Mayer / Pizer The AIDS Pandemic

Impact on Science and Society
1. Auflage 2004
ISBN: 978-0-08-047580-6
Verlag: Elsevier Science & Techn.
Format: EPUB
Kopierschutz: 6 - ePub Watermark

E-Book, Englisch, 520 Seiten

The AIDS Pandemic explores the ways in which HIV/AIDS has, and continues to transform the wide range of related disciplines it touches. Novel perspectives are provided by a unique panel of internationally recognised experts who cover the unprecedented impact onf AIDS on culture, demographics and politics around the world, including how it affected the worlds' economy, health sciences, epidemiology and public health. This important far- reaching analysis uses the lessons learned from a wide array of disciplines to help us understand the current status and evolution of the pandemic, as it continues to evolve.
* Unique and timely presentation of new theories and perspectives
* Concentrates on the changes that have taken place in a broad array of related disciplines
* Provides key contextual information, for those new to the field or at interface areas between disciplines
* Includes an international focus on evolving African and Asian experiences
* Focuses on the current strategies for developing vaccines and microbicides
* Outlines harm reduction and prevention programs
* Explores issues related to delivery of life-saving AIDS medications in resource-constrained environments

Autoren/Hrsg.

Mayer, Kenneth H.

Pizer, H. F.

Inhaltsverzeichnis

1;Cover;1
2;The AIDS Pandemic: Impact on Science and Society;4
3;Contents;6
4;Contributors;8
5;Preface;12
6;About the Editors;18
7;Introduction;24
7.1;New Century, New World: Scientific Advances in AIDS;26
7.2;Prevention Works;28
7.3;Globalization;30
7.4;Social and Ethical Dimensions;32
7.5;References;34
8;1 Virology;36
8.1;History of the Discovery of HIV;38
8.2;AIDS Denial;40
8.3;HIV-related Retroviruses of Monkeys;41
8.4;HIV-2 – HIV Closely Related to SIV;43
8.5;HIV-1 Subtypes;44
8.6;Emergence of HIV-1 Disease Phenotypes;46
8.7;Viral Load and HIV Pathogenesis;47
8.8;Primary HIV Infection and Viral Setpoint;49
8.9;HIV Therapy and Viral Load;50
8.10;What the Future Holds;51
8.11;References;52
9;2 Immunology in the Era of HIV/AIDS;59
9.1;Introduction;59
9.2;A Brief History of Immunology (from Silverstein, 1989);60
9.3;Contributions of Modern Immunology to the Understanding and Treatment of HIV/AIDS;63
9.3.1;Technological Advances;63
9.3.1.1;Molecular immunology;63
9.3.1.2;The monoclonal antibody revolution;64
9.3.1.3;High-throughput single-cell assays;65
9.3.2;Conceptual Advances;66
9.3.2.1;HIV adaptive immunity;66
9.3.2.2;Innate immunity;69
9.3.2.3;Mucosal immunology;71
9.3.2.4;Mechanisms of immune evasion by viruses;73
9.3.3;Applications of New Discoveries to HIV/AIDS Prevention and Treatment;74
9.3.3.1;Vaccines;74
9.3.3.2;Topical microbicides;75
9.3.3.3;Immunotherapy;76
9.4;What the Future Holds;77
9.5;References;78
10;3 Quantitative Science;81
10.1;Lessons;83
10.1.1;Lesson No. 1: Long-term, Excellent Follow-up is Important;84
10.1.2;Lesson No. 2: Pragmatic and Explanatory Trials are Needed;89
10.1.3;Lesson No. 3: Randomized Trials and Observational Studies are Both Important;94
10.2;Challenges;99
10.2.1;Challenge No. 1: Creating Lasting, Cost-effective Infrastructures;100
10.2.2;Challenge No. 2: Achieving Simplicity and Cost-effectiveness Without Jeopardizing Trial Conduct and Patient Safety;102
10.2.3;Challenge No. 3: Recruiting and Training Investigators to Participate in Collaborative Trials;104
10.3;Summary;105
10.4;References;106
11;4 The Public Health Response to HIV/AIDS: What Have We Learned?;113
11.1;Building San Francisco’s AIDS Program;113
11.2;Decision-Making;115
11.3;Service Needs;118
11.4;Cultural Competency and Privacy;120
11.5;Adapting the Disease Prevention Model;121
11.6;Advocacy;125
11.7;Single-Issue Advocacy;126
11.8;New Tactics;127
11.9;What the Future Holds;128
11.10;References;130
12;5 AIDS and Sexually Transmitted Disease Prevention and Control;133
12.1;The San Francisco Perspective;134
12.2;Origins of STD Control;135
12.3;Evolution of HIV Prevention Outside of STD Control Programs;138
12.4;STDs and HIV Transmission;139
12.5;STD Treatment and HIV Prevention;140
12.6;Behavioral Risk Reduction and STD Prevention;143
12.7;Condom Policy and Distribution;144
12.8;STDs in HIV Surveillance;145
12.9;HIV Counseling and Testing in STD Clinics;146
12.10;HIV Prevention as STD Control;146
12.11;Recreational Drug Use and Risk;148
12.12;The Internet and STD Transmission and HIV Prevention;150
12.13;Impact of HIV Therapy and HIV Medication Advertising;151
12.14;Post-exposure HIV Prophylaxis (PEP) in STD Clinics;152
12.15;Venue Notification;153
12.16;Collaboration with Community-based Organizations;154
12.17;What the Future Holds;154
12.18;References;156
13;6 HIV Treatment Meets Prevention: Antiretroviral Therapy as Prophylaxis;160
13.1;HIV Transmission;163
13.2;Antiretroviral Therapy for Prevention;166
13.2.1;The Pharmacology of ART in the Genital Tract;166
13.2.2;Antiretroviral Drugs Reduce Shedding of HIV in the Genital Tract;167
13.2.3;Will ART Reduce Sexual Transmission of HIV?;168
13.3;Other Considerations: New Thinking about the HIV-infected Subject;171
13.3.1;Stage of HIV Infection;171
13.3.2;Behavior Change;171
13.3.3;Resistance;172
13.3.4;Prevention Versus Treatment;172
13.4;ART for Pre- and Post-exposure Prophylaxis for HIV-negative People;173
13.4.1;Animal Studies;173
13.4.2;Post-exposure Prophylaxis for Vertical Transmission;173
13.4.3;Needlestick Injury;173
13.5;Post-exposure Prophylaxis (PEP) for Sexual Transmission of HIV;174
13.5.1;Limitations of PEP;175
13.5.2;Cost Benefit Analysis of PEP to Prevent Sexual Transmission of HIV;176
13.5.3;CDC Guidelines for Non-occupational HIV Exposure (n-PEP) 2004;176
13.6;Pre-exposure Prophylaxis;176
13.7;What the Future Holds;177
13.8;References;178
14;7 Challenges in Developing HIV Vaccines;185
14.1;The Process of Vaccine Testing;187
14.1.1;Preclinical Testing;188
14.1.2;Clinical Safety and Immunogenicity Studies;188
14.1.3;Clinical efficacy studies;189
14.2;Scientific Challenges;190
14.2.1;Humoral and Cellular Immune Responses;191
14.2.2;Models of Protection;191
14.2.3;Immune Correlates of Protection;192
14.2.4;Evasion of the Immune Response;193
14.2.5;Viral Diversity;194
14.2.6;The Vaccine Pipeline;195
14.3;Ethical challenges;196
14.3.1;Research in Vulnerable Populations;196
14.3.2;Need to Support HIV Prevention in all Vaccine Trial Participants;198
14.3.3;Vaccine-induced Positive Antibody Tests;199
14.3.4;Access to HIV Vaccines and Treatment for Vaccine Trial Volunteers;200
14.3.5;Developing and Testing Products for the Developing World;202
14.4;Practical Challenges in Implementing Clinical Trials;203
14.4.1;Building Clinical Trials Infrastructure;204
14.4.2;Regulatory Issues;205
14.4.3;Economic Considerations;206
14.5;Public Health Challenges;207
14.6;What the Future Holds;208
14.7;References;210
15;8 Microbicides;213
15.1;Impact of HIV on the Development of Microbicides;214
15.2;Parallel Tracks;215
15.3;A New Dynamic;216
15.4;Defining and Describing the Technology;218
15.5;How Microbicides Work;219
15.6;Targeting the Incoming Pathogen;221
15.6.1;Blocking the Invader and Strengthening the Host – Physical Barriers, Lubrication, Maintenance or Enhancement of Normal Microflora, Mobilization of Natural Defense…;221
15.6.2;Viral Disruption: Inactivation or Disruption of Membranes;225
15.6.3;Inhibition of Viral Entry and Fusion – Targeting the Viral Envelope;225
15.6.4;Targeting the Host Mucosal Cells, Inhibition of Viral Entry and Fusion – Targeting Receptors and Co-receptors;227
15.6.5;Inhibiting Replication;228
15.7;Looking for Combinations;228
15.8;Devices and Desires;233
15.9;Microbicides Growing Up;233
15.10;The Players;235
15.10.1;Alliance for Microbicide Development (AMD);236
15.10.2;Family Health International (FHI);236
15.10.3;Global Campaign for Microbicides (GCM);236
15.10.4;Global Microbicide Project (GMP);236
15.10.5;International Family Health (IFH);237
15.10.6;International Partnership for Microbicides (IPM);237
15.10.7;Microbicides Development Programme (MDP);237
15.10.8;Population Council;238
15.11;Funding Development Efforts;238
15.11.1;The Public Sector: Government Agencies and Institutions;240
15.11.2;The Philanthropic Sector;240
15.12;Microbicides Going Forward;241
15.12.1;Challenges in the Science;242
15.12.1.1;Basic understandings;242
15.12.1.2;Other models;243
15.12.1.3;Clinical evaluation;244
15.12.1.4;Formulation;244
15.12.1.5;Clinical trial design;245
15.12.1.6;Clinical trial infrastructure;246
15.12.2;The Future;246
15.12.2.1;Assuring access and use;246
15.12.2.2;Partial effectiveness, condom ‘migration,’ and the public health impact of microbicides;247
15.12.2.3;Access and the regulatory route;248
15.13;Common Cause and Shared Learning;249
15.14;What the Future Holds;251
15.15;References;252
16;9 AIDS Behavioral Prevention: Unprecedented Progress and Emerging Challenges;259
16.1;Progress in AIDS Prevention Science;260
16.2;Health Psychology Jumpstarted HIV/Sexually Transmitted Disease (STD) Prevention;260
16.3;Theoretical Framework for Prevention;261
16.4;Phases of Behavioral Prevention Research;262
16.4.1;Phase I: Discovery Phase of Behavioral Prevention Research;262
16.4.2;Phase II: Exploratory Phase of Behavioral Prevention Research;263
16.4.3;Phase III: Efficacy Phase of Behavioral Prevention Research;263
16.4.4;Phase IV: Effectiveness Phase of Behavioral Prevention Research;264
16.5;Levels of Prevention;265
16.5.1;Individual-level Interventions;266
16.5.2;Couple-level Interventions;266
16.5.3;Family-level Interventions;268
16.5.4;Community-level Behavioral Prevention Studies;268
16.5.5;Societal-level Interventions;270
16.5.5.1;Model development;271
16.5.5.2;Policy development;271
16.5.5.3;Communications;271
16.5.5.4;Mass media programs;272
16.5.5.5;Environmental interventions;272
16.6;Contributions of Behavioral HIV/STD Prevention Research;273
16.7;Challenges for International Behavioral Research;274
16.7.1;Cross-cultural Adaptation;274
16.7.2;Trained Behavioral Prevention Personnel;275
16.7.3;Research Infrastructure;275
16.7.4;Ethical Conduct of Research;276
16.8;What the Future Holds;277
16.8.1;Globalization of HIV/STD Prevention Research;277
16.8.2;Modeling of Prevention Strategies;277
16.8.3;Multiple-level Sustainable Interventions;278
16.9;References;278
17;10 The Evolution of Comprehensive AIDS Clinical Care;284
17.1;Understanding Chronic Viral Immunosuppression;286
17.2;Adapting the Care Environment;289
17.3;The National US Response;290
17.4;New Judicial Protections;291
17.5;Transforming Infection Control;294
17.6;A New Care Model;295
17.7;AIDS Specialty Practice;296
17.8;Short-term Versus Long-term Care;301
17.9;What the Future Holds;302
17.9.1;The Future of HIV Clinical Care in the US;302
17.9.2;The Future of HIV Clinical Care Internationally;303
17.9.3;Directly Observed Antiretroviral Therapy;305
17.10;References;306
18;11 The Ever-changing Face of AIDS: Implications for Patient Care;309
18.1;AIDS in the World: The Current Situation;310
18.2;Stopping AIDS: How have We Done so Far?;316
18.3;Limitations to the Current Paradigm;317
18.4;AIDS: Access to Care;318
18.5;Treating HIV Among the Poor: Integrating Prevention and Care;320
18.6;Brazil: Expanding Access to ARV;322
18.7;Treating HIV Among the Poor: Community-based Approaches;322
18.8;What the Future Holds;325
18.9;References;327
19;12 Economics;330
19.1;Summary of the Current Situation;331
19.2;Economic Evolution of the HIV Epidemic in the United States;336
19.2.1;Early Period: Chaos, Catastrophe, and Costly Hospitalizations;336
19.2.2;Middle Period: Transition to Integration Under Subsidy;338
19.2.3;Late Period: Pervasive Effects of Powerful Treatments;340
19.3;What the Future Holds;343
19.4;References;344
20;13 Expanding Global Access to ARVs: The Challenges of Prices and Patents;347
20.1;Expanding Access to Treatment;348
20.2;Pricing Pharmaceuticals;350
20.3;Responding to International Pressures to Lower Prices for AIDS Drugs;351
20.4;How Patents Affect Drug Prices;355
20.4.1;International Agreements Affecting Patents: The WTO and TRIPS;357
20.4.2;How TRIPS Affects Access to ARVs;359
20.4.3;Patents for AIDS Medicines;360
20.5;Approaches for Expanding Access to Medicines for HIV/AIDS;362
20.5.1;Market-based Approach;362
20.5.2;Differential Pricing;363
20.5.3;Trade Policy-based Approaches;364
20.5.4;Bulk Purchasing;365
20.5.5;Donations;365
20.6;What the Future Holds;366
20.6.1;1. Financing;367
20.6.2;2. Procurement;368
20.6.3;3. Infrastructure;368
20.6.4;4. Stigma and Discrimination;368
20.6.5;5. Testing and Availability of Diagnostics;369
20.6.6;6. Treatment Protocols;369
20.6.7;7. Operational Experience;369
20.7;Acknowledgments;370
20.8;References;370
21;14 The African Experience;374
21.1;How Different Countries in Africa are Affected;375
21.2;Risk Factors for HIV Infection in Africa;379
21.2.1;Population Migration;379
21.2.1.1;Truck drivers;379
21.2.1.2;Migrant labor;380
21.2.2;Gender;381
21.2.3;Youth;381
21.2.4;Sex Workers;382
21.2.5;Sexually Transmitted Infections;382
21.3;Consequences of the AIDS Epidemic in Africa;382
21.4;HIV Prevention in Africa;385
21.4.1;Responses of African Governments;385
21.4.2;Prevention Successes in Africa;385
21.4.3;Prevention in the Workplace;387
21.4.4;Increasing Access to Condoms;387
21.4.5;Universal Education in Uganda;387
21.4.6;Community-based Programs in Response to HIV/AIDS;387
21.5;Prevention Gaps in Africa;388
21.5.1;Provision of Condoms;388
21.5.2;Provision of Voluntary Counseling and Testing;389
21.5.3;Targeted Behavioral Interventions;389
21.5.4;Prevention of Mother-to-Child Transmission;389
21.5.5;Broad-based HIV/AIDS Awareness;390
21.5.6;Diagnosis and Treatment of Sexually Transmitted Infections;390
21.5.7;Supportive Initiatives;390
21.6;HIV-related Treatment and Care in Africa;390
21.7;What the Future Holds;392
21.8;References;394
22;15 Asia: Health Meets Human Rights;397
22.1;AIDS Enters South-East Asia;403
22.2;The Thai Experience;404
22.3;Confronting Traditional Sex Roles;405
22.4;The Thai Government Responds;406
22.5;Empowering Women, Protecting Society;407
22.6;Drug Use and Trafficking;410
22.7;Blood Transfusion;412
22.8;Widening Access to Modern Care;413
22.9;What the Future Holds;415
22.10;References;418
23;16 How HIV/AIDS Changed Gay Life in America: And What Others Can Learn from Our Experience;421
23.1;Mobilizing the Community;423
23.1.1;Gay Leaders Step Forward;423
23.1.2;Beginnings of a Gay Health Network and Movement;424
23.1.3;A Tremendous Outpouring of Support;425
23.2;Preventing the Spread of HIV;425
23.2.1;Defining ‘Safe Sex’;426
23.2.2;Targeted and Explicit Prevention Works Best;427
23.2.3;Prevention Education Worked – for a While;428
23.3;Pushing Medicine’s Limits;429
23.3.1;People with AIDS – Not Victims;430
23.3.2;Information is Power;431
23.3.3;Buyers’ Clubs;432
23.3.4;A New Way of Doing Medical Research – at the Community Level;433
23.4;Learning to Do Politics Washington-Style;434
23.4.1;AIDS and the Gay Movement;434
23.4.2;Emergence of the AIDS Lobby;435
23.4.3;The Power of Coalitions;436
23.5;The Politics of Mourning;438
23.5.1;A Community in Mourning;438
23.5.2;Mourning Rituals to De-Stigmatize AIDS;439
23.6;Looking Ahead;440
23.6.1;Prevention Politics Continue;441
23.6.2;Rethinking Prevention;442
23.6.3;Empowering Health Consumers;443
23.7;What the Future Holds;444
23.8;References;445
24;17 Drug Use;447
24.1;Historical Perspective;448
24.1.1;Opiates;448
24.1.2;Stimulants;449
24.1.3;Drug Treatment;450
24.1.4;The Advent of the AIDS Epidemic;451
24.1.5;Worldwide Epidemic;452
24.2;Interventions Targeting Behaviors;453
24.2.1;Community Outreach and Bleach Syringe-Cleaning Protocols;453
24.2.2;Harm Reduction;454
24.2.3;Increasing Access – Needle Exchange;455
24.2.4;Health-Related Services at Needle Exchange;456
24.2.5;Scientific Evidence for Needle Exchange;457
24.2.6;Increasing Access – a Sterile Syringe for Every Injection;458
24.2.7;Increasing Legal Access to Sterile Syringes;458
24.2.8;Syringe Prescription;459
24.2.9;Interrupting Sexual Transmission Among MSM Drug Users;460
24.2.10;Treating HIV-Infected Drug Users;461
24.3;What the Future Holds;464
24.4;References;466
25;18 Management of HIV/AIDS in Correctional Settings;472
25.1;Epidemiology and Background;473
25.2;Survival Experience;475
25.3;HIV Transmission in Prisons;476
25.4;HIV and Co-morbid Conditions;479
25.4.1;HIV and Tuberculosis;479
25.4.2;Hepatitis C Virus;481
25.4.3;Hepatitis B Virus;483
25.4.4;Sexually Transmitted Diseases: Syphilis, Gonorrhea, and Chlamydia;484
25.4.5;Mental Illness;484
25.4.6;Obstetric and Gynecologic Issues;486
25.4.7;Illicit Drug Use and Prisoners;486
25.4.8;Treatment of Opiate Addiction;487
25.4.8.1;Methadone;487
25.4.8.2;Naltrexone;488
25.4.8.3;Buprenorphine;488
25.5;Medical Treatment of HIV-infected Prisoners;489
25.5.1;Adherence to ART and Dispensing Medications Within Prison;491
25.6;HIV Testing and Housing Policies;493
25.7;Confidentiality;494
25.8;Education;494
25.9;Other Prevention Measures;496
25.10;Discharge Planning;497
25.10.1;Discharge Planning and Community Linkages;497
25.11;AIDS Research;498
25.12;Legal Issues in US Prisons;499
25.13;Prison Hospice;501
25.14;What the Future Holds;502
25.15;Acknowledgements;502
25.16;References;503
26;19 Medical Ethics and the Law;511
26.1;The Right to Privacy;512
26.2;HIV Prevention and Consent;517
26.3;Impact on Research Ethics;520
26.4;Antidiscrimination Law;521
26.5;Criminal Law;526
26.6;Incarceration is a Public Health Issue;528
26.7;Access to Pharmaceuticals;528
26.8;What the Future Holds;531
26.9;References;532
27;Index;534
27.1;A;534
27.2;B;536
27.3;C;538
27.4;D;541
27.5;E;542
27.6;F;542
27.7;G;543
27.8;H;544
27.9;I;546
27.10;J;548
27.11;K;548
27.12;L;548
27.13;M;548
27.14;N;549
27.15;O;550
27.16;P;550
27.17;Q;553
27.18;R;553
27.19;S;553
27.20;T;556
27.21;U;558
27.22;V;558
27.23;W;559
27.24;Y;560
27.25;Z;560

Leseproben

Preface Dr. Rieux resolved to compile this chronicle … to state quite simply what we learned in a time of pestilence: That there are more things to admire in men than to despise. Albert Camus, The Plague, Part V The premise of this book, The AIDS Pandemic: Impact on Science and Society, is that the AIDS epidemic has transformed the multiple disciplines it has touched from molecular virology to the conduct of clinical trials to bioethics and macroeconomics. I developed this perspective because I have been fortunate to work over the last two decades with remarkable people, who have taught me many unique lessons about the ways in which health care professionals, academic researchers, and community activists can mobilize to understand, and to address, a newly emerging public health crisis. I initially became aware that there was going to be a burgeoning public health problem with what came to be known as AIDS while doing an Infectious Disease fellowship at Brigham and Women’s Hospital and Harvard Medical School in Boston, while also working at Fenway Community Health in Boston. My affiliation with Fenway is ongoing, sustained, and ever changing because of the superb working environment and colleagues that I have been fortunate to know over more than two decades. The executive directors of Fenway have been a talented group of individuals, particularly Sally Deane, Dale Orlando, Michael Savage and most notably Dr Stephen Boswell, who has led the agency to develop programs of international renown in developing a paradigm for community-based responses to the AIDS epidemic. I am fortunate to have several stellar intellectual colleagues at Fenway, including Dr Steven Safran, Dr Judy Bradford, as well as administrative directors including, Louise Rice and Rodney VanDerwarker. It has been edifying to watch successive generations of Fenway research team members go on and develop their careers, going back to school to become physicians, clinical psychologists, and public health researchers, or making other contributions to community health defined as broadly as possible. It is a unique environment, given its roots in the gay and lesbian communities, while at the same time creating a new model of community-based research. When I first came to Brown University in 1983, there was virtually no organized community-based response to dealing with the rapidly emerging AIDS epidemic in Providence and south-eastern New England. My academic chief, the Director of the Division of Infectious Diseases, Dr Stephen Zinner (whose own research did not focus on AIDS), created a very supportive environment which allowed me to develop my clinical work, as well as a program of community-based research in Rhode Island. Within two years of my arrival at Brown, Dr Charles Carpenter assumed the position of Physician-in-Chief at The Miriam Hospital, and was committed to creating a center of excellence for HIV care and clinical research. Chuck was one of the first people to recognize that the emerging epidemic would severely impact America’s underclass, particularly the most vulnerable populations, e.g. women of color; and he set about to create a program that was culturally sensitive and distinctive in its ability to address the manifold concerns of people living with HIV and, at the same time, to do excellent clinical research. Chuck soon was joined by Dr Timothy Flanigan, now the Director of the Division of Infectious Disease at Brown. Tim’s dynamism expanded the programs at The Miriam Hospital Immunology Center and led to the attraction of whole cadre of talented, younger clinical investigators who have made an impact on developing community-based programs that address the real world needs of people living with HIV, while developing important clinical and laboratory information. Dr Susan Cu-Uvin, who oversees the clinic, has contributed enormously to our understanding of the gynecological manifestations of HIV disease and the effects of antiretroviral therapy on HIV acquisition and transmission. Dr Jody Rich has reframed the model of harm reduction for injecting drug users in creative ways that range from creating a drop-in center which deals with the panoply of needs that drug users may have, ranging from de-addiction services, to access to sterile syringes, to vaccination against hepatitis A and B and screening for sexually transmitted infections. I am also fortunate to have interacted with a number of outstanding junior colleagues, including Drs Michelle Lally, Jennifer Mitty, Karen Tashima, Herb Harwell, David Pugatch, Mark Lurie, Kate Morrow, and Grace Macalino. Our Chief of Medicine, Dr Edward Wing, has integrated the clinical and research environments through his unqualified support of best practices. In addition to excellent medical research colleagues, I have been privileged to work with some outstanding public health researchers and practitioners, including Drs Sally Zierler, Vincent Mor, Stephen McGarvey, and Terri Wetle. The deans at Brown’s Medical School have been uniformly supportive, starting with Dr David Greer, succeeded by Dr Donald Marsh, and most recently, Dr Richard Besdine. In summary, the environment at Brown has been extremely conducive to trans-disciplinary thinking, resulting in unique research studies and the generation of new data that has direct impact on the lives of people living with HIV and those at most risk for AIDS. One of the most wonderful parts of being a faculty member at Brown University is the access to stellar students, whose intellectual capabilities are astounding, and whose idealism and commitment to international public health continue to inspire the faculty to redouble our efforts and think creatively about our research endeavors. Although my initial work in the AIDS epidemic focused on the burgeoning epidemic in New England among men who have sex with men and women at risk for HIV, it became clear very early on that the largest impact of the epidemic would be outside the United States. About 10 years ago I took over responsibility for a program set up at Brown, in conjunction with Tufts University, to coordinate a training program to develop international research infrastructure for clinical, laboratory, and behavioral investigators from five countries in Southern and Eastern Asia. I have been particularly fortunate to develop an on-going and every-growing relationship with several remarkable Asian organizations, most notably YRG Care, a community-based organization in Chennai (Madras), Southern India. My colleagues there, Drs Suniti Solomon, and Balakrishnan, N Kumarasamy, as well as the administrative leadership, Mr AK Ganesh and Mr AK Srikrishnan have taught me an immeasurable amount about how a community-based organization can scale-up, one program at a time, to develop multifaceted responses to a burgeoning local epidemic, and in the process, create a model of community-based research that offers lessons for colleagues in other parts of Asia, as well as Africa and other developing nations, in addition to clinical researchers and students in resource-rich environments. The AIDS epidemic has led to some distinctive relationships and partnerships. One of my other full-time jobs has been to serve as a member of the Board of Directors of the American Foundation for AIDS Research, an organization that helped to jumpstart many important AIDS-related research and public policy issues. I continue to be in awe of the dynamic moral leadership of Dr Mathilde Krim, the founder of amFAR, as well as her talented staff, including the CEO, Jerry Radwin, the Vice Presidents for Public Policy, Jane Silver and now Judith Auerbach, and the Vice President for Clinical Research, Kevin Frost. The impressive volunteerism of the Board, ranging from successful people in the world of business and the media to distinguished research scientists and public health officials, also serves to remind me of the unique civil society response to AIDS that has helped us accomplish so much in the fact of this daunting epidemic. Because of the many domains that the epidemic touches, and the need for large commitments of public resources to support AIDS-related initiatives, the role of public officials needs to be acknowledged. I have been fortunate to work in two states in New England that have had enlightened responses to the AIDS epidemic, and have learned a great deal from some very dedicated public health officials, including Jean McGuire, John Auerbach, Kevin Cranston, Dr Al DeMaria, Dr Patricia Nolan, Paul Loberti, and Tom Bertrand. Without the insight and cooperation of these officials, none of our community-based research and care programs could have moved forward. In addition, the local environment that began with Fenway Community Health has been augmented by several wonderful community-based organizations, ranging from the AIDS Action Committee of Massachusetts, to the Community Research Initiative of New England, to AIDS Project Rhode Island and AIDS Care Ocean State, to the Multi-cultural AIDS Coalition and Latino-American Health Institute. The partnerships of these organizations with Fenway Community Health and Brown University researchers have served as a reality check for the development of community-focused research and clinical programs that are addressing the needs of the populations most affected by the epidemic. Last, but not least, this book could not have happened without the support of administrative colleagues, particularly Lola Wright who enables me to spend so much time on the road and still be able to maintain my focus on ongoing responsibilities and commitments. In addition, my efforts at Fenway have been greatly...