manuscript abstract

Over the last 100 years we have undergone an epidemiological transition in which the majority of mortality could be summarized by infectious disease that killed young individuals to a period in which the majority of mortality can be accounted for by chronic diseases of old age (Omran 1971). There has also been a transition in the risks factors and demographic profiles of specific diseases, such as HIV/AIDS. When AIDS was first characterized in the United States during the early 1980s, the disease was thought of as a problem within mostly homosexual communities. While the disease does still impact the homosexual community, data also clearly demonstrate that HIV/AIDS is a disease of inequality, best characterized by broader health disparities along racial and socioeconomic boundaries. It is possible that the early epidemiological production of knowledge overemphasized the relationship between AIDS and homosexuality, while underestimating the role of socioeconomic status and IV drug use (Cochrane 2004). Furthermore, over the past decade the impact of HIV/AIDS within the international community, among some of the world’s poorest countries, has escalated exponentially. The majority of AIDS cases now reside in Sub-Saharan Africa, while a growing number will be found in China and India over the coming years.

Why are poor people more likely to contract HIV? Why are certain groups, such as racial minorities, in affluent societies, like the U.S. more likely to contract HIV? During the 25 years that have elapsed since the time of the first AIDS cases, billions of dollars have been spent internationally to prevent and treat HIV/AIDS. However, this message has only been partially effective and fully adopted by a small percentage of the population. For example, many homosexual men continue to engage in high risk behavior, such as taking MDMA, having unprotected anoreceptive sexual intercourse, and interacting with multiple sex partners. On a separate scale, policy makers and educators continue to ignore pleas from public health officials and the medical community to increase condom use messages among young men and women and to create easier access to free and clean needles through needle exchange programs.

It is not an accident of history that HIV/AIDS prevention messages and treatment programs have favored some individuals while skewing the vulnerability to the disease towards other individuals throughout the world. Instead a number of historical events generated the current distribution of HIV risk and account for the epidemiological profile of current HIV prevalence disparities.

In this manuscript, I examine the natural history of the AIDS epidemic in one community – Tampa, Florida – as a device for explaining the current state of the disease and the future of HIV/AIDS policy, treatment, and risk. This book is divided into three parts. In Part 1, I explore the early reactions to the disease within the public health and medical community, gay/lesbian population, general community, and politicians through direct interviews with those physicians, administrators, officials, reporters, and citizens, as well as through examination of early newspaper clippings and other cultural artifacts. The goal of part 1 is to document the cultural context of the early AIDs community in order to create a foundation and perspective for the topics discussed in Part 2. That section focuses on the development of prevention, education, and treatment policies throughout Hillsborough County schools, businesses, hospitals, private practices, and universities - as well as how the city responded to federal and state legislation regarding AIDS. In Part 3, I draw upon my own dissertation research conducted at the Hillsborough County Health Department using the Florida AIDs surveillance dataset. In this final section, I demonstrate that within a single county, HIV+ patients may have very different health outcomes. Furthermore, the probability of having a more positive health outcome (defined by a longer time to full blown AIDs or longer period until suffering mortality) falls along similar lines to those of HIV prevention (race and socioeconomic status). However, other variables, such as neighborhood resources and social networks may predict how well a person is likely to do after receiving an HIV+ diagnosis. In this section, I focus on how cultural differences within Tampa neighborhoods may influence access to treatment programs, frequency and types of coinfection, likelihood of continued engagement in risk behavior, or premature mortality.

There are 3 goals that I hope to accomplish by writing this manuscript:

1. I hope to show ways in which we can erase health disparities that exist between socioeconomic and racial minority groups by illustrating the distribution of inequality in prevention policy that leads to a distribution of inequality in HIV prevalence and HIV outcomes. The goal of my dissertation work is to help focus future treatment efforts in order to serve all members of a HIV+ community equally, but we must also work on shifting the distribution of risk factors for HIV away from a skewed set of factors that target the poor.

2. By summarizing and documenting the official and cultural responses to an epidemic that arose and escalated rapidly, this manuscript can assist city planners and officials in coping with future epidemiological events.

3. The creation of an anthropological narrative of HIV/AIDs within a large metropolitan area provides a voice to those on the margins of this epidemic and those who have worked diligently as clinicians and observers of this disease during the past 25 years.