This World AIDS Day - 1st December 2006 - marks the 18th anniversary of the first ever World AIDS day, held in 1988, where the theme was Communication. The age of 18 years is synonymous with coming of age, the rite of passage into adulthood where a person becomes legally responsible and accountable for their lives. Therefore, it is appropriate that the theme this year is Stop AIDS: Keep the Promise - i.e., accountability.
With events marking this day across the world, perhaps we need to pause for a few moments and consider what the term accountability actually means, specifically in terms of HIV/AIDS. The dictionary defines it as the state of being accountable, liable, or answerable.
The next question is: Who is being asked to be answerable to whom? Donors, aid Agencies, many governments and businesses have, in many areas, stepped up to the plate and contributed resources and skills to do their part in this pandemic, particularly in the field of treatment. Some have not. However, progress is being made at national, regional, corporate, and organisational levels. No doubt, the statement keep the promise is directed at agencies to do more, spend more, and generally try harder. Considering the scale and impact of the pandemic in Southern Africa, this sentiment is appropriate.
However, what about accountability at the individual level: The people who are at risk of getting infected, and those already infected? How do we also apply accountability to the individuals that the myriad of strategies and agencies are seeking to serve? More specifically, why are new infections continuing - seemingly unchanged - year after year?
Most people know, for the most part, the basics of HIV infection - how you get it, how you prevent it, and the consequences of both courses of action. Some have other strange beliefs around the virus and urban legends and myths abound. However, by and large, most know the basics. People know how to prevent it and yet they still get infected in huge numbers. At the one end of the spectrum, there are commendable efforts to ensure treatment for those living with AIDS, slowly but surely turning HIV into a chronic manageable disease. However, at the other end of the spectrum we have a constant - and unchanging - increase in new infections. We are putting safety nets in place for those who get infected, but failing to stop the tide of infections.
Prevention, for the most part, has been a dismal failure across the globe, and more specifically in the developing world. Factually speaking, HIV is one of the most preventable viral infections known in the history of pandemics. Apart from mother-to-child transmission, using dirty needles, rape (a forced sexual act) or the rare unsafe blood transfusion procedures, for adults to get infected you have to engage in specific acts (unprotected sex). HIV is more preventable than the common cold or hepatitis, both of which you can get through casual contact, or mere touch.
The reality is that the great majority - 90% plus - of new HIV infections occur through consensual sex between adults: Why do people - in large numbers - knowingly (though not necessarily with a song in their heart) engage in unprotected sexual activities that place themselves at risk of HIV? We can no longer claim that they do not know to prevent infection, nor can we claim ignorance of the consequences. If one were to compare such high risk sexual activities with driving under the influence of alcohol, how can we not hold people accountable for their own infections?
We suggest that a comparison between unprotected sex and driving under the influence of alcohol is superficial and invalid - comparing apples to oranges. Instead, to understand the apparent wilful engagement in high risk sexual activities - despite knowledge, education, awareness of consequences - we need to examine the powerful motivations to engage in such activities: There are fundamentally two different motivational paradigms - perhaps even biological imperatives - that people are unconsciously driven to be accountable to: Personal, and group. The former concerns protection and enhancement of individual life, and the latter concerns protection and continuation of the groups' lives.
In basic sexual terms, this often boils down to recreational and procreational sex: If sex worker and youth prevention programs are anything to go by, it is comparatively less difficult to persuade people to wear condoms when they engage in recreational sex. Such sexual activities are for individual pleasure purposes, and preventive behaviours (e.g., condoms) do not unduly interfere with such purposes.
However, when the same methods are applied to procreational sex, they fail. There is little evidence that condom use is widely used in non-casual relationships. Our experience is that condoms are used outside the home, and not within the home. The term home does not necessarily exclude extramarital homes, such as the sugar daddy scenario and concurrent relationships, where younger women are being kept as mistresses by older (often married) men. Nor do ongoing extramarital relationships focus exclusively upon recreational sex. Often, procreation is a key factor binding the mistress to her lover.
Here's the bottom line for sex within many relationships: People want babies. You can't have a baby with a condom. Babies are the key to the future, and our sense of identity as a man or woman. As a result, people are risking their lives - and the lives of their partner(s) - to fulfil that identity. This is nothing new: History is filled with people risking life and limb for what they believe will ensure of their group's survivability.
The focus - and methodology - has been to ask people to be accountable for protecting their personal life, where this often conflicts with group survival, namely procreation: No babies, and your group has no future. It's not a matter of people being irresponsible - it's more about who (or what) they are being responsible to: Personal survival, or survival of the group, or the group's identity. We risk our personal lives and go to war for the sake of an identity, why should sex be different?
Let's get clear: We are not dismissing condoms - or any method - out of hand: Every method has its' merits and areas of potential success. Instead, our intention is to refocus our efforts to achieve a critical outcome: Prevention of new infections. In the last two decades we have confused the method with the goal. This is where prevention has failed: We have become fixated on one method, and ignored the evidence that it has not led us closer to the goal. For example, when we ask companies what they are doing about prevention, they proudly announce that they have condoms freely available. How many are married, we ask? What's the connection, they respond? That's the problem: We fail to see the connection between the purpose of consensual sex, and the likelihood of utilising specific protective measures. The method often does not fit the act, and HIV runs rampant.
The medical and social-scientific world has failed us in this regard: The focus has always been upon individuality, personal behaviours, and personal survival. Only when we can provide methods that extend our collective wisdom to helping the man or woman who wants to have children to do exactly that, are we likely to get anywhere with prevention. We have to banish the notion that prevention excludes procreation, and take it from there: "If you live with HIV, here's how you protect your partner, and have healthy babies".
Yes, we know...there is always a risk on transmitting HIV without a condom. We also know that people are taking that risk anyway, in large numbers. Isn't it time to get real about this, and focus upon lowering - not eliminating - that risk, given that we cannot stop the behaviour itself? A powerful motivation to get tested for HIV may be that, with correct monitoring of viral loads and ART where appropriate, safer procreation can occur, when viral loads are undetectable. We utilise ART for prevention of mother-to-child transmission, why can we not do the same for couples wanting to conceive? A combination of short-course ART and condoms (while viral loads are coming down) is much more likely to be accepted, if these methods allow couples to procreate once it is safer to do so. We are not going to achieve much until we start being pragmatic about this. A short-course of ART is a lot better - and cheaper, in the long-term - than a new infection of a partner, and young children left behind.
Fear of personal death has failed as a motivation strategy, both in prevention and encouraging people to get tested. Let's try something different: Desire for a future that includes children. When engaging people in these issues, we need to continue promoting condoms for recreational sex, but we need to be more pragmatic about the limitations of condoms in other situations, unless they are incorporated into a strategy that supports having babies safely.
Keep the promise - accountability: The promise to help those infected lead a normal life, with an eye on the big prize: Zero new infections. We are called upon to remind ourselves of these two goals, and shake off the comfort of confusing method with actually achieving something. We are called upon to be accountable for our efforts, and to ask whether we are actually making progress, or merely repeating the same (easy, comfortable) habits: Numbers don't lie. It's time we grew up, and starting bringing those numbers down. We repeat: Without including the possibility of having healthy children, prevention efforts have no future.
Is this the solution? Of course not! Will this be simple? Not a chance. There are many issues to consider, methods, medications, implications and consequences to figure out. However, we believe that this notion holds great promise for the future of prevention, for the simple reason that it recognises what many people are willing to live for, and die for.