11. HIV/AIDS

A. A National Perspective

ANDREW D. FORSYTH

Trends suggest that AIDS will continue to have significant impact in the United States in coming years. Throughout the 1980s and early 1990s, there was a steady increase in the number of documented AIDS cases. However, between 1993 and 1994, the number of AIDS cases reported to public health departments nationwide dramatically increased due to the implementation of an expanded surveillance definition of AIDS, which included cases of severe immunosuppression manifesting in earlier stages of HIV infection. Although the number of AIDS cases declined in 1994 relative to the previous year, it still represents a considerable increase over cases reported in 1992 (CDC 1995a).

Consistent with previous years, the most severely affected segment of the U.S. population in 1994 was men who have sex with men. Although men constitute 82 percent of all AIDS cases reported among adults and adolescents (13 years or older), men who have sex with men represent the single largest at-risk group, constituting 44 percent of all nonpediatric AIDS cases (CDC 1994a). Young men who have sex with men (between ages 20 and 24) constitute a particularly salient at-risk group for HIV infection, representing 60 percent of AIDS cases among all men of that same age. In contrast, 53 percent of all men with AIDS occur in men who have sex with men.

Even so, the number of AIDS cases reported among men who have sex with men decreased by 1.1 percent for the second consecutive year in 1992, suggesting that infection rates among this segment of the population may be leveling off (CDC 1993a). The same cannot be said for heterosexual men who inject drugs and men who inject drugs and have sex with men; they represent the second and third largest at-risk groups among men, explaining 24 percent and 6 percent of AIDS cases, respectively (CDC 1994b). Newly reported AIDS cases for these groups continue to increase sharply. Although only 4 percent of all men diagnosed with AIDS by 1994 were infected via sexual contact with an infected woman, they had the largest proportionate increase in AIDS cases among all men in recent years (CDC 1994a).

The proportion of AIDS cases reported among women has more than doubled since the mid-1980s (CDC 1994b). In 1994, 58,448 cumulative cases of AIDS were documented among women, comprising 13 percent of all adults and adolescents (13 years or older) diagnosed with AIDS in the United States (CDC 1994a). Although they represent a minority of all AIDS cases, the incidence of AIDS among women has increased more rapidly than have rates for men, with over 24 percent of all cases of AIDS among women reported in the last year alone (CDC 1994b). The impact of the CDC's implementation of the expanded case definition for AIDS is particularly salient for incidence rates among women: In 1994, 59 percent of cases of women with AIDS were reported based on the revised surveillance definitions. Correspondingly, the incidence of AIDS opportunistic illness (AIDS-01) has increased more rapidly among women than it has for men. Overall, the modes of HIV transmission for women also differ considerably from those for men: Women are most likely to be infected via intravenous drug use (41 percent) or sex with infected men (38 percent). Although 19 percent of women with AIDS reported no risk of exposure to HIV, follow-up data from local public health departments suggested an inverse trend. Most of those with previously unidentified risk exposure were infected via heterosexual contact (66 percent) or intravenous drug use (27 percent (CDC 1994b)).

Because women of childbearing age (i.e., 15 to 44 years old) represent 84 percent of AIDS cases among women, perinatal transmission of HIV presents itself as a serious problem (CDC 1994b). In comparison with the statistics for HIV transmission for all women cited above, the most frequently reported modes of HIV transmission for seropositive new mothers were by heterosexual contact with infected male partners (36 percent) and injection drug use (30 percent) (CDC 1994a). However, it is often impossible to separate these two avenues of infection, because women may be having sex with of an infected male while also using IV drugs, both before and during pregnancy. According to recent trends, approximately 7,000 HIV-infected women gave birth to infants in the United States in 1993; about 30 percent of these infants may have contracted HIV perinatally (Gwinn et al. 1991). In 1994, 1,017 cases of AIDS were documented among children less than 13 years of age, an increase of 8 percent from 1993. In 92 percent of these cases, children contracted HIV perinatally (CDC 1994a). Demographically, there were no apparent differences in perinatal transmission rates between boys and girls; however, most newly reported cases of pediatric AIDS occurred among African-American (62 percent) and Hispanic (23 percent) children (CDC 1995a). By December 1994, a cumulative total of 6,209 AIDS cases were documented among children 13 years or younger (CDC 1994a).

In any discussion of incidence, etiology, and the avenues of infection for HIV/AIDS, the official CDC statistics are quite misleading, especially when comparing figures for different years. The clinical definition of the AIDS syndrome has been expanded several times, making the incidence seem comparatively lower in earlier years. In addition, the CDC has not been consistent in studying modes of infection, especially for women. The intake interview questions asked of men and women seeking HIV testing have changed significantly over the years; they also differ significantly for men and women, with several possible avenues of infection left out in the questions for women. In the 1980s, being born in a developing country could be listed as an avenue for men and women testing HIV-positive; women, but not men, were asked if they had had sex with a person from a developing nation. Also, the criteria for assignment to the “unidentified risk” category has changed back and forth, which in turn raises or lowers the number of infected individuals in other categories.

Clearly, adolescents and young adults are at-risk for HIV infection as well, although modes of transmission for them vary considerably. In 1994, there was a cumulative total of 1,965 cases of AIDS among adolescents between ages 13 and 19 years (CDC 1994a). For this age group, males represented 66 percent of AIDS cases and most frequently contracted HIV through receipt of infected blood products (44 percent), through sex with men (32 percent), or through injection drug use (7 percent). In contrast, females between the ages of 13 and 19 most frequently contracted HIV through sexual contact with infected men (52 percent) or injection drug use (18 percent); 22 percent of these young women failed to identify an exposure category. For young adults between the ages of 20 and 24, men represented 77 percent of AIDS cases, most of whom contracted HIV through sex with men (63 percent), injection drug use (13 percent), or sex with men and injection drug use (11 percent). Young women in this group were most likely to be infected with HIV through sexual contact with infected men (50 percent) or injection drug use (33 percent). Another 14 percent of women in this age group failed to identify an exposure category, although it is possible that the most frequent mode of transmission for them and their younger peers parallels that of older women who initially failed to report an exposure category, most of whom were infected via sexual contact with infected men (CDC 1994a).

The impact of the AIDS epidemic has been especially devastating in communities of color in the United States, largely due to a number of socioeconomic factors that disproportionately affect racial and ethnic minorities (CDC 1993b). Although they represent only 21 percent of the population, racial and ethnic minorities presently constitue 47 percent of cumulative AIDS cases among adult and adolescent men, 76 percent of cases among adult and adolescent women, and 81 percent of all pediatric AIDS cases (CDC 1994a). In 1994, African-Americans and Hispanics alone represented 58 percent of the 80,691 reported AIDS cases for that year, and they had the highest rates of infection per 100,000 people (100.8 and 51.0, respectively). In contrast, Asian/Pacific Islanders and American Indians/Alaska Natives comprised 577 (0.007 percent) and 227 (0.003 percent) of AIDS cases, respectively, reported in 1994 and had the lowest rates of infection per 100,000 people (6.4 and 12.0 percent, respectively). Whites comprised 33,193 (41 percent) of AIDS cases reported in 1994 and had the third highest infection rate per 100,000 people (17.2 percent).

The disproportionate effects of AIDS on racial minorities in the U.S. are most salient among women and children. In 1994, infection rates among African-American and Hispanic adult and adolescent women (i.e., 13 years and older) were 16.5 and 6.8 times higher than were rates for white women of the same ages, respectively (CDC 1994a). Likewise, infection rates among African-American and Hispanic children (i.e., less than 13 years old) were 21 and 7.5 times higher than were rates for white children, respectively. Although racial and ethnic status do not themselves confer risk for HIV/AIDS, a number of sociocultural factors inherent to many communities of color increase the risk of HIV infection, including chronic underemployment, poverty, lack of access to health-education services, and inadequate health care (CDC 1993b).

Clearly, AIDS has quickly emerged as a leading threat to public health facing United States citizens. Although there appear to be trends indicating that the impact of AIDS is leveling off in some risk groups (e.g., men who have sex with men), it is increasing steadily in others (e.g., African-American and Hispanic women and children). Furthermore, it is possible that additional segments of the population are currently “at risk” for HIV infection, including the severely mentally ill, older adults, and women who have sex with women. AIDS cases among them may constitute a third wave in the AIDS epidemic.

Because there is no cure for AIDS, behavioral change that reduces risk of exposure to HIV (e.g., unprotected sex and sharing of needles while injecting drugs) is paramount. Interventions focusing on AIDS education, self-protective behavioral change, and utilization of existing medical and testing services together represent the most promising course of action in the prevention of HIV infection and AIDS in the United States.

The clinical definition of AIDS has been revised twice by the Centers for Disease Control, first in 1987 and then in 1993, when new female symptoms for invasive cervical (stage 4) and other disease were added, along with a revision in the T4 (helper) cell count. These redefinitions need to be considered when interpreting statistics on the rates of AIDS infection.

Confidential testing for HIV status is available nationwide, with a free or sliding-scale fee and counselors available to assist in informing partners of HIV-positive persons. Several states have won the right to test all prospective employees for HIV and share this information with related agencies. The American Civil Liberties Union has won a court decision denying mandatory testing. Legal and ethical challenges posed by HIV/AIDS are far-reaching, and it may be another decade before consistent, reasonable, and effective guidelines emerge.

Although African-Americans constitute 12 percent of the population, they represent 27 percent of the reported AIDS cases (CDC 1992), these infections being due more to heterosexual intercourse and IV drug use than to gay and bisexual men. Hispanics are also overrepresented, with 16 percent of reported cases. Consequently, there is an urgent need for development of the education and prevention programs in the African-American and Latino communities.

College students pose a particular problem. Changes in college-student behaviors between 1982 and 1988 were not encouraging. In a comparison of student behavior among 363 unmarried students in 1982 (when the term AIDS was coined and few articles were published on the subject) and 273 students in 1988, the number of students having intercourse, the number of partners, and the lifetime incidence of intercourse all increased. In 1988, 72 percent of men and 83 percent of women had received oral sex, and 69 percent of males and 76 percent of females had given oral sex; 14 and 17 percent respectively had engaged in anal sex. Twenty percent of males and 12 percent of females in 1988 had four or more partners. Students with multiple or casual partners were less likely to use condoms; there also was no increase in condom use from first to most recent intercourse (Bishop and Lipsitz 1991).

Despite the need and proven effectiveness of sterile needle-exchange programs for IV drug users and the free distribution of condoms in high schools, both programs have met considerable opposition from conservative groups and the religious right. At the same time, the need for safer-sex education for all segments of the population has allowed educators to make considerable progress in general sexuality education that might not have been possible if AIDS did not pose such a major public health problem.

B. Five Specific Emerging Issues

LINDA L. HENDRIXSON

As the AIDS pandemic continues through its second decade in the United States, unforeseen issues have emerged as important considerations in attempts to meet the needs of people living with AIDS (PLWAs).

What began as a disease syndrome affecting individuals has become a problem which confronts whole families in America. Researchers, health providers, and policymakers have had to re-work their approaches to take into account the impact that AIDS has on family members, both immediate and extended. Our definition of “family” has undergone much change throughout this pandemic. As we consider the people who care for PLWAs, and those who care about them, family has come to be defined much more broadly than before. The family of origin has been replaced or extended to include non-blood-related friends, lovers, AIDS buddies, and others who provide emotional and instrumental support.

For many PLWAs, estrangement from birth families is a way-of-life. AIDS exacerbates those earlier problems. Others become estranged after their diagnosis is discovered. Families who have not disclosed the illness of their family member live with fear of ostracism and discrimination. If an AIDS diagnosis is kept secret within the family, social isolation becomes a continuing problem. Family pressures escalate if children are involved, especially if those children are infected. The financial strain of caring for adults and/or children with AIDS can be considerable. Finding competent doctors is an additional serious challenge throughout the country. Medical costs, health insurance, adequate health care, and social support, caregiving, child custody, disclosure, stigma, discrimination, loss, and grieving are among the troubling issues facing families and others living with AIDS (Macklin 1989).

Emerging Populations and Changing Locales

AIDS is no longer found in what were originally perceived to be the only affected American AIDS populations - white, middle-class gay men and minority intravenous drug users in the inner cities (Voeller 1991; Wiener 1991). AIDS is now found in:

· people who live in rural locations;
· middle- and upper-class women, many of whom do not misuse drugs or alcohol;
· women who have only vaginal sex with men;
· women who have rectal sex with men, but do not report this behavior;
· women who have received contaminated donor semen;
· women who have had oral sex with other women;
· middle- and upper-class men;
· men who have only vaginal sex with women, and do not have sex with other men;
· black, Hispanic, and Asian gay and bisexual men;
· teenagers who have been sexually abused as children;
· people who use drugs, such as heroin, but do not use needles;
· athletes who use contaminated needles while injecting illegal steroids;
· women with blood-clotting disorders;
· people who have received contaminated organ transplants and other body tissues;
· senior citizens; and
· babies who nurse from infected mothers

The spread of AIDS to rural and small-town locations is worth noting. Most people still equate AIDS with major urban areas, and, true, the numbers of cases are highest there. However, the pandemic has diffused from urban epicenters, past suburbia, and into small, rural enclaves in the U.S. (Cleveland and Davenport 1989) The spread of AIDS in Africa along truck routes, as men seek sex away from home, is not unlike the spread of AIDS along major highways in the U.S., as people travel in and out of metropolitan AIDS epicenters. The government is paying little attention to rural AIDS in America; it is the least understood and least researched part of our national epidemic, with numbers of infected rising dramatically.

Limited research shows that some PLWAs who left their rural birthplaces for life in the city, are now returning to their rural families to be cared for. But many PLWAs who grew up in cities are leaving their urban birthplaces and moving to the country where they believe it is healthier for them, mentally and physically. This is especially true for recovering addicts whose city friends have died of AIDS, and who hope to escape a similar fate.

Besides the “in-migration” of people with AIDS to rural locations, there are many indigenous people in small towns who are infected as well. The numbers of cases of HIV/AIDS is increasing rapidly in rural America, where social services are inadequate, medical care is generally poor, and community denial is a reality. Federal and state monies continue to be channeled to inner-city agencies, leaving rural and small-town providers with scant resources to ease increasing caseloads (Hendrixson 1996).

Complexion of the Pandemic

The face of AIDS is changing in other ways, as well. There is now a considerable number of infected people who have outlived medical predictions about their morbidity and mortality. These are divided into two groups: asymptomatic non-progressors, and long-term survivors. Both groups test HIV-antibody-positive, indicating past infection with human immunodeficiency virus.

Despite being HIV-antibody-positive, the first group shows no other laboratory or clinical symptoms of HIV disease. The second group has experienced immune suppression and some opportunistic infections, and is diagnosed as having AIDS, but continues to live beyond its expected lifespan (Laurence 1994). In addition, there are others who are inexplicably uncharacteristic:

· people who have been diagnosed with AIDS, but who do not test HIV-antibody-positive, meaning that there is no indication of previous exposure to the virus, despite their illnesses

· people who have “retro-converted” from testing HIV-antibody-positive to now testing HIV-antibody-negative

· people who are repeatedly exposed to HIV through sex or contaminated blood and who do not become infected

In many ways, some new drug treatments have helped infected people forestall serious illnesses, turning AIDS into more of a chronic than an acute-illness syndrome. Yet many PLWAs have renounced AZT and other toxic anti-retroviral drugs, because of their serious side effects. Increasing numbers of patients are embracing alternative therapies - physical, mental, and spiritual - rather than taking potent AIDS drugs. Others are combining the best of conventional and unconventional medicine in their own self-styled treatment plans. The new protease inhibitors offer much promise, but it is too early to know what side effects they may produce. The bottom line is that AIDS no longer automatically equates with death (“The End of AIDS” 1996).

HIV-Positive Children Coming of Age

As life is extended, more and more children born with the virus are moving through late childhood and early adolescence in relatively good physical health. New challenges await them and their families. Some children may know they are infected with HIV; others may not. They continue to grow socially, with sexual feelings beginning to emerge. How do we help them fit in with their uninfected peers? How do we teach them about their sexuality? How do we prepare them for dating situations? What do we say when they speak of marriage hopes? How do we teach them about safer sex? What new approaches in HIV/AIDS education should health teachers consider as these children enter their classes? Parents, teachers, and youth leaders are wrestling with new questions that were unanticipated ten years ago when we believed that HIV-antibody-positive children would not live much beyond toddlerhood.

New Paradigms, New Theories

At least one revolutionary theory about AIDS is gaining prominence, as a cure for the syndrome continues to elude us. Dr. Peter Duesberg, a cancer geneticist, virologist, and molecular biologist at the University of California-Berkeley, and a member of the elite National Academy of Sciences, along with other well-established scientists, has challenged the standard medical and scientific HIV hypothesis. He maintains that AIDS researchers have never definitively proven that HIV alone causes AIDS. He theorizes that HIV cannot be the sole cause of such a complex cascade of physiological events as the complete suppression of the entire human immune system, eventually leading to fatal opportunistic infections and conditions such as cancer and dementia.

Duesberg, one of the first scientists to discover retroviruses, the family of viruses to which HIV belongs, contends that HIV is a benign “carrier” retrovirus which a healthy immune system inactivates as it would any intruder. HIV antibodies result from this normal defense response. Being HIV-antibody-positive only means that a person's immune system is working properly. It does not mean that the person will develop AIDS.

Duesberg and others believe that the serious immune suppression which manifests as severely lowered T-cell counts and opportunistic infections that may become fatal, can result from one or more of the following factors, all of which are immune-suppressive:

· continuous, long-term misuse of legal and illegal recreational drugs, including sexual aphrodisiacs such as nitrite inhalants, used by men to facilitate rectal sex with other men;

· over-use of prescription drugs, including antibiotics, anti-virals, and anti-parasitics, often taken for repeated sexually transmitted infections;

· toxic effects of AZT and other anti-retroviral drugs, which are intended to interfere with cell DNA replication (“DNA chain terminators”), and, therefore, kill all body cells without discrimination;

· malnutrition, which often accompanies long-term illicit drug and alcohol use; or

· untreated sexual diseases and other recurring illnesses, which also suppress immunity.

Duesberg points to the number of people with AIDS who do not test HIV-antibody-positive, as well as those who are HIV-antibody-positive but are not symptomatic. He questions why scientists are not interested in studying these people who defy the accepted AIDS dogma. Duesberg's efforts to have his research papers published by the mainstream American scientific press, to present his views at scientific AIDS conferences, and to be awarded funding to do additional AIDS research have met with virtual failure in this country.

Duesberg (1996) has been shut out by the powerful medical/scientific establishment which pretends to be open to new ideas and theories, but which, he maintains, is chained to the HIV-equals-AIDS hypothesis. He presented his challenge in a 1996 book entitled Inventing the AIDS Virus.

Conclusion

In the fifteenth year of the AIDS pandemic, we have no cure and no vaccine for this disease. Thousands have died in our country, most of them young people. Thousands more have died in other countries. New advances in drug treatments and alternative/holistic modalities have helped some American PLWAs, but many families continue to silently mourn the death of their loved ones. The stigma of AIDS is ever-present; the fear continues. Yet, compassion and love have emerged, as well, as caring people reach out to help those who are suffering. AIDS appears to have “dug in” for the long term while science looks for answers. In the meanwhile, we need to ask two questions. First, as scientists search for the truth of AIDS, are they asking the right questions? Second, as the disease shifts from its former pattern of early, premature death to a more manageable long-term chronic illness, are we meeting the needs of all the people infected and affected by this disease - PLWAs, their families, and their loved ones?

C. The Impact of AIDS on Our Perception of Sexuality

RAYMOND J. NOONAN

Professionals in any field often serve to support and maintain the various cultural norms of any given society. As such, with the exception of the safety-valve role of those who might be referred to as the “loyal opposition,” rarely are there expressions of sentiments or ideas that seriously challenge widely held beliefs and assumptions. Within the various disciplines encompassing the sexual sciences, the struggling theory, for example, that HIV may not be the direct cause of AIDS (see previous section), is one of the few examples of such reassessments. Among the popular press, nevertheless, various accounts have sporadically appeared with critical appraisals of either our general or specific approaches to current AIDS perspectives, including Farber (1993; 1993a; 1993b), Fumento (1990), Patton (1990), and others.

Current Trends

It cannot be denied that AIDS is a serious, debilitating, and potentially deadly disease. Yet, the American response to it has often been one in which the reality of the disease, as well as myths promoted as facts, have been appropriated to further some related or unrelated political aim. Metaphorical allusions are often used to discuss the issue, not to impart factual information about or to motivate persons to AIDS prevention, but to further a political agenda or even to attack some political group (s) perceived as adversaries. Such political goals and targets have included:

· claims that AIDS is God's punishment for sexual impropriety made by some homophobic religious leaders and others;

· instituting and promoting sex education by supporters;

· the promotion of male contraceptive responsibility by some health and sexuality professionals;

· AIDS used as a scare tactic to discourage sexual activity, particularly among the young, by some parents and others;

· providing the “scientific” reason for postponing sexual activity, being more selective about who one's sexual partners are, and reducing the number of sexual partners, by some educational, political, and health authorities;

· the promotion of monogamy and abstinence;

· the promotion of community and solidarity among compatriots, from gays to fundamentalist Christians, who perceive they are under attack;

· the use of AIDS to promote anti-male, anti-white, and/or anti-Western attitudes; and

· the advocacy of some noncoital sex practices to communicate covert negative (heterophobic) views of heterosexuality and penile-vaginal intercourse (see Noonan 1996, pp. 182-185).

Although it is well known that anal intercourse offers the most effective way for HIV to be transmitted sexually, and that vaginal-penile intercourse is far less risky, rarely have investigators asked those whose infections are suspected to have been heterosexually transmitted, particularly women, whether and how often they engaged in anal intercourse. Instead, heterosexually transmitted HIV infections are assumed to be vaginally transmitted, although this is generally unlikely on the individual scale, and not likely to result in an HIV epidemic in the heterosexual population (Brody 1995; National Research Council 1993).

Concentrating only on the condom for both contraception and STD/AIDS prevention ignores the effectiveness of spermicidal agents with nonoxynol-9 in the prevention of pregnancy and infection as a reasonable alternative for couples who object to condom use (North 1990) (see Table 7 in Section 9A). It also ignores the negative impact condoms have on sexual intimacy for some couples (Juran 1995).

In addition, our terminology with respect to AIDS has had a profound impact on our perception of sexuality. For example, the well-known slogan, “When you sleep with someone, you are having sex with everyone she or he has slept with for the last x-number of years,” is believed to be literally true by many people. The effectiveness of this slogan is seriously undermined when questions are raised about the kind of statistical and/or epidemiological evidence available to support this statement. To many, such slogans imply a view of sexuality that denigrates all sexual experiences, no matter how valid or valuable they are or have been. The “epidemic” of AIDS is another phrase that many, if not most, people believe to be literally true. They fail to realize that the word is being used in its metaphorical sense, with its emotional connotations being more important than its literal truth. The same can be said for the statement, “Everyone is equally at risk for AIDS.” Granted this statement is true, but only in the trivial sense that we are all, as mortal human beings, prone to sickness and death. The fact that ethnic and racial minorities in the U.S. are disproportionately represented in the AIDS and HIV-positive statistics (CDC 1996) should dispel that myth completely. Brandt (1988) has insightfully analyzed the notion of AIDS-as-metaphor:

At a moment when the dangers of promiscuous sex are being emphasized, it suggests that every single sexual encounter is a promiscuous encounter.... As anonymous sex is being questioned, this metaphor suggests that no matter how well known a partner may be, the relationship is anonymous. Finally, the metaphor implies to heterosexuals that if they are having sex with their partner's (heterosexual) partners, they are in fact engaging in homosexual acts. In this view, every sexual act becomes a homosexual encounter, (p. 77, emphasis in original)

It is typical within the American culture to ignore the chronic problems that result from the general American uncomfortableness with sexuality and sexual pleasure. In terms of responding to the health issues surrounding AIDS, Americans have two choices:

1. We can continue to respond as we have to other sexual issues, by spotlighting them and ignoring the broader issues of sane healthy sexuality, which includes the celebration of sexual intimacy and pleasure. This narrow panic response is typical of American culture and its dealing with such issues as teenage pregnancy, child sexual abuse, satanic ritual practices, sexual “promiscuity,” the “threats” to heterosexual marriage and the family posed by recognition of same-sex marriages, and the “epidemics” of herpes and heterosexual AIDS; or

2. We can respond to the AIDS crisis within the context of positive broad-based accommodation to radical changes in American sexual behavior and relationships. This broad-based, sex-positive approach could well include: the availability of comprehensive, more affordable, and more reliable sexual-health and STD evaluations for men, comparable to the regularly scheduled gynecological exams generally encouraged for women; the development of effective alternatives to the condom, including the availability of effective male contraceptives that are separated from the sexual act of intercourse, easy to use, and reliable; making birth control as automatic for men as the pill has been for women (ideally, they would also work to prevent STDs); the expansion of research to make all contraceptives safe for both women and men; the elimination of fear as a method to induce the suppression of sexual behavior; and sex-positive encouragement for making affirmative intentional decisions to have sex, in addition to the “traditional” support for deciding not to do so (Noonan 1996a).