I won't stand in your bedroom and shake my finger under your nose and say, "Now, don't do that, you 're going to catch something," but I'm telling you here, now, that's how we think you 're catching it. It doesn't go through the air. You can't cough it into somebody's face. You can't get it from a telephone or from shaking hands. But you can get it sexually, and if you can't stop this extreme sexual activity, at least cut it down so your Russian roulette gun will have two bullets instead of six bullets in the chamber. Because right now, the way you 're going, you've got six bullets in the chamber.
(Dr Selma Dritz, epidemiologist with the San Francisco Department of Public Health, speaking to a packed recreation hall in the Castro District, San Francisco's gay neighborhood, in the fall of 1981; Dritz, 1997).
An understanding of the transmission dynamics of infectious diseases, particularly those that are spread sexually, can explain epidemiologic trends that we see, and can aid in setting priorities for data collection and prevention programs (Anderson, 1999). Specific behaviors can foster the transmission of sexually transmitted infections (STI), determine differences in risk, and define rates of disease in selected groups. Variations in the impact of the HIV/AIDS epidemic, for example, can be tied to different patterns of specific sexual behaviors. Responding to emerging epidemics within subpopulations with circumscribed behavior change can have a major impact on ensuing epidemiology. Accounting for the varying burden of disease within an epidemic can be reduced to recognizing the interplay of human behavior and infectious disease biology. For example, researchers have long recognized that partner selection varies considerably within and between racial/ethnic groups, and this has led to a higher burden of STI in the Black community.
To illuminate the dynamics of the social ecology of STI, including HIV/AIDS, this chapter reviews three fundamental sociocultural movements which have been linked to how and when individuals find sexual partners. First, we look at a series of social changes in the second half of the last century, and evaluate the impact they had on sexual behaviors and STI in the US. These include the growth in numbers of young Americans attending college and delaying marriage, the introduction of hormonal contraception, the movement of women into the workforce, the sexual liberation movement of the 1960s, and changes in the population distribution of Blacks in post-World War II America. The connection between these changes and prevalence rates of common STI is reviewed.
The emergence of the gay pride movement in the US was a central social movement of the second half of the century - one that played a tremendously powerful role in escalating transmission rates of STI in the 1970s, and the establishment of the HIV/AIDS epidemic in the 1980s. A sexual revolution among gay men in the late 1960s facilitated the rapid transmission of the AIDS virus by inspiring widespread participation in sexual risk-taking. High HIV infection rates among men who have sex with men (MSM) and a mounting death toll throughout the 1980s devastated the gay community and led, in turn, to significant cultural and behavioral changes, with initial substantive declines in STI and HIV incidence. Medical breakthroughs, including the development of highly active antiretroviral therapy (HAART) in 1996, encouraged yet another shift in behavior and disease transmission rates, with therapeutic optimism making HIV seem manageable, resulting in new increases in sexual risk-taking behavior.
A third cultural trend, the technological innovations that dominated the end of the twentieth century and the beginning of the twenty-first century, have influenced all aspects of our society, including sexual behavior. The adoption of the Internet as a major source of communication has influenced, among other things, the practice of sexual partner selection. The Internet provides a unique source of sexual partners and allows individuals anonymously to seek specific sexual activities at a specific time and place. Use of the Internet to find sexual partners is now being linked to elevated rates of unsafe sexual practices and, once again, a significant rise in human STI.
These three sociocultural trends suggest that patterns in the human behavior of seeking out companionship and establishing a sexual relationship are intimately associated with patterns in the transmission of STI, including HIV/AIDS. We explore these three themes here.
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