Sexually Transmitted Diseases
SEXUALLY TRANSMITTED DISEASES
Until the 1980s, social science research on sexually transmitted diseases (STDs) focused primarily on the history of various pestilences, the epidemiology of those diseases, and the description of mass disasters (Brandt 1985; Aral and Holmes 1999). The disease that was most commonly researched was syphillis, long the best identified and most feared STD. Historians and anthropologists wrote numerous treatises on its origin and the social consequences of its introduction into isolated, tribal, or third world societies (Wood 1978; Hart 1978). In the early 1980s, the consequences of other STDs were studied, especially as sequelae of prostitution (Kalm 1985; Poherat et al. 1981).
When awareness of the "sexual revolution" finally induced social scientists and epidemiologists to think about the effects of STDs on less sexually active populations than prostitutes and their clients, the literature turned to the newly sexually active: vulnerable teenagers (Washington et al. 1985) and other young people who engaged in premarital sex (O'Reilly and Aral 1985). The exponential intensification of the discussion of and social science research on STDs, however, came only after the medical commmunity's horrified acknowledgment that the newest STD to become epidemiologically important, the acquired immune deficiency syndrome (AIDS), was also the deadliest and that social, not just biological, information was essential in order to combat it.
When AIDS first began to be discussed in 1981, the medical community was already alarmed at its mystery and virulence (Aral and Holmes 1999). Unhappily, it took years before more focused measures, such as those taken by fundraising organizations and institutes devoted to AIDS research, were initiated. Journalists, most notably Randy Shilts (1987), have persuasively argued that the lack of a strong reaction from the start was due to the fact that the early victims were gay men, not American Legionnaires or Girl Scouts. Today the basic facts of AIDS have been well disseminated. Almost everyone knows, for example, that in the United States gay men are disproportionately affected, as are people who mix blood while exchanging hypodermic needles. However, in the early 1980s, information was abysmally inadequate and myth and rumor educated more people than did social or medical research.
With the accuracy of hindsight, it is evident that sociologists should have looked at sociocultural histories of recent sexual behavior and used that information to help study disease transmission. But no one was proactive, and it took years for a pertinent literature to emerge. The exceptions were a small group of social researchers at the Centers for Disease Control (CDC), whose work was restricted to STD-related topics, and a few epidemiologists studying the social location of this disease among gay American men (Aral and Holmes 1999) and among heterosexuals in Africa. Otherwise, the analysis of AIDS remained mostly ghettoized in the medical literature until the mid- 1980s. Until the publication in 1994 of the results from a large national survey of adult sexuality in the United States (Laumann et al. 1994), the best available data on sexual behavior were the Kinsey studies from the 1940s and early 1950s.
Finally, the combination of organized gay activism and public alarm created the kind of political pressure that made more money available and launched a flood of AIDS research. Indeed, interest in sex research in general, previously an area treated like a poor relation, received more credibility, though not enough to allow the funding of a nationally representative study of sexual behaviors. A large national study slated to be funded by the National Institutes of Health was stopped in 1990 after Senator Jesse Helms helped persuade the U.S. Senate that Americans should not be exposed to such questions. Nonetheless, research on sexuality, especially on STDs, found funds and larger and more diverse professional audiences. Even before the prevalence of AIDS among gay men was understood or publicized, some research described how great numbers of anonymous sexual contacts in gay bars, baths, and parks happened and how such activity set the stage for infection (Darrow 1979; Ross 1984; Klovdahl 1985). By the 1990s research attention had become focused on how sexual cultures, such as a "gay lifestyle," increased exposure to the human immunodeficiency virus (HIV). Later, the issue was reframed to focus on behaviors that place people at risk (rather than on the groups to which they belong) and the social and psychological factors that influence sexual decision making. This avenue of research affirms that sex is a social behavior that must be studied in its social context.
Current AIDS literature centers on two main issues: (1) who is at risk and why and (2) risk-reduction factors, including education.
WHO IN THE UNITED STATES IS AT RISK AND WHY
Most researchers include in their lists of risk factors number of partners, sex of partners, intravenous (IV) drug use or an IV-drug-using partner (Ehrhardt et al. 1995), frequency of intercourse (Aral and Cates 1989), use of condoms (Morrison et al. 1995), contact with commercial sex workers (Plummer et al. 1999), and sex with bisexual men (Doll and Ostrow 1999). The last factor has been of increasing interest, since there seems to be more bisexuality than mainstream research acknowledged previously and because this is an obvious bridge between high- and low-HIV-rate populations. Information about bisexuality has become important in efforts to understand AIDS transmission. For example, a study of lesbian women, a group usually thought of as low-risk, showed that not only had 81 percent of these women had sex with men, at least one-third of their male partners had had sex with other men. Women with bisexual male partners were also more likely to have had anal sex, an activity thought to be an especially efficient mode of HIV transmission (Padian et al. 1987). Bisexuality among men constitutes a greater risk factor than was previously recognized because these men may make regular forays into the gay male world unknown to their female partners. This may be more likely to occur among married couples or in some minority communities, where the behavior itself may necessitate the utmost secrecy and may even be defined by the participants as "not homosexual" and therefore not risky (Carrier 1985; Blumstein and Schwartz 1977; Humphreys, 1975).
Other, less obvious risks include the possibility of deviousness or outright lies from a partner. In a poll conducted by Cochran and Mays (1990), 196 men and 226 women aged 18–25 completed an anonymous questionnaire on sexual strategies. The findings indicated that a significant number of both men and women had told a lie in order to have sex. Men lied more frequently than did women, but both sexes were actively and passively willing to deceive a date.
Sociodemographic characteristics also have been studied as risk factors. Age is one such factor. Among U.S. teenagers the rate of AIDS is low overall (less than 1 percent of AIDS cases); however, such data underestimate the risk because of the long incubation period from HIV infection to the development of AIDS (ten or more years). Moreover, AIDS rates are higher among more vulnerable subpopulations of adolescents, such as runaway and homeless youth, STD clinic populations, and young people in the juvenile justice system. Such youths are more likely to engage in activities, such as drug use and "survival sex," that put them at high risk of HIV infection. Particularly worrisome is the high rate of other STDs among teenagers, especially young women, because having an STD is thought to enhance the probability of becoming infected with HIV after exposure. Unfortunately, although condom use has increased among teenagers, adolescents still do not use condoms consistently (Sonenstein et al. 1998.). Teenagers in the United States have higher rates of nonmarital pregnancies than do their counterparts in any other industrialized nation despite the fact that they are no more sexually active than are teens in other countries. These facts suggest that teenagers in the United States are not adequately protecting themselves against the outcomes of their sexuality. This may be the result of a lack of comfort with the idea of teenage sexuality in a nation that sends mixed messages to its youth.
In general, better-educated persons are more likely to use condoms. College students, however, are surprisingly casual about condom use. In a study by Reinish et al. (1990), less than two-thirds of the students studied had used a condom in the previous year, less than one-third had used a condom the last time they had had vaginal or anal intercourse, and only half had ever used contraceptive methods that also prevent STD transmission. Those in exclusive sexual relationships reported the highest levels of intercourse. This finding prompted concern among the researchers that while it seems that being in a committed sexual relationship lowers the overall risk of HIV infection by reducing the number of partners, risk may be increased because of frequency of relations unless partners use condoms or have accurate information about each other's sexual and drug use histories. Even well-educated college students tend to use criteria irrelevant to AIDS transmission, such as "just knowing" a partner is safe, as a means of determining when condom use is necessary (Civic, in press). A set of qualitative research notes indicates that condom use may decrease, even among populations that most need to use them, for socioemotional reasons. Kane's (1990) population of women with HIV-probable partners in the drug culture refused, as an act of solidarity, to use condoms. These women felt that using a condom would indicate their awareness and condemnation of the partner's addiction, alienating him and harming the relationship.
In the United States, not all racial and ethnic groups have been equally affected by the AIDS epidemic. Although European-Americans initially were the group with the highest rate of AIDs, this is no longer true: AIDS rates among racial and ethnic minority groups have increased substantially since the beginning of the epidemic. Data from the CDC show that in 1990 whites accounted for over half the AIDS cases (56 percent in January 1990), but they now account for fewer than half the cases (46 percent in January 1998). African-Americans in impoverished inner cities have been especially hard hit. In January 1990, 27 percent of AIDS cases occurred among African-Americans, but by January 1998, this figure had increased to 35 percent. The infection rate also has been increasing among Americans of Hispanic origin (18 percent of cases in January 1998).
One of the newest groups in the United States to receive research attention is women. Since AIDS surfaced in this country among gay men, the lack of attention to women might seem reasonable until one remembers that as partners of bisexual men or drug users, as drug users themselves, or as inhabitants of countries where AIDS is not a "gay disease," women always were at risk. AIDS has been increasing steadily among women in the United States. CDC figures show that in January 1989 women represented only 9 percent of AIDS cases, but by January of 1998 this figure rose to 16 percent, a 44 percent increase in less than a decade. Women also have substantially higher rates of chlamydia—the most prevalent bacterial STD—as well as genital herpes. Unfortunately, STDs are more likely to be asymptomatic in women, thus causing delayed treatment, increased complications such as infertility, and increased vulnerability to HIV infection.
Initially, IV drug use was the primary mode of AIDS transmission among U.S. women, but today, heterosexual intercourse is the primary mode. In late 1989, 52 percent of AIDS cases among women were attributable to IV drug use, whereas in June 1998, only 23 percent of cases were thought to be IV drug use–related. Most women with AIDS are of childbearing age. This increases the chances of transmission from an infected pregnant woman to her unborn baby as well as increasing the number of children, often in single-parent families, who are forced to cope with the prolonged illness and then loss of a mother. The effects of AIDS on children have only recently begun to be studied. Studies show that between 13 and 35 percent of babies born to HIV-positive women are HIV-infected, a figure that has been rapidly declining since the beginning of the AIDS epidemic, largely as a result of the advent of newer antiviral drugs. Many pregnant HIV-infected women, even with knowledge of the risk, choose not to abort (Proceedings NIMH/NIDA Conference on Women and AIDS 1989). AIDS concerns attend other reproductive issues as well, such as the safety of artificial insemination. While the American Fertility Association has guidelines that exclude high-risk men from donating sperm, methods for testing for HIV seem to be inconsistent, and private physicians may not test at all (Campbell 1990).
The use of alcohol and drugs has been shown to be related to unsafe sex practices, although there have been contradictory findings (Leigh and Stall 1993 provide for a review). Fullilove and Fullilove (1989), for example, found that 62 percent of the 222 black inner-city teenagers they studied used crack, and 51 percent of the users said they combined crack use with sex. Forty-one percent of the teenagers surveyed had had at least one STD; those who used crack with sex had a significantly higher rate of STD infection. The correlation between crack use, sex, and STD transmission has been found by many other investigators (Aral and Holmes 1999). Although crack use has declined substantially since the late 1980s, the use of other drugs (e.g., methamphetamines) that also appear to be related to unsafe sex has risen. Leigh (1990) found that patterns of drug use and the effects of drugs on behavior differ among groups: Gay men were less affected by drinking and engaged in more risk taking when using cocaine, whereas heterosexual risk taking was predicted largely by total frequency of sex, with only a small amount of the variance explained by having partners who used drugs or alcohol. A note of caution is warranted in interpreting the findings of studies of the relationship between sexual practices and substance use. Most of this research that shows a relationship between substance use and risky sex has not demonstrated that substance use causes risky sex, because researchers rarely have information on which came first. Moreover, it is conceivable that a third factor, such as a propensity to take risks, is responsible for both substance use and sexual risk taking (Leigh and Stall 1993). Clearly, more research is needed.
Research has increasingly concentrated on infection resulting from exchange of blood caused by mutual use of needles during intravenous drug use. In a paper by Freeman et al. (1987), a comparison of gay males and IV drug users showed that peer support helped create safer sexual practices for gays while lack of social organization reduced IV drug users' chance of self-protection. Among the drug users, 95 percent were well aware of their exposure and 68 percent knew that needle sharing could transmit AIDS. Some individual attempts at decreasing the use of potentially contaminated needles had been made, but the authors felt that the only way to reduce risk in this population was to create organizations for needle dispensation that eventually could create a culture of mutual protection. Opinion has changed from considering IV drug users uneducable to recognizing substantial successes in changing their drug-taking practices to include more self-protective habits. Still, ethnography shows that needle sharing between addicted partners is seen as an intimate and bonding behavior, and this makes change more difficult. Moreover, despite their demonstrated effectiveness, needle-exchange programs are under attack by conservatives who claim that they encourage drug use, even though there is no evidence to support that contention.
Although sexual behavior certainly has biological underpinning, it is clear from the research that sexual behavior and the spread of STDs are socially driven. Sociocultural factors, not biology, determine not only with whom one has sex, whether and when one is likely to have sex, and the specific forms of sexual expression in which one engages but even which persons, activities, and things are experienced as erotic. This fact is eminently evident in the early studies of the Kinsey group, Ford and Beach's (1951) cross-cultural studies, and more recent research (e.g., Laumann et al. 1994).
RISK REDUCTION AND EDUCATION IN THE UNITED STATES
It is difficult to discuss risk without touching on risk reduction. Indeed, a growing body of research literature reports the results of studies investigating specific risk-reduction strategies, curricula, and behavior modification that targets specific populations—such as gay men, minority group members, teenagers, mothers, and drug users—with what is hoped to be a useful approach.
The most encouraging findings indicate that it is possible to change risky sexual behavior. This is a significant discovery, since many personal habits, such as drinking and overeating, are notoriously resistant to sustained modification. In the 1980s, researchers in San Francisco found that gay men there had reduced their numbers of partners and frequency of sex and increased their use of safer sex practices (McKusick et al. 1985). However, since much of this change was attributed to the extraordinary social power of organized gay groups in that city, the question arose whether such dramatic changes could occur among gay men who are less embedded in gay communities (Fisher 1988). However, change has occurred across the United States, indicating both the strength of educational and social control efforts among gay activists and, perhaps, the great motivation for change that exists when suffering and death are not only possible but probable (Martin 1987; Siegal and Glassman 1989; Roffman et al. 1998).
This conclusion is not self-evident because change in gay male circles has not been complete. Changes in behavior are associated with proximity to populations with high incidences of the disease: The more distance, the less change in behavior (Fox et al. 1987). Furthermore, even in densely infected areas, a significant minority of HIV-infected persons seem to continue engaging in risky sexual practices (Kelly et al. 1998). There is even evidence that for some men, fear wears off and unprotected sex practices increase (Martin 1987), whereas for others, initial changes toward safer sex are difficult to maintain in the long run (Kelly et al. 1998).
Naturally, there is a great deal of pressure on researchers to find out what helps all kinds of people protect themselves from AIDS. Depressingly but predictably, is has been found education alone is inadequate to induce behavior change. For example, Calabrese et al. (1987) reported that for gay men outside big cities, attendance at a safe-sex lecture, reading a safe-sex brochure, HIV antibody testing, advice from a physician, and counseling were all inadequate. Other sex education efforts have had a limited effect, often for a limited period. For example, researchers assessed the impact of a ten-week university course on human sexuality and AIDS-related behavior. While students who had taken the course possessed more information about actual risk, worried about AIDS more, and asked sexual partners more questions relating to AIDS than did a control group, they did not increase their use of condoms or other contraceptives, decrease the number of sexual partners, or spend a longer time getting to know a prospective partner (Baldwin et al. 1990). Studies have consistently shown that sex education for adolescents is necessary but not sufficient to produce behavioral changes (Kirby and Coyle 1997).
The disappointing results of sex education have led researchers to search for more viable strategies. Because self-esteem, confidence, and ego strength have been hypothesized to help individuals protect themselves from others' as well as their own desires, a number of researchers have looked for ways to bolster these characteristics (Becher 1988). To date, the most promising programs appear to be ones that are conceptually based and provide information and skill building, enhance motivation and normative support for change, and are ethnically and culturally sensitive (Fisher and Fisher 1992 provide a review).
No one believes that any single approach is appropriate for all audiences. Increasingly, this literature has been investigating separate strategies for different groups. Students of race, ethnicity, and gender understand not only that various groups use language differently but also that reality is filtered through culture. This sociological truism has benefited research and education among at-risk populations. An example is understanding how gender differences affect health behavior. Campbell (1990) noted the limitations of educational programs aimed at women, especially non–IV drug users, who resist feeling at risk. She found that the partners of IV drug users are unlikely to be assertive and to insist on safer sex. Most of these women are already in subordinate, if not abusive, situations, and their vulnerability and passivity have to be addressed before progress can be made. This fact is underscored by findings from a study in which Beadnell et al. (in press) report that a strong predictor of the extent of at-risk women's attendance at a multi session AIDS prevention intervention is whether they are in an abusive relationship. Campbell (1990) warns that there are special considerations about condom use among minority group women, since minority group men may reject condoms more resolutely than do white men. Campbell also reminds the reader that in educating commercial sex workers both for their own safety and for that of others, one needs to take into account the dual issues of their gender and their profession. She argues against overreliance on women as the safety net in sexual relations. To date, little AIDS research has focused on heterosexual men.
Among working and lower-income African-Americana women, gender issues often make safe-sex guidelines seem impossibly theoretical. Unemployment has put African-American men in transient relations with African-American women, and partners are unlikely to engage in the kind of cooperative communication many safe-sex guidelines assume (Fullilove, et al. 1994). Fullilove et al. also highlight black women's and teenagers' increased vulnerability to disease because of relatively high rates of nonmonogamy among potential partners. Those authors feel that individual strategies are unlikely to be as powerful as a "reknitting of community connections" for the evolution of protective norms. Social disorganization further complicates the problem by giving less and less accurate information to African-American and Hispanic populations.
Even designing messages for minorities or finding community outlets for their dissemination does not begin to handle the difficulty of reaching and influencing at-risk persons. Target audiences for prevention are not necessarily self-identified. For example, almost no AIDS-prevention research has been conducted with lesbian women who may have occasional intercourse with bisexual partners and do not consider themselves at risk. Latino men who occasionally visit gay bars and have anal intercourse often do not use condoms with their wives in part because, as the "activo," they do not see themselves as homosexual or as having participated in a homosexual act and therefore do not perceive themselves as being at risk (Magana 1990). Similarly, because virginity before marriage is highly valued in Latino culture, young unmarried Latinas may engage in higher-risk anal sex in order to remain "technical virgins." Given the high value placed on motherhood among Latinas, using condoms during vaginal sex can imply that a man's intentions are less than honorable by eliminating the possibility of motherhood. Almost nothing is known about the sexual practices of Asian-Americans, perhaps because they have been depicted as the "model" minority. However, some data suggest that Asian-American youths are less knowledgeable about AIDS than are other groups (Wells et al. 1995), and a substantial minority of Asian-American adolescents have been shown to engage in unprotected sex (Schuster et al. 1998). Issues of identification, culture, and gender relations bedevil both researchers and health workers.
Despite the optimism of biomedical researchers, there is still no cure for AIDS or an effective vaccine against contracting HIV. Therefore, behavioral change remains the best hope for controlling the epidemic. Sociological and psychological theories have generated a number of programs that appear to be effective in reducing an individual's risk of contracting HIV. Most of these programs have focused on changing individuals' skills, knowledge, attitudes, and behaviors. However, sexual intercourse is inherently dyadic, and partner issues will need greater attention for such programs to achieve maximum effect, especially for women, who often do not have control over their sexuality. Moreover, the advent of new antiviral drugs and protease inhibitors has transformed the character of the AIDS epidemic to the public at large and the researchers as well as to those with HIV infection. Many people in the United States now view AIDS as a manageable chronic illness rather than a death sentence. Persons with AIDS are living longer, mortality rates have decreased, and those infected with HIV do not appear to be developing AIDS at the same rate as was the case before the use of these new drugs. In response to this change, the focus of AIDS research has changed: Researchers are increasingly studying how to prevent or reduce adverse outcomes, such as depression and relapse to unsafe behaviors, and enhance the quality of life among those living with HIV and AIDS (Kelly et al. 1998 provide a cogent discussion). However, the new drugs are not a panacea. For some, they do not work at all; for others, they appear to work initially but then gradually become ineffective; and for far toomany, the enormous cost of the drugs is beyond their means. The latter fact is even more tragic when one considers that in the United States most new cases of HIV infection are occurring among society's most vulnerable populations.
THE INTERNATIONAL SCENE
Data on STDs, including AIDS, from other countries are inadequate because many countries, especially third world nations, do not have sophisticated systems to monitor these diseases. The World Health Organization (WHO) estimates that the current annual prevalence of STDs is about 333 million cases worldwide, with about 5.8 million persons being newly infected with HIV in 1997. In 1999 there were nearly 31 million persons living with HIV or AIDS worldwide. If the current trend continues, WHO estimates that more than 40 million persons will be infected with HIV by the year 2000. To date, over eleven million people worldwide have died of AIDS, and in 1998 alone, about 2.3 million deaths were attributable to AIDS, 46 percent of which occurred among women. The vast majority of cases of STDs worldwide, including AIDS, have occurred in developing countries, and the growth of the AIDS epidemic has been fastest in sub-Saharan Africa, which is thought to have two-thirds of the world's population of persons infected with HIV. Although rates of infection are lower in Asia, where the epidemic started later, the number infected there is estimated to be quite large. In North America, western Europe, Australia and New Zealand, and a few third world countries that have sound economies (e.g., Costa Rica, Thailand), rates of several STDs (e.g., syphilis and gonorrhea) have been declining steadily over the past decade, but they have been skyrocketing (or being reported better) in regions such as China and Russia and remain high in Africa and Asia.
Why is the AIDS epidemic so heavily concentrated in the developing world? Decosas (1996) argues that differences in sexual behaviors alone cannot explain this fact. He argues that the high incidence of untreated STDs that increase vulnerability to HIV infection, cultural factors such as age differences between male and female sexual partners (older persons typically have more sexual partners and therefore an increased likelihood of exposure to HIV), and demographic factors such as large-scale labor migration and refugee movements have all contributed to the difference. All these factors are related directly or indirectly to poverty and gender inequality. Young women in third world countries, for example, often have limited access to education or vocational training and may have few alternatives for economic survival other than having sex with men. Studies in Africa suggest that women in traditional relationships typically do not engage in risky sexual practices, yet they are increasingly being infected with HIV (Way et al. 1999). Even women who report having only one sexual partner in their lives and who believe that they are in monogamous relationships are found to be infected with HIV. In many regions of Africa, however, men not infrequently engage in extramarital sexual relations, often with higher-risk partners such as commercial sex workers (Way et al. 1999).
Today, the AIDS epidemic worldwide is spread primarily through heterosexual contact. As more women of childbearing age become infected, perinatal transmission from mother to infant is increasing. In urban areas of Uganda, Zambia, Malawi, and parts of Southern Africa, for example, HIV infection among pregnant women has been increasing rapidly; more than one-fifth, and in some areas up to 40 percent, of these women have been found to be HIV-positive (Way et al. 1999). There are important differences across the globe in the main mode of AIDS transmission and who has been infected as well as substantial differences in these factors within regions. In China, for example, there appears to be two epidemics: one among IV drug users in the mountainous regions and the southwestern areas and the other in the more prosperous eastern coastal areas, where commercial sex is reemerging in response to the growing gap between rich and poor. Ironically, AIDS was virtually unknown in China before that country it opened its borders. In Africa, the highest HIV prevalence rates occur in urban as opposed to rural areas. In Mexico and Latin America, the epidemic is concentrated among the poorest and most marginalized members of society, as is becoming increasingly true of the United States. In eastern Europe, IV drug use accounts for the majority of new infections. Not only are there important differences in the major modes of AIDS transmission worldwide, the modes of transmission within regions have changed over time (Way et al. 1999). This is evident in the United States, where the AIDS epidemic first appeared among gay men, then among IV drug users, and now among racial and ethnic minorities and women. In Latin America, AIDS was first concentrated among IV drug users and gay men, but heterosexual sex is playing an increasing role in its transmission. The epidemic in Asia is moving rapidly from high-risk populations to the general population, largely as a result of heterosexual transmission. In developing nations particularly, new AIDS cases are occurring among younger persons.
The rate of STDs worldwide is alarming because although the most common nonviral STDs (syphilis, gonorrhea, chlamydia, and trichomoniasis) are curable, they are often initially asymptomatic. This is especially so for women, who also are more likely than men to become infected if exposed. Moreover, the increased mobility of populations, accompanied by urbanization, poverty, sexual exploitation of women, and changes in sexual behaviors, places an increasing proportion of the world's population at risk. Because younger people make up a much larger proportion of the population in developing nations than they do in industrialized ones and because younger persons today have more sexual partners than was previously the case, one can expect to see a steeper rise in the rate of AIDS in these countries.
Uganda was among the first nations to respond to the AIDS epidemic, making a strong effort to prevent the spread of the disease that appears to be having an effect, as is evident in the declining proportion of persons infected with HIV (Asiimwe-Okiror et al. 1997). This decline is consistent with behavioral studies that show increased condom use, delay in sexual initiation, and a decline in the number of sex partners. Similarly, in Zaire, condom use among commercial sex workers dramatically increased from zero to 68 percent after a three-year condom promotion program (Adler 1998). The result was a marked decline in STDs. In Thailand, which is believed to have the best documented AIDS epidemic among developing countries, an aggressive and sustained national campaign to reduce HIV infection rates was instigated once authorities recognized that there was an epidemic. The campaign focused on increasing condom use, promoting respect for women, discouraging men from having sex with commercial sex workers, and increasing opportunities for education and employment to keep younger women from becoming commercial sex workers. The effects of this campaign have demonstrated the success of a concerted national effort. The use of condoms among commercial sex workers rose from 14 percent in 1989 to over 90% by 1994, rates of STDs declined, and the rate of new HIV infections has been declining, especially among commercial sex workers and their clients (Rojanapithayakorn and Hanenberg 1996). The success of this campaign has been attributed to several factors, including use of the existing infrastructure, a focus on a limited goal (improving condom use among commercial sex workers rather than trying to eliminate prostitution), widespread advertising, and a systematic means of monitoring the epidemic. Although less dramatic, local programs in other third world countries appear to be having some impact, as they have had in the United States. In Uganda, for example, a longitudinal study in an urban area showed a substantial increase in condom use, delay of sexual initiation, and a decrease in casual sex among adolescents over a period of two years. These changes were accompanied by a 40 percent decline in HIV seroprevalence among pregnant women who attended antenatal clinics (Asiimwe-Okiror et al. 1997). Similarly, a study of urban factory workers in Tanzania showed a decline over a two-year period in the number of sexual partners and casual sex, although condom use did not increase substantially (Ng'weshemi et al. 1996). A behavioral risk reduction program targeting truckers in Kenya has shown significant declines in extramarital sex and sex with commercial sex workers, although condom has not changed. These behavioral changes were accompanied by significant declines in STDs such as gonorrhea. In Bolivia, an HIV prevention intervention aimed at commercial sex workers appears to have increased condom use and resulted in lower STD rates in this high-risk group (Levine et al. 1998). In Jamaica, researchers have concluded that a comprehensive HIV/STD control program has resulted in reduced rates of STDs and increased condom use, although a significant minority continue to have unprotected sex in high-risk situations (Figueroa et al. 1998). Officials in some countries, such as India, deny that AIDS is a problem in their regions, and few efforts have been launched to stem the possibility of a widespread AIDS epidemic in those areas.
Studies have demonstrated that the psychosocial and economic impact of AIDS extends far beyond the persons infected (Carael et al. 1998). Families have been shown to suffer from stress, economic hardship, stigma, and discrimination when one of their members has AIDS. Women, especially in third world countries, are in structurally less powerful positions than men and often have little or no control over their own sexual safety. These socioeconomic effects of AIDS, along with increasing mortality from AIDS among those in the most productive years of their lives, are expected to increase the gap between rich and poor and contribute to the feminization of poverty (Decosas 1996). Moreover, an infrequently mentioned consequence of AIDS in developing nations is its effect on children, who are being orphaned at alarming rates; WHO estimates that over eight million children in the world have been orphaned because of AIDS. In some areas of the world, AIDS may be changing the demography. It has been estimated that in areas hardest hit by the epidemic, life expectancy has declined by as much as seventeen years and mortality rates for children under age 5 have increased by 74 percent (Stover and Way 1998). Demographers project that by the year 2005, there will be 13 to 59 million fewer people and a 27 percent reduction in life expectancy in countries with the most severe epidemic compared with what have been the case if AIDS had not hit those regions (Stover and Way 1998). Mortality rates from AIDS are expected to continue to increase, and the gap in the death rates from AIDS in developing and developed countries is expected to grow wider. Finally, most people in third world countries cannot afford or do not have access to the new drugs that have prolonged lives of persons living with HIV or AIDS in the United States; thus, mortality rates there are not likely to drop. This may mean, as Way et al. (1999, p. 90) predict, that "the worst is yet to come."
The emergence of AIDS as a social issue not only has revitalized interest in the social context and consequences of STDs, it has caused medical research to understand more fully how disease can never be studied effectively apart from social conditions or without adequate information about re1evant social actors. Still in its infancy is a fuller consideration of institutional and public responses to STDs, for example, how public policy gets made and by whom (Volinn 1989) or why some communities respond with compassion, others with fear, and others not at all. The social construction of disease, and that of STDs in particular, is an important and understudied area of social science research.
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