220 AIDS/HIV
epidemic began among MSM, it has spread to men and
women regardless of sexual orientation. AIDS cases are dis-
proportionately seen among economically disadvantaged
persons in urban settings, especially among ethnic and racial
minorities. African Americans have been particularly vulner-
able to HIV; during 1998, they represented 48% of all re-
ported AIDS cases even though they constitute only 13% of
the general population.
In the United States, AIDS has been identi“ed as a lead-
ing cause of death among young adults (men and women
aged 25 to 44 years). This age group accounts for about 70%
of all deaths from HIV infection. During 1994 and 1995,
HIV was the leading cause of death among persons 25 to 44
years old; during 1995, HIV caused almost 31,000 deaths„
19% of the total in this age group. Subsequent improve-
ments in the treatment of AIDS have extended life such that,
by 1998, AIDS has become the “fth leading cause of death
among young adults, causing about 8,500 deaths, or 7% of
the total.
Globally, the Joint United Nations Program on HIV/AIDS
(2000) estimates that 34.3 million people are now living with
HIV/AIDS (http://www.unaids.org). The total number of
deaths since the beginning of the epidemic is estimated at
nearly 19 million with 2.8 million people having died from
AIDS during 1999. The epidemic does not appear to have
slowed: It is estimated that 5.4 million people acquired HIV in
- The primary mode of transmission is believed to be
heterosexual intercourse. Consistent with this hypothesis,
women account for 46% of AIDS cases worldwide. The
overwhelming majority of people with HIV live in the devel-
oping world, with nearly 24.5 million cases on the continent of
Africa, 5.6 million cases in south and southeast Asia, and
1.3 million cases in Latin America.
Transmission and Natural Course
HIV is a ”uid-borne agent. For HIV transmission to occur, an
infected person•s blood, semen, vaginal secretions, or breast
milk must enter the blood stream of another person. In the in-
dustrialized world, the most common routes of transmission
are: (a) unprotected sexual intercourse (anal, vaginal, or oral)
with an infected partner; and (b) sharing unsterilized needles
(most commonly in the context of recreational drugs) with an
infected person. Maternal-child transmission (e.g., infection
from an infected mother through the placenta before birth or
through breast-feeding after birth) remains a problem in the
developing world (due to poverty, lack of clean water, inade-
quate food supplies, and limited access to AZT and other
medications), but has become less of a problem in developed
nations. Similarly, transmission through blood transfusions
(when receiving but not when giving blood) and through a
variety of accidental exposures (e.g., occupational needle-
sticks) are relatively rare in the developed world but continue
to be a problem in countries in the developing world.
Once a person is infected with HIV, the course of the dis-
ease is well known. Following initial infection, there is a
window period ranging from three to four weeks to as long
as several months in which a person is infectious to others
but has yet to develop HIV antibodies. It is during this win-
dow period that many individuals react with symptoms of
acute primary infection. Symptoms of primary infection
often include fever, rash, lethargy, headache, and sore
throat. Once the symptoms of primary infection subside and
HIV antibodies are produced, individuals usually enter an
asymptomatic period in which they look and feel healthy
despite the fact that continuous viral replication is occur-
ring. The time between HIV infection and progression to
AIDS varies as a function of treatment availability and
response. Without treatment, most patients experience a
progression from HIV to AIDS within 7 to 10 years of ini-
tial infection (Lui, Darrow, & Rutherford, 1988; Moss &
Bacchetti, 1989). Left untreated, most people with AIDS die
within a year of diagnosis.Psychosocial and Economic ImpactThere is no doubt that HIV disease continues to be a devas-
tating illness. Infection with HIV continues to be most com-
mon among adolescents and young adults. These persons
would be expected to live for 40 to 50 more years if not for
HIV; once infected with HIV, young people face a much fore-
shortened and, typically, lowered quality of life. They will
need to receive burdensome treatments that are inconvenient
and accompanied by side effects that hamper quality of life.
Besides the direct effects of HIV on those who are infected,
indirect effects extend to friends and family members, espe-
cially young children, who must cope with the premature loss
of their parents. It is dif“cult to truly appreciate the magni-
tude of human suffering that results from a disease such
as HIV.
The economic costs associated with HIV are also extra-
ordinary. The cost of medical treatments are prohibitive, and
out of reach for all but the best insured or most af”uent. The
estimated lifetime cost of medical care from the time of in-
fection until death is $214,707 in discounted 1997 dollars
(Holtgrave & Pinkerton, 1997). In the United States, where
40,000 people are infected annually, we face an annualized
cost of more than $6 billion each year (CDC, 2000). To arrive