. R. Lama, P. L. Anderson, et al., Preexposure Chemoprophylaxis
for HIV Prevention in Men Who Have Sex with Men, N. Engl. J. Med., 2010, 363,
258799.
105. Anon., Treatment as Prevention for HIV, 651.
106. J. L. Juusola, M. L. Brandeau, D. K. Owens, et al., The Cost-Effectiveness of
Preexposure Prophylaxis for HIV Prevention in the United States in Men Who Have Sex
with Men, Ann. Intern. Med., 2012, 156, 54150.

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also concerns about whether those receiving the drug could be
more likely to engage in risky sex because they believe they are pro-
tectedeven if they do not always take drugs as prescribed.
107
Also,
if not taking the PrEP as prescribed increases the risk of drug resis-
tance, this could pose a further challenge to treating infected people
by creating the need for ever-changing regimens of drugs in various
classes.
108
Despite these concerns, some have argued that there are
compelling reasons to adopt PrEP in clinical practice because there is
no time to lose ground against a scourge that is still infecting people
faster than they can be tested and treated.
109
Because the world does not have the resources to deliver ART to
everyone who needs them for decades and the need for people with
HIV to take drugs every day for life is not a sustainable solution for
tens of millions of infected people, researchers have a renewed interest
in scientic strategies to achieve a therapeutic cure. At the 19th Con-
ference on Retroviruses and Opportunistic Infections in 2012, a ses-
sion for the rst time was devoted to the topic of eradication of HIV.
110
Hope for a cure was raised in part by the experience of an HIV-
infected American who developed acute leukemia, underwent a bone
marrow transplant from a donor with an uncommon genetic mutation
decient in the CCR5 protein that makes cells resistant to HIV infec-
tion, and emerged free of virus without requiring HIV drugs.
111
His
story has inspired scientists to perform eradication strategies to modify a
patients own immune cells by making them resistant to infection by
chemically eliminating CCR5 then re-infusing them.
112
In addition,
ongoing studies have been designed using a drug, vorinostat, that acti-
vates latent viruses and purges it out of resting CD4 cells by reversing a
mechanism that cells use to silence genes.
113
As these approaches
107. D. Tuller, H.I.V. Drug Faces Trial and Raises Questions, New York Times,
11 October 2011, D5D6.
108. C. B. Hurt, J. J. Eron, Jr., and M. S. Cohen, Pre-Exposure Prophylaxis and Anti-
retroviral Resistance: HIV Prevention at a Cost?, Clin. Infect. Dis., 2011, 53, 126570.
109. Anon., Treatment as Prevention for HIV, 651. See also: Anon., Editorial, Still
Fighting against AIDS, New York Times, 28 November 2011, A20.
110. M. Buzon, K. Seiss, A. Stone, et al., Treatment of Early HIV Infection Reduces
Viral Reservoir to Levels Found in Elite Controllers, 19th Conference on Retroviruses and
Opportunistic Infections, Seattle, Washington, 58 March 2012.
111. Carl June and B. Levine, Blocking HIVs Attack, Sci. Am., 2012, 306, 5459.
112. C. June, P. Tebas, D. Stein, et al., Induction of Acquired CCR5 Deciency with
Zinc Finger Nuclease-Modied Autologous CD4T Cells (Sb-728-T), 19th Conference on
Retroviruses and Opportunistic Infections (CROI), Seattle, Washington, 58 March 2012.

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involve cellular reinfusion or genetic engineering, neither is appropri-
ate for testing on global scale.
114
The enthusiasm for curative therapies, PrEP, and test and treat
approaches may be considered in the context of the absence of an
effective HIV vaccine. In 2001, Jon Cohen, medical writer for Sci-
ence, maintained that we did not have an HIV vaccine because of the
lack of coordination by academic researchers, pharmaceutical com-
panies, and funding agencies in taking selected vaccine candidates to
clinical trials.
115
Subsequently, such a coordinated approach showed
that one vaccine construct had marginal efcacy, 32 percent, but
only if people received yearly booster shots or engaged in low-risk
activities.
116
All other trials have shown promising preclinical vaccine
candidates to be ineffective.
117
Scientists believe that no vaccine can-
didate has been effective to date because unique biological properties
of HIV virusits ability to mutate and avoid immune recognition
and responsepreclude recognition of the correlates of immune
protection.
118
Furthermore, neutralizing antibody responses to vac-
cine candidates have not demonstrated activity against a wide range
of viruses. Nonetheless, scientists continue their efforts to overcome
these biological hurdles to produce the vaccine people have hoped
for since the inception of the epidemic.
Prominent science writers such as Lawrence Altman and Laurie
Garrett argue that an effective vaccine will need to be available in
order to end the epidemic.
119
Providing ART to all who need it on
a continued basis is too costly and impractical, these writers argue.
Even if these biological hurdles are overcome and the vaccine
113. L. Shan, K. Deng, C. Durand, et al., Elimination of the Latent Reservoir for
HIV-1 Requires Induction of CTL Responses. Paper presented at the 19th Conference on
Retroviruses and Opportunistic Infections (CROI), Seattle, Washington, 58 March 2012.
114. M. J. Friedrich, Scientists Investigate Routing Latent HIV from Its Reservoirs to
Achieve a Cure, J. Am. Med. Assoc., 2012, 308, 32527.
115. Cohen, Shots in the Dark, 228369.
116. Supachai Rerks-Ngarm, et al., Vaccination with ALVAC and AIDSVAX to Prevent
HIV-1 Infection in Thailand, N. Engl. J. Med., 2009, 361, 220920. The study showed an
efcacy of 30 percent.
117. Corie Lok, His Best Shot: Can Bruce Walker Transform HIV Vaccine Research?,
Nature, 2011, 473, 43941.
118. Jose Esparza, Understanding the Efcacy Variables of an HIV Vaccine Trial,
Lancet Infect. Dis., 2012, 12, 499500.
119. Laurie Garrett, The Wrong Way to Fight AIDS, New York Times, 30 July 2008.
See also: Lawrence Altman, AWorld without AIDS, Still Worlds Away, New York Times,
31 July 2012.

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candidate passed through the necessary stages of clinical testing,
however, policy experts argue that they would need to be accompa-
nied by successful prevention strategies to reduce high-risk behavior
in order to be effective and ensure that all populations are engaged
in clinical care and remain in clinical care in order to receive their
booster shots.
120
Moreover, health ofcials will need to confront the
logistical task of manufacturing it in adequate quantities and deliver
it to the worldwide population at risk, and resolve ethical issues in
selecting the appropriate target population.
121
Thus, an effective vac-
cine, if available, would only be able to control the epidemic if
accompanied by efforts to address broader social and ethical issues
and to improve traditional behavioral messages.
Behavioral and Structural Prevention Programs
Social scientists and policy makers have doubted the effectiveness of the
basic tenets of conventional behavioral prevention efforts because the
epidemic continues to spread despite their use. Assuming that the risk
for HIV is based on unwise personal choices, conventional programs
focus on moderating individual behavior.
122
These preventive programs
assume that humans are rational and their key behaviors are under cog-
nitive control of the individual.
123
Cognitive approaches fail, social sci-
entists claim, because people may be unable to change their behavior
despite being aware of how HIV is spread.
124
Conventional approaches
mistakenly assume that anyone can achieve protection if they so choose
and they neglect broader socioeconomic structures at the population level
that prompt risky behavior and create environmental susceptibility.
125
The socioeconomic ingredients that create a vulnerable environ-
ment for a heightened risk for HIV transmission are present in devel-
oping and industrialized nations. Limitation of job options in
120. Supachai Rerks-Ngarm, et al., Vaccination with ALVAC and AIDSVAX to Prevent
HIV-1 Infection in Thailand, 220920.
121. Irwin, Millen, and Fallows, Global AIDS: Myths and Facts, 153185. See also: Bourke,
The Skeptics Guide to the Global AIDS Crisis, 183.
122. Barnett and Whiteside, AIDS in the Twenty-First Century, 182221.
123. Catherine Campbell, Letting Them Die: Why HIV/AIDS Prevention Programmes
Fail (African Issues) (Bloomington, Indiana: Indiana University Press, 2003), 13296.
124. Hung Y. Fan, Ross F. Conner, and Luis P. Villarreal, AIDSScience and Society
(Sudbury, Massachusetts: Jones and Bartlett Publishers, 2004), 14082.
125. Ronald O. Valdiserri, Mapping the Roots of HIV/AIDS Complacency: Implica-
tions for Program and Policy Development, AIDS Educ. Prev., 2004, 16, 42639.

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communities with chronic unemployment could humiliate men,
breeding fatalism that may encourage personal risk-taking (drug
use).
126
Also, lack of access to education may limit poor womens
employment opportunities and force them into work (e.g., prostitu-
tion) that involves increased risk, especially in regions where gender
disparities may not allow them to negotiate condom use with cli-
ents.
127
In some developing countries, men who travel long distances
to nd work (e.g., migrant workers, truck drivers, military personnel,
refugees from wars) may adopt risky behaviors including frequenting
prostitutes while being uprooted from family.
128
In Africa, the culture
of having concurrent partnerssimultaneous long-term relation-
shipsmeans a single persons infection may spread rapidly through a
group.
129
In developed countries, undereducated people, particularly
African Americans and Latinos, in poor urban neighborhoods may
nd involvement in illicit drug trade one of few economic options.
130
As inner-city residential patterns became unstable and social support
became less available, survival can elicit culture expressions that exag-
gerate risk behaviors including drug use, crime, and violence.
131
Social scientists and public health authorities insist that public
health approaches can no longer neglect wider socioeconomic
constraints imposed upon peoples lives. They claim that conven-
tional prevention programs fail because they overestimate the degree
of agency that people are able to exercise and underestimate the
extent to which people may be constrained by factors they cannot
effectively control.
132
For example, AIDS prevention campaigns that
126. Mark Hunter, Love in the Time of AIDS: Inequality, Gender, and Rights in South Africa
(Bloomington: Indiana University Press, 2010), 15578.
127. Greg Szekeres, The Next 5 Years of Global HIV/AIDS Policy: Critical Gaps and
Strategies for Effective Responses, AIDS, 2008, 22, S9S17.
128. Ezekiel Kalipeni, HIVand AIDS in Africa: Beyond Epidemiology (Malden, Massachu-
setts: Blackwell Publishers, 2004), 17590.
129. Epstein, The Invisible Cure, 14152.
130. Jacob Levenson, The Secret Epidemic: The Story of AIDS and Black America
(New York: Pantheon Books, 2004), 12668.
131. David McBride, From TB to AIDS: Epidemics among Urban Blacks since 1900, SUNY
Series in Afro-American Studies (Albany: State University of New York Press, 1991),
15972. See also: R. Wallace, M. Fullilove, and A. Flisher, AIDS, Violence and Behavioral
Coding: Risk Behavior and Dynamic Process on Core-Groups Sociogeographic Net-
works, Soc. Sci. Med., 1996, 43, 33952.
132. Chris Collins, Thomas J. Coates, and James Curran, Moving beyond the Alphabet
Soup of HIV Prevention, AIDS, 2008, 22, S5S8.

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tell economically disadvantaged women to avoid commercial sex
work may be asking them to relinquish their only source of support
for their families.
133
Similarly, knowledge that barrier methods can
prevent transmission of HIV or distributing condoms to them is of
little value if a womans economic dependence leaves her unable to
negotiate condom use with her sexual partners.
134
Additionally,
attempts to change behavior in Africans with concurrent partners
will not be effective without taking into account indigenous African
values about simultaneous long-term relationships in which friend-
ship and trust may thwart routine condom use.
135
Moreover, asking
drug users not to share needles will not result in this behavioral alter-
ation unless safe facilities are available and repressive laws that inhibit
drug users from using these facilities are changed.
136
The only hope
of changing behavior, social scientists, and policy experts maintain is
to recognize and address the underlying societal and legal structural
factors that constrain individual agency and propel groups into risky
situations.
137
Structural programs, either proposed or implemented in a various
communities, aim to change a broad array of environmental factors
that determine population vulnerability.
138
They target the physical
environment (e.g., improving street lighting to reduce the likelihood
of rape, or improving road surfaces to reduce transportation time and
the number of overnight stops made by truck drivers). They involve
health and safety legislation to improve the working environment of
sex workers (e.g., registration of commercial sex workers and inspec-
tion of brothels to ensure they comply with regulations, licensing
workers who have medical inspections and are cleared medically, and
mandating customers comply with regulations to use condoms). They
expand clinical services (e.g., needle and exchange programs, ensuring
133. Campbell, Letting Them Die, 120.
134. James R. Hargreaves, Christopher P. Bonell, Linda A. Morison, et al., Explaining
Continued High HIV Prevalance in South Africa: Socioeconomic Factors, HIV Incidence
and Sexual Behaviour Change among a Rural Cohort 20012004, AIDS, 2007, 21, S39
S48.
135. Epstein, The Invisible Cure, 15571.
136. McBride, From TB to AIDS, 15972.
137. G. R. Gupta, J. O. Parkhurst, J. A. Ogden, et al., Structural Approaches to HIV
Prevention, Lancet, 2008, 372, 76475.
138. K. M. Blankenship, S. R. Friedman, S. Dworkin, and J. E. Mantell, Structural
Interventions: Concepts, Challenges and Opportunities for Research, J. Urban Health,
2006, 83, 5972, 59.

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access to drug substitution therapy for chemical dependence) or create
a shift in legal policy where the use of certain drugs or employment in
sex work is illegal.
139
They can address society-level factors and can
empower sex workers through community mobilization and peer
counseling to establish norms of responsible behavior within a specic
community.
140
They include cash-transfer programs to provide
women with capital to start their own income-generating activities, or
use cash payments to encourage children and adults in poor house-
holds to improve their education and healthcare.
141
These diverse
structural programs target the drivers of HIV risk at the population
and environment rather than the individual level.
Effective structural programs are context-specic and tailored to a
given group within urban and rural communities.
142
The right choice
and combination of strategies depends on the prole of the particular
population engaging in risky activities. Programs may focus on needle
exchange programs to reduce needle sharing in some Eastern Euro-
pean countries, reducing concurrent sexual partners in monogamous
couples in rural South Africa, or using peer-education to reduce
high-risk behaviors among gay men, particularly African American
gay men, in urban American settings.
143
To be successful, peer-
education strategies must not be uniform, but customized to the social
make-up of particular targeted vulnerable group, such as female sex
workers, female bar workers in truck stops, and male transport work-
ers, who are often alienated from boilerplate generic prevention
messages and formal service providers who are not members of their
group.
144
Such customized approaches involve gaining access to social
networks through key individuals and asking them to disseminate
HIV risk reduction messages throughout their networks.
145
Messages
139. Ibid., 20.
140. David Dickinson, Changing the Course of AIDS: Peer Education in South Africa and Its
Lessons for the Global Crisis, The Culture and Politics of Health Care Work (Ithaca: ILR
Press, 2009), 180203.
141. H. Kohler and R. Thornton, Conditional Cash Transfers and HIV/AIDS Preven-
tion: Unconditionally Promising?, World Bank Econ. Rev., 2011, 10, 126.
142. T. J. Coates, L. Richter, and C. Caceres, Behavioural Strategies to Reduce HIV
Transmission: How to Make Them Work Better, Lancet, 2008, 372, 66984.
143. Dickinson, Changing the Course of AIDS, 20416.
144. S. Allen, Effect of Serotesting with Counseling on Condom Use and Seroconver-
sion among HIV-serodiscordant Couples in Africa, Br. Med. J., 1992, 304, 16059.
145. Coates, Richter, and Caceres, Behavioural Strategies to Reduce HIV Transmis-
sion, 676.

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delivered in groups at social institutions including the workplace, pri-
son, military, faith-based organizations, and schools are examples of
context-specic community mobilization aimed at enhancing social
support for HIV-infected people.
Comprehensive Strategies to Control HIV
Public health experts argue that HIV control programs must be com-
prehensive and combine biomedical strategies with structural and
individual prevention strategies. Michael Merson, from the Duke
Global Health Institute and Joep Lange, for example, argue that since
many people will remain viremic and able to transmit HIV to others
despite test and treat strategies, combination HIV prevention includ-
ing widespread ART, individual behavior counseling and structural
programs will be required to control the HIVepidemic.
146
Anthro-
pologist Joao Biehl has evaluated one comprehensive program, the
Brazilian AIDS Control Program (BACP), and found that it has not
employed a sufcient mix of available prevention tools.
147
He posits
that the Brazilian government made ART available without charge
to all HIV-infected citizens but ignored the structural conditions that
gave rise to the epidemic. Biehl argues that the BACP failed because
it was too narrow in its focus and neglected the social disparities that
fueled the epidemic, including demands for adequate housing and
employment and the provision of the social support infrastructure.
148
The governments of several developed and developing nations
have implemented comprehensive biomedical and structural HIV
control programs. Uganda, Philippines, and Thailand, in fact, have
provided roll-out programs that make ART accessible to patients,
served as sites for ART and vaccine clinical trials, endorsed tailored
structural approaches to HIV prevention aimed at groups at elevated
risks.
149
These nations have licensed, controlled, and regulated the
health of sex workers within a legally sanctioned framework whereby
146. Lange, Test and Treat: Is It Enough?, 8012. See also: M. Merson, N. Padian,
T. J. Coates, et al, Combination HIV Prevention, Lancet, 2008, 372, 18056.
147. Joao Guilherme Biehl and Torben Eskerod, Will to Live: AIDS Therapies and the
Politics of Survival (Princeton, New Jersey: Princeton University Press, 2007), 105336, 148
and 285.
148. Ibid., 105336.
149. Ethan Kapstein and Josh Busby, Antiretrovirals as Merit Goods, in Richard Parker
and Marni Sommer, eds., Routledge Handbook of Global Public Health, (New York:
Routledge, 2011), 46170.

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workers are examined regularly in clinics, provided with diagnostic
screening tests and treatment services and are required to be medically
cleared in order to continue working.
150
These programs enlisted the
cooperation of sex establishment owners and sex workers to encour-
age all clients to use condoms and implemented multimedia educa-
tion campaigns, including school education on AIDS.
151
Canada has
provided environments in which IVDUs can protect themselves
against HIV that include needle exchange programs and sites where
injection can take place under the watch of healthcare personnel in
order to insure safe practices.
152
In the United States, Kevin Fenton,
Director of HIV Prevention at the Centers for Disease Control and
Prevention (CDC), for example, has advocated broadening the scope
of traditional prevention programs to include structural programs.
153
The AIDS control programs of these nations are based on the
principle that public health efforts that rely solely upon biomedical
efforts and individual behavioral moderation will not be successful
unless they also take into account strategies to rectify the environ-
mental and social ills responsible for those behaviors. These nations
have not relied on technology alone to control HIV spread. Rather,
their national control programs show that the sensational advances of
virology and technology that produced ART does not work by itself
divorced from social, economic, or environmental considerations.
The HIV programs of these countries illustrate how the biomedical
approach aimed at the individual and the social approach aimed at
the environment are not always mutually exclusive. Biomedical
approaches that focus on individual treatment and prophylaxis and
social approaches that take into account social and economic factors,
as well as addressing risky environments can be complementary
rather than binary.
Comprehensive public health programs that include structural
measures are not unique to HIV and are used in a variety of con-
texts in global public health. For example, they have been put into
150. Gupta, Parkhurst, and Ogden, Structural Approaches to HIV Prevention, 764.
151. Barnett and Whiteside, AIDS in the Twenty-First Century, 31646.
152. Donald McNeil, Vancouver Injection Site Aimed to Show That Treatment Is Pre-
vention. Now the City Is Driving Back the Disease, New York Times, 8 February 2011, D1.
153. Kevin Fenton, Social and Structural Barriers to HIV Prevention, Emerging Les-
sons from the U.S. Session 35, Paper 116, Programs and Abstracts from the 17th Conference
on Retroviruses and Opportunistic Infections, San Francisco, California, 27 February
2 March 2010.

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place to address income disparities and improve problems of sanita-
tion that have led to feculent contamination of the water supply to
counteract cholera and other causes of diarrheal illnesses globally.
154
Examples of other structural programs include reducing barriers to
access essential medicines to treat Chagas disease, including com-
munity education to address the stigmatization of persons with the
disease that prevent them from seeking healthcare.
155
Notwithstand-
ing these particular examples, public health ofcials maintain that
policy changes that address the structural factors may be seen as
being too inefcient, expensive, imprecise, taking too long to make
any meaningful change, or trying to address factors that may not
have any relevance to controlling a disease.
156
In addition, there may
not be a good way to measure the effectiveness of such broad struc-
tural strategies that seek to change society-level factors in controlling
these infections. It has been proposed that, for these reasons, the
health sector tends to gravitate toward more efcient proximal con-
trol of the epidemic by targeting the causative microbe using bio-
medical approaches.
157
HI STORI C ROOTS FOR COMPREHENSI VE STRATEGI ES TO
HANDLE AI DS AS A CHRONI C DI SEASE
The nineteenth-century idea that preventive efforts need to take
social responsibility into account and be directed toward rectifying
environmental factors to stop infectious epidemics is the historic ana-
logue for structural measures being used to rectify the factors that cre-
ate a vulnerable HIV environment today. The nineteenth-century
public health movement was based on the idea that the environment
in which the person lived was the major determinant of physical dis-
ease. There was the assumption that lthy and degrading surroundings
doomed particularly the poor to unhealthy lives. Throughout the
nineteenth century, the considerable death and destruction that chol-
era, tuberculosis, smallpox, and yellow fever caused in American cities
prompted public health programs to control the disasters that
154. Sharon Friel and Michael Marmot, Global Health Inequities, in Parker and
Sommer, eds., Routledge Handbook of Global Public Health, 6579.
155. Richard Parker and Marni Sommer, Introduction, in Parker and Sommer, eds.,
Routledge Handbook in Global Public Health, 18, 6.
156. Kapstein and Busby, Antiretrovirals as Merit Goods, 467.
157. Gupta, Parkhurst, and Ogden, Structural Approaches to HIV Prevention, 765.

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occurred. Consequently, much of the work during the nineteenth
century rested on the prevailing theory that dirt caused disease and
that social conditions led a person toward an unhealthful life.
The rst step in reducing mortality among the poor was to reform
the physical and social environment in which they lived.
158
Health
ofcers developed a broad range of responses that included massive
urban sanitation projects to bring clean water into the city, prevent the
pollution of streams to reduce feculent water supply, to clean streets,
remove dead animals and other nuisances, institute efcient sewage and
garbage disposal. Preventive efforts were directed toward regulating ten-
ement housing to rectify its inadequacies, improving poor working
environments to prevent consumption (e.g., ventilation and sunlight,
whitewashing and repairing tenements), and restraining slaughter-
houses. These strategies also involved social and economic reforms
designed to rectify the low wages in which workmen were caught in
order to reduce behaviors such as excessive alcohol use that were
unhealthy. Efforts to instruct an individual to change behavior without
taking social factors that determine behavior into account were thought
to be unsuccessful.
159
Unhealthy behavior was rooted in environmental
defects and efforts to change behavior were thought to be necessary in
order to correct remediable environmental defects.
160
Thus, as is the
case in HIV today, the nineteenth-century public health ofcials
located the program of prevention in a framework of social and envi-
ronmental deterrents that rendered the individual powerless to protect
himself.
The nineteenth-century public health campaigns also assumed
that freedom from disease depended on everyone accepting the social
responsibility as well as moral obligation to behave with personal
moderation in order to protect society.
161
Thus, there is historical
precedence in public health measures addressing the assumption of
personal obligation for changing habits and assuming personal
158. Elizabeth Blackmar, Accountability for Public Health: Regulating the Housing
Market in Nineteenth-Century New York City, in David Rosner, ed., Hives of Sickness
(New Brunswick, New Jersey: Rutgers University Press, 1995), 4263.
159. John Duffy, The Sanitarians (Urbana and Chicago: University of Illinois Press,
1990), 13892.
160. Barbara Gutmann Rosenkrantz, Public Health and the State; Changing Views in Mas-
sachusetts, 18421936 (Cambridge, Massachusetts: Harvard University Press, 1972), 3774,
171.
161. Ibid., 3796.

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moderation to protect ones own health and to promote the health
of the general population. In liberal democratic societies, it is the
responsibility of the infected person to behave responsibly, to restrict
their behavior while maintaining their liberty in order to protect the
uninfected and insure the survival of the community. These behav-
iorsbathing, no spitting, breastfeeding, and reduction in alcoholism,
guided by morals and norms of the community, were once the focus
of nineteenth-century public health movements. Accepting individual
responsibility to restrict personal liberties and moderate personal
behavior in order to benet the health of the population is a historical
analogue of gay men in the 1980s and of the messages of peer-educators
in multiple settings today who took responsibility to moderate their
behavior in order to protect the survival of their community.
These nineteenth-century public health efforts made sense at a
period of time when the lth theory of disease led to the view that
susceptibility to disease was due to environmental conditions. But
the dominant belief that the absence of lth was sufcient safeguard
against contagion was contested as scientists identied microbes that
caused specic disease entities. The hope and promise following the
discovery of new microbes in the 1890s led public health workers to
incorporate the ndings of bacteriology into their public health
practices. In the case of diphtheria in the 1890s, a shift in public
health efforts from general environment toward the individual was
beginning to occur.
162
By the mid-1890s, health departments began
to utilize bacteriology laboratories to perform diagnostic tests on an
individual basis to determine whether it was appropriate to adminis-
ter a preventive vaccine or a therapeutic serum.
163
This marked a
shift from a policy directed to the restraint of disease through sanitary
engineering and social reform at the environmental level to a pro-
gram designed to identify, control, and eradicate disease through
medical and scientic means at the individual level.
By the early twentieth century, public health authorities argued
that a scientic understanding of the elements involved in the trans-
mission of communicable diseases permitted greater discrimination
162. Evelynn Hammonds, Childhoods Deadly Scourge (Baltimore, Maryland: The John
Hopkins University Press, 1999), 1787.
163. Bela Schick, Die Diphtherietoxin-Hautreaktion des Menschen als Vorprobe der
prophylaktischen Diphtherieheilserum-injection, Munchen. med. Wchnschr, 1913, 60,
260810.

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in implementing disease control measures than had been previously
possible. In 1901, Charles Chapin, Superintendent of the Depart-
ment of Public Health in Rhode Island, was a leader in using bac-
teriology to move the focus of public health work away from
environmental sanitation and toward scientic testing of individu-
als.
164
As bacteriologists identied microorganisms responsible for
specic diseases and uncovered their mode of action, Chapin argued
to replace indiscriminate municipal environmental cleanup programs
with methods that would be made more precise and denite by the
use of bacteriologic tools to identify infection in an ill or healthy
person (carrier), then correctly choose the corresponding practice
that logically followed this testingvaccination, isolation, or treat-
ment with serum.
165
He advocated tailoring these specic interven-
tions on an individual basis, as determined by bacteriologic testing,
instead of the abatement of nuisances and inefcient sanitary envi-
ronmental efforts that characterized previous public health efforts.
Physicians and medical historians later in the twentieth century
further articulated Chapins argument that bacteriology allowed
for development of public health along more specic lines than
had been possible before. Stephen Smith, public health ofcer in
New York Metropolitan Board of Health, stated in 1921, knowl-
edge of disease transmission among individuals has superseded indis-
criminate sanitary practices and superstition.
166
Howard Kramer, a
medical historian, said in 1948 that bacteriology allowed for cer-
tainty as to diagnosis . . . [and] knowledge of the method of disease
transmission.
167
John Duffy, a professor of history, also argued in
1990 that the bacteriology laboratory yielded accurate and precise
methods of preventing the spread of disease by the use of vaccines.
168
George Rosen, a physician and professor of medical history, stated in
1958 that the empirical shotgun environmental methods of an
164. Charles V. Chapin, Dirt, Disease and the Health Ofcer, Public Health: Papers and
Reports, 1902, 28, 29699. See also: James E. Cassedy, Charles V. Chapin and the Public Health
Movement (Cambridge, Massachusetts: Harvard University Press, 1962), 12642.
165. Charles V. Chapin, The Sources and Modes of Infection (New York: John Wiley &
Sons, 1910), 11025.
166. Stephen Smith, The History of Public Health, 18711921, in Mazyck P. Ravenel,
ed., A Half Century of Public Health (New York: American Public Health Association, 1921),
79.
167. Howard D. Kramer, The Germ Theory and the Early Public Health Program in
the United States, Bull. Hist. Med., 1948, 22, 23347.
168. Duffy, The Sanitarians, 2056.

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earlier day could now be made more precise and denite.
169
These
historians concurred with Chapin that bacteriology had directed the
focus of public health away from rectifying generally risky environ-
ments toward more individualized, scientic, and focused means of
control.
As medical prophylaxis and therapy were introduced, the emphasis
of public health during the twentieth century shifted away from
social reform and environmental improvements and was directed
toward scientic interventions that emphasized germ prevention or
eradication of disease in the individual.
170
A faith in science that
began to replace social reform as a means to halt the spread of infec-
tious epidemics in the early twentieth century was reinforced by suc-
cesses of antibiotics and vaccines in handling a variety of bacterial
and viral infections in the 1950s. There was increasing condence
that specic cures and preventive vaccines could be developed,
focusing on specic disease-prevention programs.
171
The need for
social reform and environmental changes seemed remote following
the successes of the biomedical model in handling the polio and
smallpox epidemics during the decades immediately preceding the
AIDS pandemic.
But as the AIDS pandemic has evolved, public health authorities
have insisted on social measures targeted at the environmental level to
accompany the biomedical approach. The AIDS pandemic shows that
public health policies that target social and environmental issues, which
were once the focus of nineteenth-century public health issues, remain
an important component of a public health campaign against epidemics
todaytogether with biomedical therapeutic and preventive strategies.
The new treatment and public health policies that have been advocated
for HIV illustrate that social reforms targeting changing risky environ-
ments and biomedical approaches targeting individuals are comple-
mentary and not dichotomous approaches. For AIDS, public health
measures that emphasize personal responsibility and incorporate social
factors that target the environment remain relevant as they were in late
nineteenth-century America.
169. George Rosen, A History of Public Health (1958; rpt. Baltimore, Maryland: The
John Hopkins University Press, 1993), 270319.
170. Rosenkrantz, Public Health and State, 97127.
171. Dubos, Mirage of Health, 21235.

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CONCLUSI ON
I examine AIDS as a chronic disease with its own set of vexing medi-
cal and ethical problems and place it in historic perspective. In the
early phase of the epidemic, when AIDS was a fatal disease, historians
placed AIDS in historic perspective, using the idiom of pestilence, to
underscore the dangers caused by blaming maligned victims. But his-
torians have not placed AIDS as it has evolved into a chronic disease
into historic perspective. In this article, I show how public health
ofcials argue that a variety of biomedical strategies proposed to end
the epidemic today, including treatment as prevention and PrEP,
cannot handle the epidemic by themselves without being accompa-
nied by structural prevention measures that address social problems
that account for risky environments. Late nineteenth-century pre-
germ public health approaches to rectify social issues that underlie
vulnerable environments are the historic roots of the comprehensive
biomedical and structural programs used to handle AIDS today.
This analysis about the historic roots of AIDS as a chronic disease
supports arguments made by historians who contest any implication
that bacteriology may have reduced public health departments to scien-
tic considerations alone. These historians have examined public health
practices in the domestic setting, state health departments, or schools of
public health. Nancy Tomes, for example, maintained that it was not
until the rise of the early twentieth century bacteriologically based
public health that popular education and domestic hygienic practices
became imperatives of the movement.
172
Similarly, Barbara Rosenkrantz
argued that the public health movement maintained its interest in
the broader social and economic determinants of disease while the
conception of state medicine became increasingly biomedical.
173
Like-
wise, Elizabeth Fee asserted that newer bacteriologic views of public
health did not extinguish competing models for public health that
related ill health to the larger social environment.
174
These authors,
172. Nancy Tomes, The Private Side of Public Health: Sanitary Science, Domestic
Hygiene, and the Germ Theory, 18701900, Bull. Hist. Med., 1990, 64, 50939.
173. Rosenkrantz, Public Health and the State, 12327.
174. Elizabeth Fee, Disease & Discovery: A History of the Johns Hopkins School of Hygiene
and Public Health, 19161939 (Baltimore: John Hopkins University Press, 1987), 925.

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along with Judith Walzer Leavitt, point out that the need to relate dis-
ease to the larger social environment persists even in the germ era.
175
The AIDS pandemic, with its spectacular scientic advances, dem-
onstrates how public health measures that take into account social,
moral, and economic considerations remain a mainstay of public
health activities. AIDS is an epidemic where the remarkable advances
of biomedicine have been moderated with policies that take the social
context of a vulnerable environment into account. Virology has not
isolated HIV from its environment and social and moral context any
more than nineteenth century predecessors who were driven by the
lth theory of disease. Identication of the microbe as a single cause
of HIV did not limit health practices and policies to the dimension of
nding and eliminating the virus. Even if a cure, vaccine, or both
were available today, the moral, social, and economic facets that have
accompanied the pandemic to date would endure. There would be
persistent ethical issues regarding which the groups should receive it
given limited global funding, and social issues regarding how to mini-
mize risky behavior among recipients. There would also be human
rights issues regarding which patients should receive a curative drug
given that it would be costly and not affordable by all nations. Thus,
the history of AIDS shows that the biomedicine constitutes only one
determinant of public health activity and that reductionist solutions
Chapin had hoped for are not applicable.
For AIDS, public health activities cannot avoid taking into account
the broader, structural elements that encompass social, political, and
economic determinants of disease along with technological campaigns.
According to historian Nancy Leys Stepan, narrow technologic public
health approaches were common in the 1950s when politicians used
technologic, vertically structured campaigns in attempts to eradicate
various epidemics that neglected to include broader political or eco-
nomic considerations.
176
Stepan links the failure to eradicate epidemics
for which there is a cure, such as yaws, to the absence of health services
capable of taking over vertical public health programs on a routine
175. Judith Walzer Leavitt, Typhoid Mary Strikes Back: Bacteriological Theory and
Practice in Early 20th Century Public Health, in Judith Walzer Leavitt and Ronald L.
Numbers, eds., Sickness & Health in America. Readings in the History of Medicine and Public
Health, 3rd ed. (Madison: University of Wisconsin Press, 1997), 55572.
176. Nancy Leys Stepan, Eradication: Ridding the World of Diseases Forever? (Ithaca, New
York: Cornell University Press, 2011), 22461.

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basis, lack of grass-roots support, and failure to address patients eco-
nomic and political circumstances (e.g., rural poverty, poor housing,
poor sanitation, and other structural factors). Her argument that the
narrow scope of these public health campaigns was responsible for their
failure to control these epidemics is familiar to the arguments made by
social scientists during the AIDS epidemic today, where there has been
an effort to accommodate a more comprehensive healthcare approach
that encompasses the biomedical within the broader social and envi-
ronmental context. Such an integrative approach has been adopted
those who have approached the idea of eradicating the HIVepidemic
with an integrative model that has taken comprehensive healthcare into
account.
177
AIDS reinforces that biomedical advances have not worked
by themselves divorced from their social, economic, and ethical con-
siderations. Today, a comprehensive approach to handle or end the
AIDS epidemic with widespread ART as treatment and prevention
stresses the importance of both social approaches at the environmental
level to complement biomedical approaches at the individual level.
ACKNOWLEDGMENTS
The author would like to thank Allan Brandt, Joel Howell, and
Martin Pernick for their helpful insights and invaluable suggestions
in writing this manuscript. He would also like to thank Carly Kish
for preparing the manuscript.
FUNDI NG
None.
177. Clinton, Remarks on Creating an AIDS-Free Generation. Clinton advocates a
comprehensive approach that includes biomedical methods along with a broad array of
structural public health interventions.

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