A number of institutions played key roles in amplifying the epidemic: bathhouses, backrooms, shooting galleries and hospitals in some parts of Africa.

During the early 1980s there were bitter debates within the gay community over the wisdom of closing the bathhouses and policing sexual behaviour in backrooms on the grounds that these places were the sites in which unsafe sex was taking place. It is arguable that the worst epidemics of AIDS have occurred in those cities and countries where bathhouses existed, such as the United States and France, while it is arguable that Britain owes its relatively small epidemic by European standards to the fact that bathhouses and backrooms were illegal.

Closing the bathhouses was like attempting to put out a forest fire with a bucket of water (see Early safer sex messages below), although most histories of the epidemic consider their closure to have been an act of self-evident good sense (Fitzgerald: Shilts). In Holland however, the bathhouses remained open throughout the epidemic, with one crucial difference from their North American counterparts: the provision of condoms and safer sex education. Today it is clear that educational efforts which target locations where HIV transmission may take place play an important role in limiting the spread of HIV during the early phase of an epidemic.

Shooting galleries also played a crucial role in the dissemination of HIV. Cities in which these institutions were a feature of drug using culture had earlier and larger epidemics of HIV and AIDS amongst injecting drug users (Joseph). Prevention efforts were never targeted at these locations or at other places where injecting drug use took place, largely for political reasons.

In Africa it is arguable that hospitals which did not sterilise needles between injections disseminated HIV to large numbers of patients. This may explain the parity of male to female seroprevalence figures for African cities, which have generally been interpreted as supporting the hypothesis that male-to-female transmission and mother-to-baby transmission are the key routes of HIV transmission. In fact, the African cultural preference for delivering medication by injection rather than pill or suppository may have influenced the development of the epidemic.

Another hypothesis suggests that these figures can also be interpreted as showing that the re-use of needles and blood transfusions are responsible for a sizeable proportion of infections in Africa (for further discussion of this view see Packard and Epstein in AIDS: the Making of a Chronic Disease).

A key form of prevention which could be targeted at hospitals is the provision of sufficient clean needles and/or sterilising equipment to ensure that transmission did not take place. Instead, prevention policies in Africa have focused almost exclusively on the 'social marketing' of condoms, in other words, encouraging people at risk to buy and use condoms. They have also emphasised monogamy, a message which may be counter-productive in a high prevalence population if monogamy means abandoning condoms. This message was promoted to gay men in the earliest years of the epidemic in advance of any firm knowledge about routes of transmission or prevalence of the infectious agent, and undoubtedly placed many individuals at greater risk.

Distance from the epicentre of the epidemic and travel also played a crucial role in determining the degree to which HIV had spread in the population by the time that the alarm began to be raised. In Britain for instance, this happened early in 1983, and one of the earliest informal methods of protection adopted by gay men was to avoid sex with Americans. This may have been an effective strategy at that time, since a high proportion of the early UK cases amongst gay men had US contacts. Another factor which may have minimised the harm of HIV was London's relative underdevelopment as a gay holiday resort compared with Paris or Amsterdam at this time. In this sense, London was culturally more distant from the epicentre of the epidemic than Amsterdam or Sydney.

In Africa the epidemic has spread along pathways which were already well-defined trade routes and highways. The development of prostitution to service truck drivers on transcontinental trade routes is one example of the way in which travel interacted with sexual activity to further the transmission of HIV. In the United States the epidemic spread outwards from the major gay communities and centres of drug use to regional nodes, which in turn served as centres for local epidemics, a phenomenon which should have allowed prevention efforts to be targeted not only at risk groups and risk behaviours but at risk regions.

These characteristics and institutions were of crucial importance in the early spread of HIV, and continue to be important factors in introducing HIV into new populations. However, other social factors tend to explain the continued spread of HIV once it has been identified in a population or region. These social factors are discussed in more detail in Understanding the epidemic.

Further reading

Elizabeth Fee and Daniel M.Fox (eds): AIDS: the making of a chronic disease, University of California Press, 1992.

Gould P. The Slow Plague, Blackwell, 1993.

Randy Shilts: And the band played on: politics, people and the AIDS epidemic, Penguin, 1997.