UNDERGRADUATE RESEARCH PROJECT

(As per New Education Policy -2020)

STUDY OF DEATH CASES AND MORTALITY

RATES OF HIV AIDS IN PAST FEW YEARS

NAMRA KHAN
B.Sc. III (Sem. 6th)

Under the Guidance of

Mr. HIMANSHU DIXIT

DEPARTMENT OF ZOOLOGY

Christ Church College Kanpur

ACADEMIC YEAR 2023-2024

 PROJECT COMPLETION CERTIFICATE

This is to certify that “NAMRA KHAN” of “B.Sc. III (sem. 6th)” has

completed the project titled “Study of death cases and mortality rates of

Typhoid in past few years” as a course requirement (as per New Education

Policy 2020) of her final year (Session: 2023-24) of CSJMU Kanpur.

This project is bonafide work done under my guidance and supervision.

PROJECT SUPERVISOR IN CHARGE

DEPARTMENT OF ZOOLOGY
 ACKNOWLEDGEMENT

I would like to express my profound gratitude to Mrs. NAMRA KHAN,

HIMANSHU DIXIT (In charge) of Department of Zoology, and Prof.

Joseph Daniel, (Principal) of Christ Church College, Kanpur for their

contributions to the completion of my project titled Study of death cases and

mortality rates of H I V A I D S in past few years.

I would like to express my special thanks to our mentor Mrs. HIMANSHU

DIXIT for her time and efforts she provided throughout the year. Your useful

advice and suggestions were really helpful to me during the project’s

completion. In this aspect, I am eternally grateful to you.

I would like to acknowledge that this project was completed entirely by me and

not by someone else.

Signature

NAMRA KHAN

B.Sc. III (Sem. 6th)

 TABLE OF CONTENTS

S. No. Contents Page No.

1 Introduction 1- 2

2 Literature Review

3 Methodology

4 Observations

5 Discussion

6 Summary

7 References
 INTRODUCTION

Introduction How to use this module What you should know before the course

The human immunodeficiency virus (HIV)/acquired immunodeficiency

syndrome (AIDS) epidemic continues to grow worldwide and to devastate

individuals, communities and entire countries and regions. Behavioural

surveillance measures trends in the behaviours that can lead to HIV infection. It

has been shown to make an important and useful contribution to national

responses to HIV. Conducting behavioural surveillance requires many skills,

including coordination among various partners. Although there are useful

reference materials available for behavioural surveillance, there has not yet been

a comprehensive effort to train surveillance teams. This training course aims to

help address this. This course is meant primarily for people involved in

planning and using behavioural surveillance. You should already have a basic

understanding of the epidemiology of HIV/ AIDS and public health

surveillance. This module is part of a set of four modules that have been

designed with a focus on the World Health Organization’s (WHO) Eastern

Mediterranean Region. The modules were designed for use in training

workshops. The other modules are: ● Module 1: Overview of the HIV/AIDS

epidemic with an introduction to public health surveillance ● Module 3:

Surveillance of most-at-risk and vulnerable populations ● Module 4:

Introduction to respondent-driven sampling. Similar training modules have been

developed for WHO’s African, Americas, European and South-East Asia

regions. Although the overall framework of the modules is the same, each

region has different patterns of HIV epidemics and distinct social and cultural

contexts. Also, different countries may have different HIV surveillance

capacities and different needs. Thus, these modules were developed taking into

account the specific context of the HIV epidemic in the countries of the Eastern

Mediterranean Region. The modules are also intended for use in the countries of

the Joint United Nations Programme on HIV/AIDS (UNAIDS) Middle East and

North Africa Region. For the purpose of this training course, all countries in the

WHO Eastern Mediterranean Region plus Algeria are therefore the intended

audience. We refer to these collectively as Eastern Mediterranean

Region/Middle East and North Africa (EMR/MENA) countries. 8 Surveillance

of hiv risk behaviours Module structure This module is divided into units. The

units are convenient blocks of material for a single study session. This module

can also be used for self-study. Because you already know quite a bit about

HIV/AIDS, we begin each unit with some warm-up questions. Some of the

answers you may know. For other questions, your answer may be just a guess.

Answer the questions as best you can. You will keep your answers to the warm-

up questions in this module. No one will see your answers but you. We will

study and discuss the unit, and then you will have time to go back and change

your warm-up answers. At the end of the unit, the class will discuss the warm-

up questions and you can check your work. As you study this module, you may

come across terms and acronyms that are unfamiliar. In Annex 1, you will find a
glossary that defines many of these. Annexes More information is provided in

the following annexes: Annex 1: Glossary Annex 2: Useful links Annex 3:

Answers to warm-up questions and case studies Annex 4: Action plan for

implementing HIV behavioural surveillance of most-at-risk populations in

EMR/MENA countries Additions, corrections, suggestions We welcome

feedback on this training module.

HIV stands for Human Immunodeficiency Virus. It's a virus that attacks the

immune system, specifically the CD4 cells, which are crucial for fighting off

infections and diseases.

HIV is primarily transmitted through unprotected sexual intercourse, sharing

needles or syringes, and from an infected mother to her baby during childbirth

or breastfeeding. It cannot be transmitted through casual contact like hugging or

shaking hands.

If left untreated, HIV can progress to a more advanced stage called AIDS

(Acquired Immunodeficiency Syndrome). However, with early diagnosis and

proper medical care, people living with HIV can lead healthy lives and manage

the virus effectively.

Prevention methods include practicing safe sex, using condoms, getting tested

regularly, and using pre-exposure prophylaxis (PrEP) for individuals at high

risk. Treatment involves antiretroviral therapy (ART), which helps suppress the

virus and allows individuals to maintain good health and reduce the risk of

transmission.
 LITERATURE REVIEW

While HIV and AIDS continue to spread rapidly throughout Africa and Asia,

especially among young people aged 15-24, children aged 5-14 remain largely

free of the virus. This group has been termed the “window of hope” for limiting

the spread and mitigating the damage being wreaked by HIV. Education has

been cited by several well-respected sources, including the World Bank, as one

of the most important factors in helping to prevent this group from contracting

HIV and AIDS. Knowing the successful role that school feeding and take-home

rations have played in increasing enrolment and attendance rates in poor

schools, especially among girls, the World Food Programme has attempted to

address the needs of orphans and other vulnerable children in countries with

high HIV prevalence rates through support to education. Relatively little

research exists on the impact that education levels (i.e. number of school years

completed) have on new cases of HIV (incidence) and the percentage of a

population group which is HIV positive (prevalence). A Global Campaign for

Education report (2004) states that without education, young people are less

likely to understand the information regarding HIV/AIDS education provided,

and less confident in accessing services and openly discussing the HIV

epidemic. Kilian (1999) and Blanc (2000) support this idea that school
attendance may directly affect access to health services and exposure to health

interventions. The World Bank (2002) states that education protects against HIV

infection through information and knowledge that may affect long-term

behavioural change, particularly for women by “reducing the social and

economic vulnerability that exposes [them] to a higher risk of HIV/AIDS than

men”, including prostitution and other forms of economic dependence on men.

Gregson et al. (2001) conclude in their research that participation in

wellfunctioning community groups has a negative correlation with HIV

prevalence rates for young women in rural eastern Zimbabwe. They conclude

furthermore that “the school setting can both facilitate the development of

[community group formation] and provide students with easy access to it.”

Thus, not only do schools provide the education, knowledge and life skills for

decreased vulnerability to HIV infection, but they also provide the environment

for communities to be able to protect themselves. In this qualitative examination

of the effect that educational attainment is expected to have on HIV prevalence

rates, there is a more fundamental, extensively researched question to consider:

what are the effects of educated populations on the socio-economic

development of a country? Education’s effect is felt not only on literacy, but

also on the “promotion of democratic and tolerance values, and increased

productivity…and better health” (Roundtable on Human Resources

Development, March 2002). The World Bank reports that better-educated

populations lead to higher economic growth. The recently released report, Teach
 a Child, Transform a Nation (2004) by the Basic Education Coalition, which

includes CARE, International Youth Foundation, Save the Children and

Women’s Edge, also finds a negative correlation between education and

important indicators, for example, health statistics such as infant mortality and

fertility rates. An analysis of African data by the former World Bank chief

economist, Lawrence Summers, showed that children born to mothers who had

received five years of primary education were on average 40 percent more

likely to survive to age five (Summers, 1994). Multi-country data show that

educated mothers are around 50 percent more likely to immunize their children

than are uneducated mothers (Gage, Sommerfelt and Piani, 1997). Another

multi-country study indicates that doubling the proportion of women with a

secondary education would reduce average fertility rates from 5.3 to 3.9

children per woman (Subbarao and Raney, 1995). While the overwhelming

evidence in support of the positive impact of education on such health

indicators would allow us to logically conclude that education imparts similar

influences on HIV infection, the correlation of levels of education and HIV

prevalence rates is more complex and requires further empirical studies. Still

others point to inconsistent analyses of the early evidence, claiming that much

of it is based on data when young women were becoming sexually active in the

early and mid-1980s and little was known about AIDS (Vandemoortele, 2000).

Vandemoortele also claims that some studies have been illdesigned, referring to

Hargreaves and Glynn (2000) who used data collected before 1996 and
aggregated evidence from different countries at different stages of the epidemic,

which do not accurately portray the patterns between levels of education and

HIV prevalence. While Hargreaves and Glynn determined a positive correlation

between education and HIV prevalence, they did acknowledge that at the time

of publishing their article, conflicting data was beginning to emerge in various

countries in Africa. This literature review summarizes the research undertaken

to date, drawing upon both qualitative and quantitative studies undertaken

mostly in sub-Saharan Africa. It identifies gaps in the available research and

raises some issues for WFP’s programming on HIV and AIDS. Qualitative

research conducted to date points to the benefits of education on individuals:

increased ability to understand HIV prevention information, better access to

health services, reduced social and economic vulnerability that exposes women

to risky activities and a higher likelihood of participation in community groups

that foster protection against AIDS. It appears that there is a shift in the

quantitative evidence surrounding education and HIV prevalence. In the early

1990s, evidence suggested that populations with higher education levels were

likely to have higher HIV rates. More recent evidence in countries such as

Zambia and Uganda suggests that now, more years of education are increasingly

associated with safer sexual behaviour and lower HIV prevalence. This is

particularly true for young women with secondary education, who demonstrated

significantly lower HIV prevalence rates than their peers who had dropped out

of school earlier. These findings argue in favour of WFP continuing to expand

 its efforts to attract children, especially girls, into school, and to link closely

with effective HIV prevention education and awareness.

It may seem, therefore, that educational levels are positively correlated with

HIV prevalence rates, when in fact they are not. This analysis is supported by

Mead Over (2001) of the World Bank, whose research arrives at the same

conclusions: that gender inequality in illiteracy rates and access to work,

together with poverty and income inequality, facilitate the spread of HIV. He

concludes that controlling the epidemic requires economic and social

development to reduce income and gender inequality. Moreover, processes often

correlated with higher socioeconomic development, such as increased

urbanization, can increase the spread of HIV, leading to the “perverse possibility

that some HIV epidemics might be better described as epidemics of

development than of poverty” (Gregson, Waddell and Chandiwana 2001).

 METHODOLOGY

Notes on UNAIDS methodology Unless otherwise stated, findings in this report

are based on modelled HIV estimates. Modelled estimates are required because

it is impossible to count the exact number of people living with HIV, who are

newly infected or who have died of AIDS in the world. To know this for certain

requires testing every person for HIV regularly and investigating all deaths,

which is logistically impossible and ethically problematic. Partnerships in

creating UNAIDS estimates Modelled HIV estimates are created by country

teams using UNAIDS-supported software. The country teams are comprised

primarily of epidemiologists, demographers, monitoring and evaluation

specialists and technical partners. Country-submitted files are reviewed at

UNAIDS, and selected HIV service data contained in the files are reviewed and

validated in partnership with WHO and UNICEF. UNAIDS review aims to

ensure comparability of results across regions, countries and over time. The

software used to create the estimates is Spectrum, developed by the Futures

Institute, and the Estimates and Projections Package, developed by East-West

Center (www.futuresinstitute.org). The UNAIDS Reference Group on

Estimates, Modeling and Projections provides technical guidance on the

development of the HIV component of the software (www.epidem.org). A brief

description of UNAIDS methods to create estimates Country teams use

UNAIDS-supported software to create national HIV prevalence curves that are

consistent with all pertinent, available HIV data in the country. These data

typically consist of HIV prevalence results from surveillance among pregnant

women attending antenatal care clinics and from nationally-representative

population-based surveys in countries with generalized epidemics, where HIV

transmission is sufficiently high to sustain an epidemic in the general

population. Because antenatal clinic surveillance is performed on a regular

basis, these data can be used to inform national prevalence trends. Data from

population surveys, which are conducted less frequently but have broader

geographic coverage and also test men, are more useful for informing national

HIV prevalence levels. For countries with generalized epidemics that have not

conducted population surveys, HIV prevalence levels are adjusted downwards

based on comparisons of antenatal clinic surveillance and population survey

data from other countries in their region. In countries with concentrated, or low-

level HIV epidemics, where HIV transmission is largely contained within key

populations at higher-risk of HIV infection (e.g., people who inject drugs, sex

workers, men who have sex with men), repeated HIV prevalence studies in

these populations are used to inform national estimates and trends. Estimates of

the size of key populations are increasingly derived empirically in each country

or, when studies are not available, based on regional values and consensus

among experts. Other data sources, 2 including population surveys, surveillance

among pregnant women, and HIV case reporting data are used to estimate HIV
prevalence in the general, low-risk population. The HIV prevalence curves and

numbers on antiretroviral therapy are used to derive national HIV incidence

trends. For countries with insufficient HIV surveillance or survey data but

strong vital registration and disease reporting systems, trends and levels in

national HIV prevalence and incidence are matched directly to HIV case

reporting and AIDS-related mortality data. To obtain age and gender-specific

incidence, prevalence and death rates, along with other important indicators,

including program coverage statistics, assumptions about the effectiveness of

HIV program-scale up and patterns of HIV transmission and disease

progression, are applied to the national incidence curve. These assumptions are

based on systematic literature reviews and analysis of raw study data by

scientific experts. Demographic population data, including fertility estimates,

are based on United Nations Population Division, World Population Prospects

2012. Uncertainty bounds around UNAIDS estimates The software calculates

uncertainty bounds around all estimates, which can be used to measure how

precisely we can speak about the magnitude of the epidemic. These bounds

define the range within which the true value lies. There are two factors that

determine the width of the ranges around the HIV estimates. The first is the

quantity and source of the HIV data available -- countries with more HIV

surveillance data have smaller ranges than countries with less surveillance data

or smaller sample sizes. Countries in which a national population-based survey

has been conducted will generally have smaller ranges around estimates than
countries where such surveys have not been conducted. The second factor that

determines the extent of the ranges around estimates is the number of

assumptions required to arrive at the estimate – the more assumptions, the wider

the uncertainty range since each assumption introduces additional uncertainties.

For example, ranges around estimates of adult HIV prevalence are smaller than

those around estimates of HIV incidence among children, which requires

additional data on the probability of mother-tochild HIV transmission. The latter

are based on prevalence among pregnant women, the probability of mother-to-

child HIV transmission, and estimated survival times for HIV-positive children.

Although UNAIDS is confident that the actual numbers of people living with

HIV, people who have been newly infected or who have died of AIDS lie within

the reported ranges, more and better data from countries will steadily reduce

this uncertainty. Improvements to the 2013 UNAIDS estimates model Country

teams create new Spectrum files every year. Files from one year to the next may

differ for two reasons. First, new surveillance and program data are entered into

the model, which can change HIV prevalence and incidence trends over time,

including for past years. Second, improvements are incorporated into the model

based on the latest available science and understanding of the epidemic.

Between the previous and current rounds of estimates, 3 the following changes

were applied to the model under the guidance of the UNAIDS Reference Group

on Estimates, Modelling and Projections: • Updated population data from the

United Nations Population Division 2012 World Population Prospects • Revised

calibration of HIV prevalence from antenatal clinics to the general population in

countries with generalized epidemics without national surveys • Corrected

calculations of incidence trends among people 15-49 to be informed by the

number of people receiving antiretroviral therapy among persons ages 15-49

instead of ages 15+ • Revised estimates of non-AIDS mortality among people

who inject drugs based on recent literature • Adjusted AIDS mortality for key

populations in concentrated epidemics keeping the sizes of key populations the

same as those entered by the user Because there are improvements to the data

and methods used to create the estimates each round, users of the data should

not compare results from one round to the next. A full historical set of estimates

are created for each round allowing for estimation of trends over time from

within the same round.

 OBSERVATION

1. Twenty years after the first case of AIDS was diagnosed, the pandemic of

HIV/AIDS is widely seen as a major public health and development crisis

and apotential threat to people at both national and regional levels – as

recognized bythe United Nations Security Council in January 2000. What sets

the disease

apart from other epidemics is the speed of its spread and the extent of its

devastation globally. It affects not only the lives of individual men, women and

children, but also future social and economic development. Estimates by

UNAIDS drawn up jointly with WHO, indicate that at the end of the year 2000,

36.1 million people were living with HIV/AIDS and 21.8 million had already

died. These numbers are significantly higher than those projected in 1991. Of

the 5.3 million new infections in 2000, 1 in 10 occurred in children and 4 in

10 occurred in women. In 16 countries of sub-Saharan Africa more than 10%

of thereproductive age population is now infected with HIV. HIV/AIDS has

particularimplications for young people entering their sexual and reproductive

lives and

affects the most productive segments of the population, lowering economic

growth and reducing life expectancy by up to 50% in the hardest hit countries.

2. The epidemiological data gathered by WHO and UNAIDS clearly show

thegreat variations of the epidemics of HIV and AIDS across the world,

with for instance heterosexual transmission of HIV dominating in sub-

Saharan Africa

and parts of Asia, injecting drug use a major feature of the spread of the virus
in
Eastern Europe and Central Asia, and sexual transmission between men who

have sex with men figuring not only in North America, Western Europe and

Australia but also in Latin America and the Caribbean. Transmission of HIV is

determined by the social, economic, cultural and behavioural context, and is

associated with risky behaviour. Currently with neither cure nor vaccine,

prevention of transmission must be central to the response; together, care and

support for those already infected with or affected by HIV are inseparable and

mutually reinforcing elements of effective strategies to combat the epidemic.

Several interventions, applied promptly and with courage and resolve, have

reduced or kept HIV prevalence rates low and lessened the burden on those

already infected, and the crucial elements for success have been identified.

However, where prevention efforts have been ineffectual or inadequate, the

epidemic has accelerated. The needs for care and support of the more than 36

million women, men and children currently living with HIV/AIDS pose a major

challenge to health systems for the future. 3. WHO has been an active

cosponsor of UNAIDS since its inception. Because of the scale and nature of

the pandemic, and its implications for health systems, WHO has been asked to

intensify its support for Member States’ efforts with a focus on the health sector

and is doing so within the context of the wider multisectoral response to HIV,

reflecting the overarching importance of good sexual and reproductive health.

A54/15 2 4. In response to resolution WHA53.14, which called for an increased

response to HIV infection and AIDS, the Director-General has initiated internal
consultations and discussions with other organizations of the United Nations

system, together with a careful appraisal of WHO’s relative advantages. This

document, submitted to the E

4. In response to resolution WHA53.14, which called for an increased response

to HIV infection and AIDS, the Director-General has initiated internal

consultations and discussions with other organizations of the United Nations

system, together with a careful appraisal of WHO’s relative advantages. This

document, submitted to the Executive Board at its 107th session in January

2001 and updated before its submission to the World Health Assembly in order

to reflect significant recent developments, summarizes the main elements of the

intensified response throughout WHO.

5. A solid body of evidence on effective interventions is now available and

many projects are under way. Given that they are often limited in scope and

scale, there is an urgent need to inject major new resources and implement

interventions of proven effectiveness on a scale sufficient to contain or alter

significantly the course of the epidemic. Doing so will necessitate a substantial

strengthening of the capacity of national health systems to fulfil their functions

of stewardship, resource generation and fair financing and thus ensure that

services are available on an equitable, acceptable and affordable basis. Priority

interventions that must constitute the core of the health sector response have

been identified and are the focus for WHO’s normative work and its technical
support to countries. 6. The health sector is increasingly important in view of

the growing evidence of the interlocking benefits of care and prevention.

Individuals who know they are infected with HIV and who are able to receive

care can break through the barrier of denial by talking to their families and

communities. By caring for people living with HIV/AIDS health workers

illustrate that there is no reason to fear becoming infected through everyday

contact. Prevention measures such as voluntary counselling and testing help to

improve access to care; provision of care is itself a key entry point for efforts to

prevent further transmission. Awareness is growing of the value of community-

based groups, nongovernmental organizations and associations of people living

with HIV/AIDS in contributing to care and support as well as prevention. These

groups have become key partners in the fight against the epidemic through

promoting greater societal acceptance of people with HIV/AIDS, reducing

infection rates among their peers, and mitigating the personal and social impact

of the disease.
 DISCUSSION

This is the first study of its kind to address awareness of HIV among adolescents

utilizing longitudinal data in two indian states. Our study demonstrated that the

awareness of HIV has increased over the period; however, it was more prominent

among adolescent boys than in adolescent girls. Overall, the knowledge on HIV

was relatively low, even during wave-II. Almost three-fifths (59.9%) of the boys

and two-fifths (39.1%) of the girls were aware of HIV. The prevalence of

awareness on HIV among adolescents in this study was lower than almost all of

the community-based studies conducted in India10,11,22. A study conducted in

slums in Delhi has found almost similar prevalence (40% compared to 39.1%

during wave-II in this study) of awareness of HIV among adolescent girls31. The

difference in prevalence could be attributed to the difference in methodology,

study population, and study area.

The study found that the awareness of HIV among adolescent boys has increased

from 38.6 percent in wave-I to 59.9 percent in wave-II; similarly, only 30.2

percent of the girls had an awareness of HIV during wave-I, which had increased

to 39.1 percent. Several previous studies corroborated the finding and noticed a

higher prevalence of awareness on HIV among adolescent boys than in adolescent

girls16,32,33,34. However, a study conducted in a different setting noticed a

higher awareness among girls than in boys35. Also, a study in the Indian context

failed to notice any statistical differences in HIV knowledge between boys and
girls18. Gender seems to be one of the significant determinants of comprehensive

knowledge of HIV among adolescents. There is a wide gap in educational

attainment among male and female adolescents, which could be attributed to

lower awareness of HIV among girls in this study. Higher peer victimization

among adolescent boys could be another reason for higher awareness of HIV

among them36. Also, cultural double standards placed on males and females that

encourage males to discuss HIV/AIDS and related sexual matters more openly

and discourage or even restrict females from discussing sexual-related issues

could be another pertinent factor of higher awareness among male adolescents33.

Behavioural interventions among girls could be an effective way to improving

knowledge HIV related information, as seen in previous study37. Furthermore,

strengthening school-community accountability for girls' education would

augment school retention among girls and deliver HIV awareness to girls38.

Similar to other studies2,10,17,18,39,40,41, age was another significant

determinant observed in this study. Increasing age could be attributed to higher

education which could explain better awareness with increasing age. As in other

studies18,39,41,42,43,44,45,46, education was noted as a significant driver of

awareness of HIV among adolescents in this study. Higher education might be

associated with increased probability of mass media and internet exposure leading

to higher awareness of HIV among adolescents. A study noted that school is one

of the important factors in raising the awareness of HIV among adolescents,

which could be linked to higher awareness among those with higher

education47,48. Also, schooling provides adolescents an opportunity to improve

their social capital, leading to increased awareness of HIV.

Following previous studies18,40,46, the current study also outlines a higher

awareness among urban adolescents than their rural counterparts. One plausible

reason for lower awareness among adolescents in rural areas could be limited

access to HIV prevention information16. Moreover, rural–urban differences in

awareness of HIV could also be due to differences in schooling, exposure to mass

media, and wealth44,45. The household's wealth status was also noted as a

significant predictor of awareness of HIV among adolescents. Corroborating with

previous findings16,33,42,49, this study reported a higher awareness among

adolescents from richer households than their counterparts from poor households.

This could be because wealthier families can afford mass-media items like

televisions and radios for their children, which, in turn, improves awareness of

HIV among adolescents33.

Exposure to mass media and internet access were also significant predictors of

higher awareness of HIV among adolescents. This finding agrees with several

previous research, and almost all the research found a positive relationship

between mass-media exposure and awareness of HIV among adolescents10. Mass

media addresses such topics more openly and in a way that could attract

adolescents’ attention is the plausible reason for higher awareness of HIV among

those having access to mass media and the internet33. Improving mass media and

internet usage, specifically among rural and uneducated masses, would bring
required changes. Integrating sexual education into school curricula would be an

important means of imparting awareness on HIV among adolescents; however,

this is debatable as to which standard to include the required sexual education in

the Indian schooling system. Glick (2009) thinks that the syllabus on sexual

education might be included during secondary schooling44. Another study in the

Indian context confirms the need for sex education for adolescents.
 SUMMARY

The human immunodeficiency virus (HIV), now known to be the cause of

acquired immune deficiency syndrome, or AIDS, is only one element of the

complex problem that is commonly called the AIDS epidemic. The spread of HIV

infection and, consequently, AIDS is the product of human behaviors enacted in

social contexts. Both the behaviors and the circumstances in which they occur are

conditioned and shaped by culture and larger social structures. The epidemic is

thus as much a social and behavioral phenomenon as it is a biological one.

Understanding how HIV infection is spread, encouraging behavioral change so as

to retard this spread, and coping with the social consequences of the epidemic

raise questions that lie within the domain of the social, behavioral, and statistical

sciences. Following publication of the 1986 report on AIDS of the Institute of

Medicine/National Academy of Sciences,1 the present committee was established

in the fall of 1987 to provide a focus for AIDS activities within these disciplines

at the National Research Council. At the request of the Public Health Service

(PHS) and with additional support from the Rockefeller and Russell Sage

Foundations, the committee has begun its work by reviewing the contributions

that can be made by the paradigms, data, and methods of the social, behavioral,

and statistical sciences2 in mounting an effective national response to the

HIV/AIDS epidemic.3

The committee's report is divided into three parts. The first part presents evidence

on the current extent of HIV infection in the U.S. population (Chapter 1) and on
the patterns of sexual behavior and drug use (Chapters 2 and 3) that spread HIV

infection. The second part describes intervention strategies and principles that

hold promise for producing behavioral change to slow the spread of HIV infection

(Chapter 4) and methods for evaluating the effectiveness of such interventions

(Chapter 5). The third part (Chapters 6 and 7) discusses some of the barriers that

impede effective research and intervention programs. The organization of this

summary follows that of the report, and it includes some of the report's key

recommendations. (All of the committee's recommendations are listed

in Appendix A.)

At the outset of its report, the committee believes it is important to comment on

the term epidemic, which is sometimes misunderstood in connection with

HIV/AIDS. During an epidemic, the occurrence4 of new cases of a disease in a

community follows a well-known pattern: it may increase dramatically in a short

period of time, peak, and then decline. During the course of an epidemic, there

may be cycles of rise and decline in the number of new cases.

In 1989 the United States stands at the base of a rapidly rising curve of AIDS

cases and deaths. Barring a dramatic breakthrough in treatment, it is projected that

more than 50,000 Americans will die of AIDS during 1991. The number of deaths

during this 12-month period alone will exceed the total number of deaths in this

country from the beginning of the epidemic through 1988.

Such rapid growth in the occurrence of a disease is the defining characteristic of

an epidemic, but it is important to recognize two further points about the

HIV/AIDS epidemic.
First, the occurrence of AIDS cases lags behind the spread of HIV infection.

Several years typically elapse between the time an adult is infected with HIV and

the appearance of clinical signs sufficient to warrant the diagnosis of AIDS. The

contemporary spread of HIV cannot therefore be discerned from the current

counts of new AIDS cases. So, for example, in the absence of therapies that retard

the progression from HIV to AIDS, the epidemic of AIDS cases will continue to

rise for several years after the spread of HIV infection begins to decline in a

population. Similarly, a sharp decline in the occurrence of new AIDS cases in a

given year would not preclude the possibility that the occurrence of new HIV

infections had increased during that same year. Unfortunately, the barriers that

impede tracking of the spread of HIV infection exceed those that impede tracking

of the spread of AIDS cases. Hence, currently available information about the

spread of HIV infection is considerably less reliable than information about the

occurrence of AIDS cases.

Second, the committee would emphasize that a decline in either the spread of HIV

infection or the occurrence of new AIDS cases (or both) would not signal that the

danger has passed. HIV is already substantially seeded in the U.S. population—

the number of people who are now infected may surpass I million—and the virus

is likely to continue to spread, if not in epidemic form, then in a persistent, more

stable ''endemic" form (literally, "dwelling with the people"). The threat of

epidemic and endemic disease will be most serious for those groups that are most

heavily seeded with HIV infection, including IV drug users and men who have

sex with men, as well as for their sexual partners and offspring. Currently
available data also indicate that the black and Hispanic populations of the United

States are experiencing a disproportionate burden of AIDS cases (in particular,

cases associated with IV drug-use, heterosexual, and mother-infant transmission).

The AIDS case data suggest that these populations may be more heavily seeded

with HIV infection than are other ethnic groups and may be disproportionately

threatened with further spread of the virus.

Our committee is concerned with understanding and reducing the spread of HIV

infection, whether this spread be epidemic or endemic in character.

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