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Public health experts and economists share a common dissatisfaction towards previous economic analyses of the impacts of HIV/AIDS. A growing body of evidence now allows a better understanding of the full economic and societal dimensions of the epidemic. It is now certain that poverty contributes to HIV/AIDS epidemics and that AIDS contributes to poverty, although we still do not know enough about the complex pathways of this relationship. To illustrate this idea, an "endogenous" growth model- which takes into account the evolution of society's human capital-is used in order to re-assess the macroeconomic impact of HIV/AIDS. A fairly wide range of epidemic effects modify the economy's long-term growth regime, creating the risk of what we might call an epidemic or "regressive trap" of rapidly falling GDP. Government action should be designed in view of this risk, with health and educational interventions. [ABSTRACT FROM AUTHOR]

This chapter explores the association between psychological and behavioural factors and HIV infection. While it is acknowledged that the relationship between psychological and behavioural factors and HIV disease progression is an important one, it is also clear that there are complex methodological problems that make it hard to establish clear and definite causal links, in particular in the area that is known as psycho-immunology. Even if it could be established conclusively that psychological status, attitudes and ways of coping can have an important effect on disease progression, it is also relevant to establish the strength of their contribution, in particular by comparison with the role of antiretroviral medication or prophylactic treatment, or indeed to neuropsychological function. It is nevertheless important to continue encouraging individuals with HIV infection to maintain a positive outlook and an active coping style, so that they develop control over their lives and avoid depressed mood or undue stress levels. These are all good things in themselves, whether or not they translate into a better immune function and subsequent improved prognosis. However, what has been described as the tyranny of positive thinking may well lead individuals with HIV infection to feel guilty and blame themselves should their HIV infection progress and their immune function decline.

This chapter hypothesises that preventive behaviour is linked more to the perception of personal risk and therefore to socially constructed vulnerability than to knowledge or attitudes concerning illness. Because individualistic theories of risk management are too rationalist and exclusively cognitive, they cannot properly account for the link between knowledge and action which is mediated by perceptions of risk. Likewise, they fail to explain the internal dynamic of action whereby emotional, cognitive and social activity and interaction appear linked. Because of this deficiency and the need to untangle several complex behaviours, theories capable of accounting for this complexity were developed. Risk perception and management depends more on the contexts and situations that provide resources to individuals than on knowledge or intrinsic individual characteristics. Moreover, the links between risk perception and action must be considered not in a linear perspective from cognition to action as is usually done, but in an interactive perspective. Action, while dependent on processes of interpretation and risk perception, may also engender new ways of perceiving risk. For instance, varying experiences with mastery, or lack thereof, can foster alternatively feelings of vulnerability or control. Such a global approach is necessary for conceiving prevention programmes based on a dynamic of empowerment.

This chapter offers an overview of issues pertaining to the modelling of sexual networks and their relevance to HIV prevention. The models considered are dynamic models that incorporate a description of the transmission process and relate this to epidemiological outcomes. In relation to HIV prevention, models provide a cheap and controllable means of testing different strategies and comparing their effectiveness. In modelling HIV transmission, relevant parameters include the probability of transmission per contact or per partnership, the incubation time distribution, infectivity at various stages of infection, and disease-related mortality. A prevention approach that targets not only individuals, but also their partner(s), is even more important for HIV than for other sexually transmitted diseases, because effective prevention is as yet the only means we have to fight AIDS. It is increasingly recognised that an individual's behaviour cannot be understood outside the context of the partnership within which it takes place, and cannot be reduced to simple quantities such as the rate of partner change.

This chapter explores the public health consequences of a substantial increase in HIV testing, assuming normalisation might lead to more testing being offered in the case of Great Britain. At the present time in England and Wales HIV infection is overwhelmingly confined to behaviourally vulnerable minorities--gay men, injecting drug users and migrants from high-prevalence countries--and practically all HIV infection can be predicted by the presence of major risk factors. Most of the HIV infected have probably had their infection diagnosed clinically and transmission of HIV infection due to sexual intercourse between men is probably continuing at an appreciable rate despite widespread HIV testing. There is generally easy access to voluntary confidential testing for those at greatest risk of HIV infection. Lack of awareness of their infection status in those who are HIV infected may be the outcome of either a considered decision not to be tested or relatively recent infection, or both. Those at greatest risk who choose not to be tested are unlikely to change their minds until evidence in favour of early HIV diagnosis becomes more compelling. Normalisation of HIV testing has become a rallying cry at the same time as it is clear that HIV infection in Europe is likely to remain largely within marginalised groups in society. Normalisation of testing rests partially on the belief that HIV infection can be diagnosed before onward transmission takes place and that the rest of the population would be protected if all the infected could be diagnosed. Pursuing a policy of early testing may divert effort from strengthening primary prevention. People at higher risk of HIV infection generally choose to be tested when they feel ready or when they fall ill. The key issue is not why were they tested late, but rather why were they at risk in the first place.

This chapter examines the factors shaping the development of AIDS policies in several European countries, including France, Great Britain, Italy and Germany. Normalisation describes the integration of the AIDS issue into existing agendas, priorities and networks of public policies, in particular health and welfare policies. The process endows the newly introduced policies with long-term sustainability. Normalisation is a dynamic process, combining the path dependency of health policy and AIDS-rooted innovations. It has proved to be more complex and laden with conflicts in countries that were poorly equipped for public health management and, therefore, opposed to the recognition and the practical treatment of the new public health risks. Far-reaching consequences can be expected, particularly in these countries, because the epidemic contributes to the consolidation of the poorly established parts of the public health sector. This calls into question elements of the political culture, like the boundary between what can be considered public and private rights or responsibilities. Collective norms have had to undergo changes, which explains the existence of political controversy in many countries.

This chapter suggests that changes in French drug policy were part of a broader global renewal of social policy for health. The social and health conditions of injecting drug users were no longer to be seen as an individual phenomenon, but were viewed as a consequence of social exclusion. This process is an effect of the functioning of health and social institutions themselves. Social exclusion as a phenomenon is not specific to drug users, but common to a wide variety of marginalised population groups. In spite of the universal coverage guaranteed by the French Social Security Sickness Fund, various subgroups (to which HIV-infected drug users often belong) face multiple barriers when it comes to accessing care. These include economic barriers. In 1996, for example, 16 per cent of a representative sample of the French general population reported having delayed or given up medical care in the last twelve months because of financial constraints. A key factor influencing the switch in drug policy was the growing popularity of social exclusion as a framework by which to understand drug-related vulnerability to HIV. Harm reduction strategies in France seem already to have produced some positive outcomes. In particular, the medicalisation of services offered to drug users has improved the quality of care and, in drug treatment programmes, nurses and doctors now commonly work alongside psychologists and social workers.

This chapter presents a study which investigated why and how neighbourhood reactions appear, develop, are debated, and usually change when the harm reduction professionals intervene cooperatively in support of harm reduction facilities for the users of illegal drugs. Harm reduction facilities are central to HIV prevention among injecting drug users and make a significant contribution to the improvement of their state of health as well as their social situation. The implementation of harm reduction programmes has, however, given rise to serious difficulties. Since these facilities are accessible to a part of the population that continues to live in conditions of illegality and whose behaviours are considered taboo, their presence not infrequently triggers hostile reactions from neighbourhood groups. The integration of a harm reduction facility in city neighbourhoods and the sustainability of this integration are dependent on the processes of adaptation and change. If facilities are integrated on a flexible and negotiable basis, the neighbourhood may come to understand that its requests and needs will be taken into account. Gradually, the representations that the various groups have of the others (neighbours-professionals, professionals-drug users, drug users-neighbours) will start to change. It is possible to influence this evolution consciously by paying attention to the modalities of the social experience that the opening of the service represents.

This chapter examines the role of drug users' views in evaluating two key HIV prevention strategies: substitute methadone prescribing and the provision of sterile injecting equipment. The data have shown that the opinions of drug users are similar to those often expressed by policy makers, providers and researchers. Nevertheless, it has also been evident that drug users have additional concerns about service provision. Moreover, the opinions of service users vary depending on the individual concerned and the particular circumstances of that individual at any given moment in time. Drug users' views are, in other words, diverse but also susceptible to change over time. Furthermore, individuals with drug problems often demonstrate a high level of insight into their personal circumstances and seem well placed to make a contribution to decisions about their own treatment and service requirements. Inevitably, some drug users will require services which they dislike (such as prison) or their views will differ from those of other professionals or from research evidence. For example, some individuals may be offered very low levels of substitute medication and others forced to comply with conditions (such as urinalysis, supervised consumption or compulsory counselling) in order to receive their prescriptions. Such potential sites of conflict require further consideration.

This chapter deals with the issue of the epidemiology of HIV/AIDS in prisons in Europe. The analysis shows that European health and prison administrations are concerned with the issue of HIV/AIDS in prison, and improvements in prevention policy have already been achieved. However, all published data highlight the frequency of risk behaviour among prisoners, before, during and after incarceration, and the inadequacies of current prevention policy. Access to harm reduction measures in European prisons still falls short of the World Health Organisation's 1993 Guidelines on HIV Infection and AIDS in Prisons. This situation presents public health and penitentiary administrations with a tremendous challenge to provide much-needed educational, prevention and treatment services. Although it has been shown that prevention strategies aimed only at eliminating drug use are inadequate among injecting drug users living in the community, there is still a tendency in European prisons to adhere to this old belief. Debates about harm reduction in prison are not broad enough, and are less advanced than those held by people in general. Such debate is crucial. Prisoners are part of the community, and they come from and return to the community. They deserve the same level of information, protection and care received by people outside prison. Communicable diseases in prisons should be considered as a general public health issue and not one restricted to this subgroup of the population.

This chapter examines whether problems in communication increased young people's vulnerability to HIV and AIDS and risk behaviour in Bulgaria. Communication with parents was often perceived as a violation of the young person's own personality, because most of the time parents' knowledge (including their norms and values) served as a base for judgements and comparisons. The consequence was a self-limited form of communication, because adolescents felt they knew what would be the reaction of their parents. Didactic ways of transferring knowledge from parents to children were seen as preventing young people gaining their own experience. As regards help, parents are kept on standby in case problems arose that could not be solved either by the young people themselves, or by friends. Young people talked about sex spontaneously with their friends in almost all of the groups, with the exception of the youngest group of girls. When asked, respondents said that they talked about sex a lot. In young people's eyes, sexually transmitted infections, including HIV/AIDS, are not a major concern. The decision to engage in sex is mainly influenced by group norms that are quite different from those of the older generation and are shaped by a feeling of liberation from outdated values and norms. At the same time, however, these norms are linked to fears that the system to which this behaviour is a reaction that may sanction them.

This chapter discusses the dramatic changes in the age of sexual debut which took place in Russia in the mid 1990s, analyzes the consequences of these changes, and examines current Russian views on sex education. Data suggest that school students need sex education and are very interested in questions of sexuality. This interest has primarily a pragmatic motivation. Young people's curiosity about sexuality in the absence of an elementary knowledge of human anatomy, physiology and hygiene (to say nothing about psychological differences in the sexual response cycles of boys and girls) makes initial experimentation in sexual relationships potentially dangerous. At the moment, the pedagogical impact of sex education (so far as there is any) seems limited. In fact, schools hope that sex education will be provided by the family, whereas parents rely upon schools to do this. Meanwhile, the main source of information about sexuality is the printed and electronic media, as well as peers. As a result, young people know little about sexually transmitted diseases, have only an overall idea about contraception, and yet their views and attitudes towards sexual behaviour become more permissive year by year.

This chapter describes the use of condoms at first and last intercourse among young people in France in a biographical and relational context, taking into account the dynamics of the relationship, the degree of sexual experience of the partners, and the awareness of AIDS. Talking about condoms with one's sexual partner does not bring about any variation in condom use as far as boys are concerned. There was, however, a slight tendency to use condoms less during most recent sexual intercourse when a boy had talked about them with his partner (though this variation did not attain the threshold of significance). For girls, the reverse was true. Talking about condoms with their partners went hand in hand with greater condom use, regardless of the sexual relationship in question. When girls talked about condoms with their partners, it was as though talking facilitated use, whereas for boys it was as though that talk enabled some to dispense with condoms during the most recent sexual relation. Multivariate logistic analysis shows that biographical elements--age, year that active sexual life began--together with relationship characteristics--frequency of sexual relations, length of relationship--play a major role in determining condom use. Prevention and contraception choices made the first time affect later practices: boys who used a condom during their first sexual experience continue to do so in greater proportion during later relations, even several years later with a different partner.

This chapter investigates the class-specific effect of social inequality in two European countries, France and Germany, on the prevalence of HIV among gay men. In the 1996 survey, there are marked differences between the three socioeconomic groups with respect to the percentage of HIV-positive men. Among the 73 per cent of western Germans who were tested, 20 per cent of the lowerclass men are HIV positive, as opposed to 13 per cent of the lower-middleclass men, and 7 per cent of the middle-class men. The percentage of HIV positive men among the tested western German respondents in 1993 were as follows: 17 per cent for the lower class; 13 per cent for the lower middle class, and 8 per cent for the middle class. Thus, the incidence of men with HIV infection or with AIDS is twice as high among respondents of the lower class than among middle-class men. Figures for the eastern German subsamples revealed no clear class-specific differences in both surveys. This may reflect something of the more egalitarian social structure still found in eastern Germany. In addition, it should be noted that overall rates of HIV infection are much lower in eastern as compared with western Germany. Strong class-related differences regarding infection rate were apparent in the 16-29 and 30-44 age groups. A chi-square analysis reveals a significant association for both of these age groups between socio-economic status and being HIV positive.

This chapter focuses on sexuality and risk management strategies among people with HIV/AIDS (PWHAs). In contrast to certain messages or positions that consider it legitimate and obvious to expect the HIV-positive person always to engage in risk-free behaviour or to protect the other person perfectly by adopting safe sex, the focus should be on how various stakes and thus the various risks belonging to the different registers can influence the ways partners adapt in their relationships. The paradox is as follows. On the one hand, reduced risk (or safer sex) has gradually become the goal of prevention campaigns that have recognised that zero risk is an unrealistic, and therefore counterproductive, objective. On the other hand, the idea that PWHAs might make others run the slightest risk seems intolerable for many people, as a result of which the implicit aim is for a zeroing of risk. By situating risk in the interaction, the emphasis is shifted from persons to situations. The risk of AIDS, whether for the self or the other, is part of a hierarchy of concerns, the order of which is not predetermined. The complexity of vulnerability must therefore be understood by means of an analytic framework that allows for this very complexity, yet tries to clarify it for the various agents of prevention. Among these, PWHAs are prime interlocutors.

This chapter discusses how HIV and AIDS have renewed interest in patients' responses to medical treatment, and describes how issues of patient adherence came to the fore with the advent of highly active antiretroviral therapy (HAART). In the early years of the AIDS epidemic, when no effective antiretroviral drugs were available, compliance to treatment among HIV-infected patients was not a matter of much debate. The potential detrimental effects of delays in access to HIV testing in populations with a high frequency of HIV-related risk behaviours, as well as delays between first medical visit for HIV care after an initial HIV diagnosis, on the natural history of HIV infection were, however, commented upon. Later, clinicians, epidemiologists and public health experts expressed concern that important biases might be introduced into randomised clinical trials of the first antiretroviral drugs (zidovudine--Azido-Thymidine--and the other nucleoside reverse transcriptase inhibitors) if a significant number of enrolled patients were lost for follow-up and/or failed to comply with the study protocols without medical staff knowing it. The constraints that current HAART combinations impose on patients' daily lives make it difficult to anticipate that a medical norm of 80-100 per cent adherence can be reached and sustained by most individuals. The daily number of prescribed pills for antiretroviral treatments alone varies from ten to twenty, and daily intakes from three to four. Although some patients will have more difficulties than others with treatment, it can be expected that nearly all patients will not strictly adhere to the prescribed regimens at some point in time.

This chapter presents a study which investigated the effect of a group psychotherapy programme on psychological, immunological and clinical outcome measures in HIV-1-positive gay men in the Netherlands using the Protease Inhibitor Attitudinal Questionnaire (PIAQ). The introduction of the protease inhibitors and Highly Active Antiretroviral Therapy (HAART) to the medical treatment of HIV-1-positive people has largely been responded to with great enthusiasm and optimism by the media and the medical community. The response of HIV-1-positive individuals is more ambivalent and varied, however. Clinical experience with HIV-1-positive gay men at the time that the protease inhibitors became available in the Netherlands strongly indicated that attitudinal factors were among the important determinants in their decision of whether or not to begin on HAART and in their adherence to HAART once it was begun. Initial data from this study indicate that the scale of the PIAQ can be used to assess relevant attitudinal factors in research investigating adherence to HAART. A less optimistic attitude towards HAART was found to be related to better adherence. This finding differs from those of earlier studies that found a positive relationship between attitudes and adherence when studying antiretroviral monotherapy. This suggests that the determinants of adherence to HAART may differ from the determinants of adherence in the time of antiretroviral monotherapy and argues for the use of instruments specifically designed to assess the variables relevant to adherence to HAART in research investigating this topic.

This chapter describes the findings of one of a small number of studies which have begun to explore the nature of the experience of young families of HIV-infected children from an African background. In contrast to previous studies, a substantial proportion of the families recruited included individuals who had emigrated from East and sub-Saharan African countries where heterosexual transmission of HIV infection is common. Like previous studies, however, it is limited by a small sample size and a poorly developed theoretical framework within which to interpret the findings. The very high degree of stigma associated with HIV infection and the notions of shame within the extended family made it virtually impossible for parents to confide even in their own immediate family. This contrasts with the position of the majority of families reported in other studies who generally distinguish between family and others in disclosing their diagnosis. These differences highlight the way culture shapes responses to illness and the unexpected variations that are found in different social groups. They also point to the importance of extending this kind of research to other population groups and examining the response of families in different social and cultural contexts. Natural parents were described as finding the future difficult to face, feeling isolated and alienated from others and as particularly concerned about not being present at the severe illness and death of their HIV-infected child. Similar feelings were described by parents in this study. However, instead of the optimistic denial and hopes for the future described by uninfected parents in the present study, the researchers described foster parents as appreciating the present and as feeling better prepared to deal with the eventual death of their HIV-infected child.

This chapter presents a study which identified the difficulties that people living with AIDS and HIV (PLWA/HIV) in Greece face in everyday life. Of particular interest was the interface between people with HIV/AIDS and non-governmental organizations, therapeutic and medical services, and the social environment. Also of concern was sexuality, experiences of therapy and information management in relation to seropositivity as a quality of the self that needs to be kept secret. These experiences and responses were analysed in relation to time since learning of an HIV/AIDS diagnosis, health status (symptomatic or asymptomatic), socio-demographic characteristics (age, family, educational level, profession) and possible cause of infection. Overall, there is evidence from this study that HIV infection can function as a turning point in people's life careers as, entering into the world of the epidemic, they are obliged to revise and reorganise their relationships, their abilities and sources of support. In the Greek socio-cultural environment, people with HIV/AIDS confront specific challenges which they perceive, evaluate and face in different ways. Three strategies are especially prevalent: what may be termed a universal strategy similar to that employed when confronting any infectious condition and involving close ties with medical and other personnel; a Greek strategy utilising the ties and support of family; and a personal strategy reliant on personal psychological forces and living positively.

This article introduces the studies included in the book, AIDS in Europe: New Challenges for the Social Sciences. The contributions in this book represent some of the most important attempts by European social scientists to engage with recent changes in the epidemic. All the papers in this book were initially presented at the 2nd European Conference on the Methods and Results of Social and Behavioural Research on AIDS (New Challenges for Social and Behavioural Science) organised in January 1998. While much earlier HIV and AIDS-related social and behavioural research focused on issues related to prevention and collective and individual behaviour change, recent developments have made studies of the impact of new treatments on HIV care, and of the experience of people living with HIV, a priority. Innovative studies linked to the themes of Living with HIV and therapeutic advances are therefore presented in the first part of the book. Another part of the book is devoted to the issue of drug use: user and policy perspectives. It is a well-established fact that HIV-infected injecting drug users tend to have poorer access to medical care, and especially to antiretroviral treatment, than other groups, even in European countries where free or low-cost public sector care is available. It is also clear that drug users are especially vulnerable to the cumulative effects of various sources of inequality. This vulnerability is of course exacerbated by the illegal character of drug use in all European countries which exposes active drug users to a high risk of imprisonment.

Presents acknowledgments in line with the publication of the book "AIDS in Europe: New Challenges for the Social Sciences," edited by Jean-Paul Moatti, Yves Souteyrand, Annick Prieur, Theo Sandfort and Peter Aggleton.

This article provides an overview of the book AIDS in Europe: New Challenges for the Social Sciences edited by Jean-Paul Moatti, Yves Souteyrand, Annick Prieur, Theo Sandfort and Peter Aggleton. Major changes in the nature and dynamics of the AIDS epidemic over the last few years are reflected in changing epidemiological trends as well as in the progress made by biomedical research and treatment. AIDS in Europe brings together papers from leading social science researchers to look at the opportunities and challenges these changes bring in their wake and the different ways in which they are being responded to in both Western and Eastern Europe. Four main topics are covered: living with HIV and therapeutic advances, new perspectives on sexuality, drug use--user and policy perspectives and accounting for the epidemic. AIDS in Europe provides a comprehensive overview of current social and behavioural research on HIV and AIDS for all health professionals.