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Bioethics: An Introduction to the History, Methods, and Practice, Third Edition Nancy S. Jecker, Albert R. Jonsen, & Robert A. Pearlman

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Fundamentals of Microbiology, Tenth Edition Jeffrey C. Pommerville

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Human Biology Laboratory Manual Charles Welsh

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Principles of Cell Biology George Plopper

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LUIS P. VILLARREAL University of California, Irvine

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All rights reserved. No part of the material protected by this copyright may be reproduced or utilized in any form, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without written permission from the copyright owner.

AIDS: Science and Society, Seventh Edition is an independent publication and has not been authorized, sponsored, or otherwise approved by the owners of the trademarks or service marks referenced in this product.

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Production Credits Executive Publisher: Kevin Sullivan Senior Acquisitions Editor: Erin O’Connor Editorial Assistant: Michelle Bradbury Production Manager: Louis C. Bruno, Jr. Marketing Manager: Lindsay White V.P., Manufacturing and Inventory Control: Therese Connell Composition: Lapiz Cover Design: Karen Leduc Rights & Photo Research Associate: Lauren Miller Cover Images: (top) © Medioimages/Photodisc/Thinkstock; (bottom, background) © Ingram Publishing/Thinkstock; (bottom, virus) © iStockphoto/Thinkstock

Printing and Binding: Edwards Brothers Malloy Cover Printing: Edwards Brothers Malloy

To order this product, use ISBN: 978-1-284-02551-4

Library of Congress Cataloging-in-Publication Data Fan, Hung, 1947-

AIDS : science & society / Hung Y. Fan, Ross F. Conner, and Luis P. Villarreal — 7th ed. p. ; cm.

ISBN 978-1-4496-8332-0 I. Conner, Ross F. II. Title. [DNLM: 1. Acquired Immunodeficiency Syndrome. 2. HIV Infections. WC 503] 614.5’99392—dc23



Printed in the United States of America 17 16 15 14 13 10 9 8 7 6 5 4 3 2 1

To our HIV-infected friends and acquaintances who are courageously battling the disease or who have succumbed to it.

In their honor, and to hasten the day when this book is no longer necessary, a portion of the royalties from this book will be donated

to foundations and community organizations dedicated to AIDS research and service.

Brief Contents

CHAPTER 1 Introduction: An Overview of AIDS

CHAPTER 2 Concepts of Infectious Disease and a History of Epidemics

CHAPTER 3 The Immune System

CHAPTER 4 Virology and HIV

CHAPTER 5 Clinical Manifestations and Treatment of AIDS

CHAPTER 6 Epidemiology and AIDS

CHAPTER 7 Modes of HIV Transmission and Personal Risk Factors

CHAPTER 8 Individual Assessments of HIV Risk

CHAPTER 9 Prevention of AIDS

CHAPTER 10 Living with AIDS: Human Dimensions

CHAPTER 11 Living with AIDS: Societal Dimensions

CHAPTER 12 Future Directions in Combating AIDS

Glossary Appendix: Reference Resources Index



CHAPTER 1 Introduction: An Overview of AIDS AIDS in Brief The AIDS Epidemic

CHAPTER 2 Concepts of Infectious Disease and a History of Epidemics Factors That Affect the Spread of Epidemics

Host and Virus Populations The Transmission Rate Population Densities and Infections Chronic Infections Controlling Infectious Diseases

A History of Epidemics The Old World The New World

Modern Concepts of Infectious Disease and Koch’s Postulates Epidemics in Modern Times

Syphilis: The Social Problems with a Sexually Transmitted Disease Infections from Other Species

CHAPTER 3 The Immune System Blood

Cells of the Blood Red Blood Cells White Blood Cells

The Lymphatic Circulation Innate Immunity Adaptive Immunity

B-Cells and Humoral Immunity: The Generation of Antibodies Antibodies How Do B-Lymphocytes Respond to New Antigens? The Primary Immune Response How Do Antibodies Fight Infections? Immunological Memory The Secondary Immune Response Vaccines Tolerance

T-Cells and Cell-Mediated Immunity Tkiller Lymphocytes Thelper Lymphocytes T-Lymphocyte Recognition of Antigen-Containing Cells T-Cell Memory

CHAPTER 4 Virology and HIV A General Introduction to Viruses

What Are Viruses? How Does a Virus Infect a Host? A Typical Virus Infection Cycle How Do We Treat Viral Infections?

The Life Cycle of a Retrovirus The AIDS Virus: HIV

Features of HIV The Nature of the HIV Receptor Additional Genes Killing of Thelper Lymphocytes Nonlytic Infection of Macrophages Dendritic Cells and HIV Co-Receptors for HIV

The Effects of HIV Infection in Individuals The HIV Antibody Test

Potential Problems with the HIV Antibody Test How Does HIV Evade the Immune System? Azidothymidine (AZT): The First Effective Drug Treatment in HIV/AIDS

Limitations of AZT Protease Inhibitors: Another Class of Drugs Against HIV

Where Did HIV Come From?

CHAPTER 5 Clinical Manifestations and Treatment of AIDS Exposure, Infection, and Disease

Exposure Versus Infection Infection Versus Disease

HIV Infection in Untreated Individuals Primary Infection and the Asymptomatic Period Mononucleosis-Like Illness Brain Infection (Encephalopathy) The Asymptomatic Period Initial Disease Symptoms Damage to the Immune System and Full-Blown AIDS AIDS

High Turnover of Thelper Cells in AIDS Patients Mutation and Evolution of HIV During Infection Antiviral Drugs for HIV

Reverse Transcriptase Inhibitors Protease Inhibitors Integrase Inhibitors Fusion Inhibitors CCR5 Antagonists

Clinical Management of HIV-Infected Individuals Monitoring Infection and Disease Antiretroviral Therapy (ART) Limitations and Uncertainties in ART Therapies Timing the Initiation of ART Prophylaxis for Opportunistic Infections

ART in Prevention of HIV Infections

CHAPTER 6 Epidemiology and AIDS An Overview of Epidemiology and AIDS Basic Concepts in Epidemiology

Descriptive Studies Analytical Studies Correlations Criteria for a Causal Relationship

Epidemiology and AIDS in the United States The Current Picture of AIDS in the United States Epidemiology and Modes of HIV Transmission The Effectiveness of AZT The Changing Face of AIDS

AIDS Around the World AIDS in Africa AIDS in Asia New Areas of Rapid Spread

HIV Subgroups and Clades

CHAPTER 7 Modes of HIV Transmission and Personal Risk Factors Biological Bases of HIV Transmission

Sources of Infectious HIV Stability of HIV Targets for HIV Infection

Modes of HIV Transmission Activities Not Associated with HIV Transmission: Casual Contact Activities Associated with HIV Transmission: Birth, Blood, and Sex

CHAPTER 8 Individual Assessments of HIV Risk Introduction to Individual Decision Making and Action Risk Assessment

Normative Model Subjective Probability Model

HIV Testing and Risk Assessment Nature and Accuracy of the HIV Test Testing Options

CHAPTER 9 Prevention of AIDS Disease Prevention and Health Promotion Models of Health Behavior Change

Health Belief Model Health Decision Model Precaution-Adoption Process Model

Principles of Health Behavior Change The Cognitive Principle

The Emotional Principle The Behavioral Principle The Interpersonal Principle The Social Ecological Principle The Structural Principle The Scientific Principle

Examples of HIV/AIDS Prevention Programs AIDS Prevention Among Young Gay and Bisexual Men AIDS Prevention Among Mexican Migrant Farm Workers

CHAPTER 10 Living with AIDS: Human Dimensions Theoretical Perspectives from Social Psychology

Role Theories Cognitive Theories

Human Dimensions of HIV/AIDS Confronting the News of Infection Accepting the Reality of Infection Opportunities and Challenges of Drug Therapies

CHAPTER 11 Living with AIDS: Societal Dimensions Theoretical Concepts

Prejudice Discrimination

Societal Dimensions of HIV/AIDS Needle Exchange for Injection Drug Users HIV Prevention for Teens Healthcare Practices

CHAPTER 12 Future Directions in Combating AIDS Future Directions for Biomedical Efforts

Prevention of Infection Treatment of Infected Individuals

Future Directions for Social Efforts Education Research

A Final Note of Optimism: Time Is on Our Side

Glossary Appendix: Reference Resources Index


THE PURPOSE OF THIS TEXT is to provide the nonspecialized student with a firm overview of AIDS from biomedical and psychosocial perspectives. The biological aspects include cellular and molecular descriptions of the immune system and the AIDS virus (human immunodeficiency virus, or HIV). The consequences of HIV infection from cell to organism are also covered with a clinical description of the disease. We then move from the organism level to the interorganism level covering both the psychological and social aspects of HIV/AIDS. These topics can be covered only in a survey fashion because of the comprehensive nature of this approach and the additional aim of making this text appropriate for a one-quarter (or semester) course (or part of such a course). We focus on presenting the relevant fundamental principles. Following a brief presentation of these principles for each topic, we generalize and apply these concepts to the case of AIDS.

This book began as The Biology of AIDS. The first edition of AIDS: Science and Society expanded from The Biology of AIDS and included consideration of social issues related to HIV/AIDS: personal risk assessment, HIV prevention, and the human and societal dimensions of living with HIV/AIDS. In the current edition of AIDS: Science and Society, we have provided updates and new sections in several of the chapters and provided the latest statistics on AIDS that were available as the book went to press. Chapter 3, on immunology, has been modified to include the concepts of adaptive and innate immunity. The book contains a reference appendix in which students can obtain additional information on AIDS. A major feature of this appendix is the inclusion of several organizations that have websites students can explore to find up-to-date information about AIDS.

This book is patterned after a one-quarter course, AIDS Fundamentals, taught at the University of California, Irvine. Approximately half the course covers biomedical aspects of AIDS, and the other half covers social issues raised by the disease. The text represents the material covered in the course. At UCI, AIDS Fundamentals is open to all undergraduate students and is taught with the assumption that they have had a high school–level modern biology course. The material contained in Chapters 3 (immunology), 4 (virology), 6 (epidemiology), 9

(preventing HIV), and 10 (living with AIDS) is covered in three hours of lecture per chapter. Material covered in the other chapters is taught in a single one and one-half hour lecture per chapter. We have found that students are able to assimilate and retain the material when delivered at this rate. The course includes another important component: small discussion groups led by students who previously took the class. These peerled groups use experiential exercises as a catalyst for a deeper understanding of the human and social aspects of HIV/AIDS. More details about this aspect of the course are in the instructor’s resources available from Jones & Bartlett Learning. Another important feature of the AIDS Fundamentals course is two panel presentations by people affected by HIV/AIDS: a panel of people living with AIDS and a panel of HIV/AIDS healthcare workers.

Most researchers and scholars in AIDS-related fields were unprepared for the dramatic impact of the AIDS epidemic when it emerged in 1981. As virologists and social scientists, we might have expected modern biomedical technology to provide a quick technical solution or to at least prevent, through vaccine development, the spread of this major new viral epidemic. Although there has been biomedical progress, it is now clear that the HIV/AIDS issues pose new and unforeseen difficulties with no quick biological solution in sight. These difficulties challenge both our scientific abilities and the ability of our society to respond appropriately. It is our goal to provide students with a conceptual framework of the issues raised by HIV/AIDS so that they will be able to deal better with the challenges posed by this disease. This is particularly important because new information about scientific aspects of HIV/AIDS appears regularly; with this information comes new implications for the clinical, social, psychological, legal, and ethical aspects of the disease. We hope that the framework provided in this book will help students understand and make informed decisions about HIV/AIDS-related issues as they develop in the future.

Ancillaries For Students Jones & Bartlett Learning has developed a Navigate Companion Website especially for this text, revised and updated by Anne Bongiorno of SUNY Plattsburgh, featuring numerous interactive and informative learning resources that gauge understanding and help students study more effectively. Please visit for useful study tools, including summaries of the main points from each chapter, short-answer review questions, and additional links to HIV/AIDS-related sites. Links to the organizations

mentioned in the appendix can also be found here.

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