Mountains Beyond Mountains Study Guide
Mountains Beyond Mountains book cover


HIV, AIDS and the “Great Epi Divide”

By Professor Jane M. Simoni, Psychology, University of Washington

Many of the groups of people living on the wrong side of the epi divide have brown or black skin. Many are female. What they all have in common is poverty.
– Tracy Kidder, Mountains Beyond Mountains, p. 125

 What You Can Learn from this Topic

  • What is HIV and how is it different from AIDS?
  • What is the epidemiology (i.e., the prevalence and distribution) of AIDS in the United States (U.S.) vs. Haiti?
  • How has structural violence affected the spread and treatment of AIDS worldwide?
  • What can I do to help?

How is HIV Different from AIDS?

HIV stands for Human Immunodeficiency Virus, a virus which weakens the immune system, your body’s natural defense system. In HIV infection, a subset of white blood cells called CD4+ T-cells are damaged. Without a healthy immune system, your body is vulnerable to infections that normally would not be serious in a healthy person. When an HIV-positive individual has a very compromised immune system or acquires certain infections, he or she is diagnosed as having Acquired Immune Deficiency Syndrome or AIDS.

People can become infected with HIV by exposure to infected body fluids such as blood, semen, vaginal fluid, and breast milk. These fluids can be passed between people in a variety of ways such as unprotected sex and sharing needles. People do not get HIV from hugging, shaking hands, insect bites, or from living with a person who is HIV-positive.

What is the Epidemiology (the Prevalence and Distribution) of AIDS in the U.S. vs. Haiti?

In the United States (U.S.), around 40,000 people become newly infected with HIV every year, over two-thirds of them men. The U.S. Center for Disease Control and Prevention estimates that one-half of the new infections in men and close to two-thirds in women occur among African Americans, even though this group constitutes less than one-fifth of the U.S. population. One-quarter of all new HIV infections are among injecting drug users, and some 42 percent of people infected every year are men who have sex with men. Heterosexual sex without condoms accounts for most of the remaining infections. With 0.8 percent of adults estimated to be HIV-positive, the U.S. has the highest prevalence of any developed country.

Haiti is the most HIV-affected country in the Western Hemisphere. In some areas of the country as many as thirteen percent of pregnant women tested anonymously for HIV in 2000 were found to be HIV-positive. Overall, around ten percent of adults in urban areas and four percent in rural areas in Haiti are HIV-infected. The vast majority were infected during unprotected sex between women and men. Many of those infected early on in the epidemic have already died. In Haiti, as in most heterosexual epidemics, both HIV infection and deaths are concentrated in young adults—women and men with children to raise and aging parents to support. The country estimated that 4.5% of adults are currently infected with HIV and that AIDS is the leading cause of death. ( U.S. Census Bureau, 2001; USAID, 2006).

Structural Violence and the Treatment of AIDS Worldwide

HIV infection is caused by a virus, but which individuals in a society are exposed to HIV, get tested and treated, and how quickly their illness progresses to AIDS is affected largely by social and political forces. HIV seeps into the cracks in the foundations of society—targeting weakness and inequality caused by sexism, heterosexism, racism and poverty. While the medical and scientific communities seek a vaccine and we all hope for a cure to the disease, the resolution of the HIV crisis will also depend upon how quickly we can address these underlying inequities in our world.

In Mountains Beyond Mountains: The Quest of Dr. Paul Farmer, A Man Who Would Cure the World, Farmer refers to this concept when he talks about the “great epi (epidemiological) divide” and its impact on tuberculosis (TB). The world can be divided into two groups. One group includes those who fare relatively well in terms of their health and longevity, dying of diseases typically associated with old age. The other group consists of individuals who die much younger, often from violence and hunger and communicable diseases for which treatment is known. “Many of the groups of people living on the wrong side of the epi divide have brown or black skin. Many are female. What they all have in common is poverty” (p. 125). Kidder goes on to explain Farmer’s theory of how TB vividly illustrates this epi divide. Effective prevention efforts and treatments are available in the more affluent areas of the world, where TB has been almost eradicated. In the developing world, however, TB is dreadful, lethal, and fairly common, killing two million people a year. Because TB affects mainly those on the indigent side of the “epi divide,” the West, along with the large pharmaceutical interests, is not actively pursing new technologies for diagnosing and treating TB.

A similar argument can be made about HIV/AIDS. AIDS has ravaged poor communities that are more vulnerable because of poor sanitation, substandard medical care, contaminated blood supplies, non-sterile medical facilities, and lack of access to high-quality condoms and HIV testing. Substance use and sex work provide an escape from poverty and also drive segments of the epidemic. In the U.S., HIV first affected stigmatized groups such as gay men and injection drug users. Many think this was the main reason for governmental inaction in the early years of the epidemic. The stigma towards the disease increased as the most vulnerable in society, including sex workers and people of color, became infected at higher rates. The AIDS epidemic in the developing world seemed hopeless to many in the West. Although successful treatments for HIV have been available since 1997, until very recently many assumed that treatment for AIDS was too expensive and too complicated for the poor in the developing world. Research on vaccine development for the types of HIV that most affect the developing world and on how to make treatment there more effective may not be as well-funded as more profitable projects.

What Can You Do to Get Involved?

Raise awareness, raise funds, volunteer for your local HIV/AIDS organization or join the fight against discrimination and prejudice. From protecting yourself and your partner with safer sex and getting tested to caring for people living with HIV/AIDS in your own community, anything you can do will be a valuable and welcome contribution. Start by talking to your family and friends about HIV, AIDS and safer sex (UNAIDS, n.d.).


Kidder, Tracy. (2003). Mountains Beyond Mountains: The Quest of Dr. Paul Farmer, A Man Who Would Cure the World, New York: Random House.
UNAIDS: Joint United Nations Programme on HIV/AIDS. Uniting the world against AIDS: Young People. (n.d.) Retrieved from

U.S. Census Bureau. HIV and AIDs in the Americas: An epidemic with many faces. (2001). Retrieved from

USAID from the American People. HIV/AIDS: Haiti. (2006). Retrieved from

Internet resources for further reading

AIDSinfo: A Service of the U.W. Department of Health and Human Services:

Department of Health and Human Services’ Centers for Disease Control and Prevention. Fact Sheets.

Department of Health and Human Services’ Centers for Disease Control and Prevention. HIV/AIDS Prevention

World Health Organization. WHO and HIV/AIDS

National Institutes of Health United States National Library of Medicine. HIV/AIDS Information: Specialized Information Services

Suggested Courses

EPI 101 Public Health Issues in the Media (5) I&S DeRoos
Reviews epidemiologic studies and popular media to compare original research results with the message disseminated to the public, and to analyze how and why data from public health research can sometimes be misleading to the public.

GEOG 280 Introduction to the Geography of Health and Health Care (5) I&S Mayer
Concepts of health from a geographical viewpoint, including human-environment relations, development, geographical patterns of disease, and health systems in developed and developing countries.

GEOG 380 Geographical Patterns of Health and Disease (4) I&S Mayer
Geography of infectious and chronic diseases at local, national, and international scales; environmental, cultural, and social explanations of those variations; comparative aspects of health systems.

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