Lessons learned for the journey ahead

The journey our society has traveled over the last 50 years in its expectations of social and sexual behaviors has been a dramatic one. It has been characterized by victory and loss, freedom and imprisonment, peril and promise. Some women and men have watched their worlds broaden to more than they could ever imagine, while others just as rapidly watched as every dream shattered. At times, these men and women were one and the same. Throughout the journey we have learned much about how the behaviors of individuals and communities can shape the destiny of whole populations.

Of the lessons learned, one of the most striking is the power of an intentional community. The response of the gay community to the crisis of AIDS is particularly notable. With urgency and creativity, gay men constructed not only a self-imposed behavioral response which interrupted the transmission of infectious disease, but also a coordinated assault on industry and the government to ensure that progress be made in slowing the progression of disease. We have also witnessed dramatic changes in condom use adherence in diverse groups of sex workers in Thailand (Hanenberg et al., 1994) and the Dominican Republic (Kerrigan et al., 2003), as well as drug users (Institute of Medicine, 2006), reducing their sexual risks after HIV voluntary counseling and testing. Another central lesson has been the disruptive power of societal change. A transformation in the fundamental roles of American women in the second half of this century engendered a permanent alteration in basic expectations of the social and sexual behavior of young women and young men. Finally, a social change of particular power has been the broad acceptance of computers and the Internet, as well as other technologies such as cell phones. Core elements of our society have been restructured, and this restructuring has again permanently altered some of our most basic behaviors.

If these and other lessons have been learned, how can we apply them to populations both here and abroad as they face epidemics of STI, particularly HIV/ AIDS? One population of real concern in our own country is minorities. Black women and men, in particular, are disproportionately burdened by HIV/AIDS; 50 percent of all Americans diagnosed with HIV/AIDS in 2004 were African-Americans (CDC, 2006d). Some have suggested that the lesson of community may be usefully applied in this context. Advocates have turned to Black churches to help them spread information and understanding about the spread of AIDS in the Black community (Avery and Bashir, 2003). Organizations such as The Balm in Gilead, which sponsors The Black Church Week of Prayer for the Healing of AIDS (Avery and Bashir, 2003), have become an effective community voice in the fight against HIV/AIDS.

Other lessons may be usefully applied to international communities and their burgeoning HIV/AIDS epidemics. The social and technological changes that have characterized our country's development over the last several decades are now occurring in other countries. In Thailand, for example, dramatically shifting sexual roles are starting to be reflected in alarming rates of STI among young Thai women (Celentano et al., 2006b). The spread of technology in Thailand, where almost half the population has cell phones and more than a tenth have Internet access (CIA, 2006), is also encouraging greater connections between young people. Preparing for the consequences of these developments, by implementing educational programs which are aimed at this segment of the population and which make use of available technologies, may be one way of applying lessons we have learned from epidemics in this country to potential epidemics in other countries.

Clearly, understanding the relationships between social developments and their impact on social structures and human behaviors, specifically sexual behaviors, is an essential component in understanding the sexual transmission of disease. We have learned much in this country about the interplay of these processes. Applying this knowledge prospectively both in our country and in other countries remains one of our greatest challenges in the field of STI.

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