Research and the global response
Carlos F. Cáceres and Kane Race
Few events in the modern history of public health have elicited social consequences comparable to those of the HIV epidemic, and even fewer have had such dramatic effects on the way we think about and discuss sexuality. The HIV crisis has brought about dramatic changes in sexual cultures (Martin 1987; Evans et al. 1989), while simultaneously having a powerful impact on the health and social sciences (Patton 1990; Treichler 1988; Rosenbrock et al. 1999), the arts (Crimp 1988; Gott 1995), the women’s and sexual diversity movements (Schneider and Stoller 1995; Jagose 1996) and the fields of both human and health rights (Mann and Tarantola 1998; Mann and Gruskin 1999; Petchesky 2003).
As several authors have argued (Watney 1987; Patton 1990; Epstein 1996; Sendziuk 2003), these processes of change were anything but consensual, and implied a complex chain of dialogue, negotiation and struggle involving a large number of institutions and constituencies. The source of disagreement varied with time: from the cause of the crisis, to the best forms of HIV prevention and care, to the responsibilities of the individual and government. Also in tension have been different forms of knowledge, which, based on their specific origin, producers and loyalties, called for contrasting courses of action. Rich understandings emerging from the community response have often been in tension with the scientific evidence (Watney 1990; Escoffier 1999; Rofes 1998; Kippax and Race 2003) posing problems for the consensual integration of knowledge, and reflecting epistemological positionings that are impossible to reconcile (Kippax 2003). While the need to move forward has pushed for solutions and helped to bring about consensus, evolving contexts constantly pose new and often unexpected tensions.
The goal of this chapter is to discuss how different epistemological positionings have determined specific forms of knowledge that have shaped the response to HIV, with a special focus on how this has affected both sexuality politics and the evolution of sexual cultures. We will also highlight a number of lessons learned from this analysis and suggest areas in which remaining gaps should be addressed to save time, energy and resources in the response to the epidemic and in the advance of sexual rights.
While a detailed historical account of the emergence of HIV is beyond our focus and possibilities, an analysis of key elements in the history of the epidemic and the social response to it is crucial here. Early on, authors such as Susan Sontag (1989) were among the first to describe the powerful social meanings that AIDS had acquired: it was a deadly disease associated with painful deterioration of usually young bodies, but also affecting those on the margins of society, often on grounds of their sexuality. Interestingly, and regardless of the transmission routes taken by HIV in the 1970s, the epidemic was first recognised in the large urban centres of industrialised countries among members of the gay community, some of whose ideologists were still discussing the revolutionary potential of the gay lifestyles and mores. The early thesis of HIV being a sexually transmitted disease triggered a call for drastic changes in sexual behaviour, including condom use. It also mobilised the gay community and its allies to fight the crisis, while truncating ideological debate regarding the transgressive/liberating potential of gay culture (Crimp 2002). The significant decrease in unprotected anal sex observed among gay men of cities in the industrialised north during the first half of the 1980s is now recognised as a formidable achievement driven mostly out of the common sense knowledge of men who had (and enjoyed having) sex with other men, but who also realised how their practices could be linked to STI epidemics. It was this practical knowledge, in a community with high social capital, outraged and frightened by the crisis, that guided a major shift in this early history.
The identification of HIV in 1983 (Popovic et al. 1984) confirmed the infectious basis of the crisis. HIV was recognised as a lethal infectious disease with complex social causes as well as complex clinical and psychosocial manifestations. As a consequence, practitioners within a number of scientific fields became involved in the search for responses and solutions in an unprecedented fashion. They included professionals working in the basic sciences of virology and immunology, clinical medicine specialities, epidemiology, psychology and fields within the social sciences and cultural studies (Patton 1990; Stengers 1997). This heterogeneous ‘expert’ perspective interacted, on the one hand, with the needs of programme managers and decision makers, and, on the other hand with those of the community, which continued to play a key role particularly in asking for more resources, questioning international inequality in access to these, and especially calling for the accelerated search for a cure, for which they critiqued procedures for testing and approving new medicines (Epstein 1996). Such unprecedented community involvement significantly influenced the way in which the interaction with communities for now conceived of in health research and in other aspects of health policy, with concrete implications in what might stand as valid knowledge (Epstein 2007).
As the HIV epidemic gradually became visible in the rest of the world, including the Caribbean, Latin America, Asia and especially Africa, issues such as resources, economic and demographic consequences, human rights/health rights and north– south inequalities emerged, leading to an increasing number of professional fields becoming interested in HIV: economics, mathematical modelling, political science and the law (Petchesky 2003). Likewise, since the mid-1980s an official international response had started to take shape under the lead of the World Health Organisation, and one decade later the whole United Nations system would become involved through the creation of the Joint United Nations Programme on HIV/AIDS (UNAIDS) (Seckinelgin 2008).
While an in-depth analysis of disciplinary involvement and the power issues implicit in the scientific response to AIDS is also beyond the scope of this chapter, we will focus here on certain aspects that, reflecting distinct epistemological positioning of disciplinary bodies, had a direct impact on the formulation of a response to the epidemic in terms of (a) a discourse on causation, with moral implications; and (b) a prescription for a preventive response, particularly in relation to sexuality and sexual behaviour.
From the early 1980s until the mid-1990s, lack of effective treatment for HIV resulted in AIDS being seen as ‘a death sentence’ and a focus on primary prevention. Understanding of factors increasing the risk of HIV acquisition were largely defined by epidemiology, a discipline related historically to hygiene and tropical medicine, devoted to the study of the distribution and determinants of diseases. The first epidemiological studies compared persons diagnosed with AIDS with supposedly healthy controls, and suggested that specific risk factors included male homosexuality, haemophilia and injection drug use (Sonnabend et al. 1983). When HIV was later identified and a test became available to ascertain infection, studies were conducted to ascertain further the correlates of infection. Studies then identified unprotected anal and vaginal sex, high numbers of sex partners and sharing needles and equipment for drug use as key risk factors (Murray and Payne 1989).
In response to these findings, the first wave of science-led HIV prevention work aimed to modify ‘high-risk behaviours’, interpreted as the consequence of individual, rational decisions (Fishbein and Middlestadt 1989), and a number of prevention interventions were designed at this time by health psychologists and health educators. Over this same period, however, a significant tension emerged between those who advocated ‘test and contain’ strategies (i.e. the mass testing of ‘high-risk’ populations and restricting the movement and rights of infected individuals) and those who advocated community education, the protection of civil rights and anti-discrimination measures (Sendziuk 2003). The latter approach formed the basis of a new or ‘social’ public health, and came to be regarded as a more effective response to HIV (Rosenbrock et al. 2000; Kippax and Race 2003).
While in the past 50 years epidemiological theories and methods have become increasingly complex with the inclusion of multicausal frameworks and methods to study those frameworks, the use of more classical social theory (from which useful ideas could feed into causal models) in epidemiological reasoning has been very limited. In consequence, hypotheses about social phenomena or social determinants have often been poorly articulated in epidemiological and surveillance studies (Kippax and Race 2003). When theories were utilised, they were often highly individualistic. Social cognitive theories, for example, used to guide behavioural interventions also presumed empowered individuals making decisions based on rational choices, and disregarded the extent to which individuals either did not decide what they did sexually or did not have a chance to so decide given power imbalances with partners or broader conditions of vulnerability (Ingham et al. 1992; Kippax and Crawford 1993; Paicheler 2000). The limited impact that many programmes based on such models have had in the epidemic, as revealed both by research and programme evaluation (Cáceres 2000a) has led to a consensus about the insufficiency of individual models of sexual risk behaviour and behaviour change and has triggered the growth of other approaches that take a social/ structural perspective.
During the early 1990s an alternative paradigm began to emerge: significant interest began to be placed on ethnographic inquiry in an effort to describe sexual cultures under the assumption that (a) the specificities of sexual cultures implied the need to tailor behaviour change goals to each culture, and (b) approaches that changed cultural norms were needed to effective behaviour change (Cáceres 2000a). While this approach had some utility, the need was identified to go beyond a largely apolitical view of culture and recognise issues of power and inequality which, together with cultural meanings, play an important role in defining sexual practices across societies. This led to the development of a framework that has been central in understanding the difficulties experienced by prevention programs: that of vulnerability. This concept highlighted the structural inequalities that posed fundamental barriers to behaviour change: from limited access to resources, to gender power imbalances, to the exclusion of sexual and ethnic minorities. Vulnerability analysis has become a key element in international discourse on HIV since the late 1990s (Parker et al. 2000; Aggleton 2004), leading to efforts to mainstream the HIV response beyond the health sector, and justifying a multisectoral response (UNAIDS 1998).
While concepts of vulnerability have been powerful as an anchor to political commitment, their implications for response planning have been less clear. Conditions of vulnerability tend to be broad based, involve several factors simultaneously, and are not easily reducible to explanation within a single conceptual framework. While ‘interventions’ for vulnerability reduction have been implemented (Cáceres 2000b), the principle has never become generalised as such. Moreover, the practice of positioning certain (usually already marginalised) groups as vulnerable has drawn criticism to the extent that it failed to recognise the agency of such groups, shoring up support for paternalistic strategies, while leaving the practices of more dominant groups (such as heterosexual men) largely unexamined (Brown 2000; Waldby et al. 1993).
The onset of the new century was marked by increasing concern for universal access to the combination antiretroviral treatment that had become accessible in higher income countries in the mid-1990s and which transformed the disease into a chronic, treatable condition. A landmark meeting of the United Nations General Assembly in 2001 focused on AIDS led to new global commitments and established the goal of universal access to prevention and treatment as a human rights issue (Petchesky 2003). In consequence, new resources have been made available through so-called global HIV initiatives (Bernstein and Sessions 2007) with a clear focus on scaling up antiretroviral therapy. Since the mid-2000s, however, renewed attention has been given to HIV-prevention goals after it became clear that universal access to treatment would not be sustainable if high levels of infection continued to take place. In this new focus on prevention, however, novel elements emerged as well.
First, in programmes funded by the US President’s Emergency Programme for AIDS Relief (PEPFAR), the focus was put on ‘ABC’, abstinence, be faithful and (if all else fails) use condoms. Such an approach was received with scepticism and regret by the international community given its overemphasis on A and B, being regarded as a controversial formula not supported by evidence (Collins et al. 2008). Second, adequate access to HIV prevention by ‘key populations’ (a term opted for to avoid the paternalistic flavour of ‘vulnerable groups’) began to be debated, with an increasing emphasis on a strengthened human rights discourse. Concern was expressed about the need to amend laws penalising homosexual behaviour, sex work or drug use, and to end violations of human rights towards the groups involved, not only because these pose structural barriers to prevention and care, but also for the sake of human rights per se. Third, new emphasis was given to biomedical prevention, encompassing preventive vaccines, post- and pre-exposure oral prophylaxis, microbicides and diaphragms, male circumcision and strategies based on the diagnosis and treatment of other STIs (Padian et al. 2008). While some concern was expressed about the re-emergence of a quest for ‘magic bullets’ in the biomedical field, recent failures of progress in these strategies have led to a call for a ‘combination prevention’ approach in which biomedical, behavioural and social/ structural prevention strategies are combined to maximum effect (Coates et al. 2008).
Productive exchanges and debates have also taken place between epidemiology and the social sciences. Social scientific approaches understand sex as a social practice, shaped and constructed in social contexts. A crucial concern within such approaches is how particular practices are given meaning and interpreted by those involved. This emphasis differs considerably from epidemiological understanding, which tends to focus mainly on enumerating sexual behaviours and disease incidence and correlating these items with individual variables. The focus on meanings and contexts found in social approaches is perhaps better able to position members of affected populations as agents, actively grappling with sexual and health understandings (Kippax and Race 2003). Such an approach has been particularly significant in identifying the changing HIV-prevention strategies or ‘prevention ethics’ devised by affected populations (Race 2003). These include the practice of ‘negotiated safety’ where regular but non-monogamous partners of HIV-negative status dispense with condoms in the context of the relationship but maintain condom use in sex outside the relationship (Kippax et al. 1993). This practice, which was first identified among gay men in countries such as Australia, was initially invisible from a conventional epidemiological perspective, which measured safety in terms of condom use only.
What have been the effects of HIV-prevention work on sexual behaviours during the past 25 years? There is no simple answer, but among gay and other homosexually active men in most parts of the world there were significant reductions in unprotected anal sex with non-stable partners, particularly during the 1980s and 1990s (Evans et al. 1989). Over the past decade, however, changes seem to be occurring towards lower levels of condom use, reflecting the development of new risk reduction strategies, including serosorting, role selection, selective protection (‘negotiated safety’) and withdrawal before ejaculation (Van de Ven et al. 2002; Race 2003; Elford 2006). Among non-gay identified homosexually active men, practices have varied largely depending on education, access to services and feasibility of controlling the conditions in which they had sex (Cáceres et al. 2008a, 2008b). Among heterosexually active populations, condom use between stable partners has rarely become an established norm, even among serodiscordant couples (Grunseit et al. 1997), but has in some countries become more accepted with casual partners and especially with sex workers (Cáceres 2004).
And how have different constituencies been affected in this process? First, the different academic disciplines within the HIV field have experienced robust development over the past 20 years, not only because of need, but also because of increased resources. Likewise, HIV-related social movements have experienced transformations not thought of before the advent of AIDS. Concern to limit the sexual transmission of HIV has forced society to confront issues such as sexual diversity that were silenced beforehand. It has also helped legitimise academic work on sexuality. While early discourses were often unsympathetic to non-conventional sexualities, both the need to confront realities and renewed consciousness about the right to diversity has opened an unprecedented space for the discussion of sexuality and gender, and for the central inclusion of women’s and lesbian/gay organisations in such discussion. This occurred first in higher income countries but has since extended to the rest of the world, including countries where homosexuality is still illegal (Petchesky 2003). Finally, a human rights perspective has become central in international HIV work, with a strong commitment to community building among people living with HIV (Mann and Tarantola 1998; Mann and Gruskin 1999).
This historical review of the social response to AIDS with a focus on sexuality and sexual constituencies has sought to illustrate the impact that the epidemic had on the way people think about, discuss and have sex. It has also attempted to describe key processes involved in that transformation, influenced by a changing discourse on sexuality which departed from an epidemiological perspective but has later been informed by views from the social sciences, human rights and affected communities themselves. A short account such as that which can be provided here inevitably simplifies a complex process full of contradictions, inconsistencies and partial certitudes. It does, however, stress the importance of different groups of stakeholders and their privileged discourses, based on power and authority, as well as on access to resources.
While the global response to HIV has brought greater commitment towards universal access and unprecedented resource mobilisation, the history recounted here illustrates how often contradictory discourses around HIV prevention can emerge, which have their origins in somewhat different understandings of social and human reality. While consensus building is often presumed necessary for global policy development, different stakeholders’ positions are not equal. For example, the authority of epidemiology and biomedicine to articulate strategies for HIV-related behaviour change could not be questioned until their insufficiency became progressively clear. And despite some progress in multidisciplinary work, experience in cross-discipline collaboration remains limited; models requiring the instrumental involvement of social scientists to meet the goals set by biomedical scientists and epidemiologists remain more typical. Disagreements go far beyond epistemological perspectives, however, since new actors represent a broader array of interests. For example, pharmaceutical companies have become powerful stakeholders in HIV prevention now that a number of biomedical prevention strategies are being tested. Research demonstrating the effectiveness of their products may lead to the largescale use of antiretroviral medications in prevention, with major consequences for the future funding of sexual health programmes (Rosengarten 2009). Other actors too (e.g. academic groups, development agencies, activist organisations and others) often have competing interests beyond the epistemological realm.
Foucault (1978) was among the first to highlight how, in the nineteenth century, sexuality became the subject of a proliferation of discourses. The advent of HIV generated, and continues to generate, sexual prescriptions and pedagogies that reflect deeply held beliefs about sex and the sexual, but has also led to the emergence of new stakeholders and new notions of actorship. Out of ‘disaster’ (Altman 1988), the epidemic has transformed sex in a fundamental way, and has given a voice to many who did not have one before. This, in turn, has had many positive consequences – in research, in international relations and in perspectives on citizenship and rights. But this history will remain in progress until the epidemic comes to a close. Lessons to be learned from this process are numerous, and they point to the importance of truly horizontal transdisciplinary work, community involvement, transparency, accountability and real political will.
Aggleton, P. (2004) ‘Sexuality, HIV Prevention, Vulnerability and Risk’, Journal of Psychology & Human Sexuality, 16 (1): 1–13.
Altman, D. (1988) ‘Legitimation through Disaster: AIDS and the Gay Movement’, in Fee, E. and Fox, D. (eds) AIDS: The Burdens of History, Berkeley: University of California Press.
Bernstein, M. and Sessions, M. (2007) ‘A Trickle or a Flood: Commitments and Disbursements for HIV/AIDS from the GFATM, PEPFAR and the World Bank’s Multi-Country AIDS Program’, Washington, DC: Center for Global Development.
Brown, T. (2000) ‘AIDS, Risk and Social Governance’, Social Science and Medicine, 50: 1273–84.
Cáceres, C. (2000a) ‘The Production of Knowledge in the AIDS Era: Some Opportunities and Challenges’, in Parker, R., Barbosa, R. and Aggleton, P. (eds) Framing the Sexual Subject: The Politics of Gender, Sexuality and Power, Berkeley: University of California Press.
Cáceres, C. (2000b) ‘Relevant Social Dimensions for the Prevention of HIV/AIDS in Latin America and the Caribbean’, in Izazola, J. (ed.) A Multi-disciplinary Review of HIV/AIDS. Relevant Aspects for Decision-making in Latin America and the Caribbean, Mexico City: FUNSALUD.
Cáceres, C. (2004) ‘Intervenciones para la Prevención del VIH e ITS en América Latina y Caribe: Una Revisión de la Experiencia Regional’, Cadernos de Saúde Pública 20 (6): 1466–83.
Cáceres, C. F., Aggleton, P. and Galea, J. (2008a) ‘Sexual Diversity, Social Inclusion and HIV/ AIDS’, AIDS, 22 (Suppl. 2): S45–S55.
Cáceres, C. F., Konda, K. A., Segura, E. and Kyera, R. (2008b) ‘Epidemiology of Male Samesex Behaviour and Associated Sexual Health Indicators in Low and Middle-income Countries: 2003–2007 Estimates’, Sexually Transmitted Infections, 84 (Suppl. 1): i49–i56.
Coates, T. J., Richter, L. and Cáceres, C. (2008) ‘Behavioural Strategies to Reduce HIV Transmission: How to Make them work Better’, Lancet, 372 (9639): 669–84.
Collins, C., Coates, T. J. and Curran, J. (2008) ‘Moving beyond the Alphabet Soup of HIV Prevention’, AIDS, 22 (Suppl. 2): S5–S8.
Crimp, D. (ed.) (1988) AIDS: Cultural Analysis/Cultural Activism, Cambridge, MA: MIT Press.
Crimp, D. (2002) Melancholia and Moralism: Essays on AIDS and Queer Politics, Cambridge, MA: MIT Press.
Elford, J. (2006) ‘Changing Patterns of Sexual Behaviour in the Era of Highly Active Antiretroviral Therapy’, Current Opinion in Infectious Diseases, 19 (1): 26–32.
Epstein, S. (1996) Impure Science: AIDS, Activism and the Politics of Knowledge, Berkeley and Los Angeles: University of California Press.
Epstein, S. (2007) Inclusion: The Politics of Difference in Medical Research, Chicago: University of Chicago Press.
Escoffier, J. (1999) ‘The Invention of Safer Sex: Vernacular Knowledge, Gay Politics and HIV Prevention’, Berkeley Journal of Sociology, 43: 1–30.
Evans, B., McLean, K., Dawson, S., Teece, S., Bond, R., MacRae, L. et al. (1989) ‘Trends in Sexual Behaviour and Risk Factors for HIV Infection among Homosexual Men, 1984–7’, British Medical Journal, 289: 215–18.
Fishbein, M. and Middlestadt, S. E. (1989) ‘Using the Theory of Reasoned Action as a Framework for Understanding and Changing AIDS-related Behaviors’, in Mays, V. M., Albee, G. W. and Schneider, S. F. (eds) Primary Prevention of AIDS, New York: Sage.
Foucault, M. (1978) The History of Sexuality, New York: Pantheon Books.
Gott, T. (1995) Don’t Leave Me This Way: Art in the Age of AIDS, Canberra: National Gallery of Australia.
Grunseit, A., Kippax, S., Aggleton, P., Baldo, M. and Slutkin, G. (1997) ‘Sexuality Education and Young People’s Sexual Behaviour: A Review of Studies’, Journal of Adolescent Research, 2 (4): 421–53.
Ingham, R., Woodcock, A. and Stenner, K. (1992) ‘The Limitations of Rational Decisionmaking Models as Applied to Young People’s Sexual Behaviour’, in Aggleton, P., Davies, P. and Hart, G. (eds) AIDS: Rights, Risk and Reason, London: Falmer Press.
Jagose, A. (1996) Queer Theory, Melbourne: Melbourne University Press.
Kippax, S. (2003) ‘Sexual Health Interventions are Unsuitable for Experimental Evaluation’, in Stephenson, J., Imrie, J. and Bonell, C. (eds) Effective Sexual Health Interventions: Issues in Experimental Evaluation, Oxford: Oxford University Press.
Kippax, S. and Crawford, J. (1993) ‘Flaws in the Theory of Reasoned Action’, in Terry, D. J., Gallois, C. and McCamish, M. M. (eds) The Theory of Reasoned Action: Its Applications to AIDS-preventive Behaviour, Oxford: Pergamon.
Kippax, S. and Race, K. (2003) ‘Sustaining Safe Practice: Twenty Years On’, Social Science and Medicine, 57: 1–12.
Kippax, S., Crawford, J., Davis, M., Rodden, P. and Dowsett, G. (1993) ‘Sustaining Safe Sex: A Longitudinal Study of a Sample of Homosexual Men’, AIDS, 7: 257–63.
Mann, J. and Gruskin, S. (1999) Health and Human Rights: A Reader, New York and London: Routledge.
Mann, J. and Tarantola, D. (1998) ‘Responding to HIV/AIDS: A Historical Perspective’, Health and Human Rights, 2 (4): 5–8.
Martin, J. L. (1987) ‘The Impact of AIDS on Gay Male Sexual Behavior Patterns in New York City’, American Journal of Public Health, 77 (5): 578–81.
Murray, S. and Payne, K. (1989) ‘The Social Classification of AIDS in American Epidemiology’, Medical Anthropology, 10: 115–28.
Padian, N., Buvé, A., Balkus, J., Serwadda, D. and Cates, W. (2008) ‘Biomedical Interventions to Prevent HIV Infection: Evidence, Challenges, and Way Forward’, Lancet, 372 (9638): 585–99.
Paicheler, G. (2000) ‘Understanding Risk Management’, in Moatti, J. P., Souteyrand, Y., Prieur, A., Sandfort, T. and Aggleton, P. (eds) AIDS in Europe: New Challenges for the Social Sciences, London and New York: Routledge.
Parker, R. G., Easton, D. and Klein, C. (2000) ‘Structural Barriers and Facilitators in HIV Prevention: A Review of International Research’, AIDS, 14 (Suppl. 1): S22-S32.
Patton, C. (1990) Inventing AIDS, New York: Routledge.
Petchesky, R. (2003) Global Prescriptions: Gendering Health and Human Rights, London: Zed Books.
Popovic, M., Sarngadharan, M. G., Read, E. and Gallo, R. C. (1984) ‘Detection, Isolation, and Continuous Production of Cytopathic Retroviruses (HTLV-III) from Patients with AIDS and Pre-AIDS’, Science, 224: 497–500.
Race, K. (2003) ‘Revaluation of Risk among Gay Men’, AIDS Education and Prevention, 15 (4): 369–81.
Rofes, E. (1998) Dry Bones Breathe: Gay Men Creating Post-AIDS Identities and Cultures, New York and London: Harrington Park Press.
Rosenbrock, R., Dubois-Arber, F., Moers, M., Pinell, P., Schaeffer, D. and Setbon, M. (2000) ‘The Normalization of AIDS in Western European Countries’ Social Science and Medicine, 50: 1607–29.
Rosenbrock, R., Schaeffer, D., Dubois-Arber, F., Moers, M., Pinell, P., Setbon, M. et al. (1999) The AIDS Policy Cycle in Western Europe: From Exceptionalism to Normalization, Berlin: Research Unit, Public Health Policy.
Rosengarten, M. (2009) HIV Interventions: Biomedicine and the Traffic between Information and Flesh, Washington: University of Washington Press.
Schneider, B. and Stoller, N. E. (eds) (1995) Women Resisting AIDS: Feminist Strategies of Empowerment, Philadelphia: Temple University Press.
Seckinelgin, H. (2008) International Politics of HIV/AIDS, New York: Routledge.
Sendziuk, P. (2003) Learning to Trust: Australian responses to AIDS, Sydney: University of New South Wales Press.
Sonnabend, J., Witkin, S. and Purtilo, D. (1983) ‘Acquired Immunodeficiency Syndrome, Opportunistic Infections and Malignancies in Male Homosexuals: A Hypothesis of Etiologic Factors in Pathogenesis’, Journal of the American Medical Association, 249: 2370–4.
Sontag, S. (1989) AIDS and its Metaphors, New York: Farrar, Straus, & Giroux.
Stall, R. D., Coates, T. J. and Hoff, C. (1988) ‘Behavioral Risk Reduction for HIV Infection among Gay and Bisexual Men. A Review of Results from the United States’, American Psychologist, 43: 878–5.
Stengers, I. (1997) Power and Invention: Situating Science, Minneapolis and London: Minnesota University Press.
Treichler, P. (1988) ‘An Epidemic of Signification’, in Crimp, D. (ed.) AIDS: Cultural Analysis/ Cultural Activism, Cambridge, MA: MIT Press.
UNAIDS (1998) Expanding the Global Response to HIV/AIDS Through Focused Action: Reducing Risk and Vulnerability: Definitions, Rationale and Pathways, Geneva: UNAIDS; available at www.un.org.kh/unaids/pdfs/una98e1.pdf (accessed 14 February 2009).
Van de Ven, P., Kippax, S., Crawford, J., Rawstorne, P., Prestage, G., Grulich, A. et al. (2002) ‘In a Minority of Gay Men, Sexual Risk Practice Indicates Strategic Positioning for Perceived Risk Reduction rather than Unbridled Sex’, AIDS Care, 14: 471–80.
Waldby, C., Kippax, S. and Crawford, J. (1993) ‘Cordon Sanitaire: “Clean” and “Unclean” Women in the AIDS Discourse of Young Men’, in Aggleton, P., Davies, P. and Hart, G. (eds) AIDS: Facing the Second Decade, London: Falmer Press.
Watney, S. (1987) Policing Desire: Pornography, AIDS and the Media, London: Methuen.
Watney, S. (1990) ‘Safer Sex as Community Practice’, in Aggleton, P., Davies, P. and Hart, G. (eds) AIDS: Individual, Cultural and Policy Dimensions, London: Falmer Press.