At the other end of the spectrum, we might want to reduce risk options, for example by raising taxes on risk-related products such as alcohol or through "seat-belt" constraints such as the Thai policy of obligatory condom use in brothels, which eliminates the client's risk option of unprotected sex and at the same time "empowers" the sex worker to insist on condom use.
We must be wary of venturing too far into structural or coercive risk reduction, however, and not only for human rights reasons. Government coercion is rarely neutral, because it tends to constrain the powerless rather than the powerful. For example, although sexual HIV transmission is obviously a two-way risk, far more coercion is typically applied to sex workers than to sex work clients, increasing the power imbalance instead of leveling the playing field.
Like prevention, the provision of care and support for people affected by HIV and the alleviation of the epidemic's impact necessarily involve a wide range of actors, processes, and sectors. Not all the links are obvious, however. For example, in high-prevalence countries, the interface between AIDS and schools is not limited to introducing lifestyle skills or sex education into the curriculum but involves training extra principals and teachers to replace those dying of AIDS. The implications of AIDS for agriculture are not simply that children are taken out of school to weed fields that their sick parents cannot tend but also the threat that parents will not live long enough to pass on their precious knowledge of soil conservation and crop rotation. In sum, an expanded response also means weaving AIDS issues and implications into social and economic development.
Realistically, what can an expanded response achieve? A smaller epidemic involving a more tolerable level of suffering. Expanded response will not, however, stop the epidemic. Short of universal population coverage with a highly effective HIV vaccine, we cannot expect all transmission to cease.
In terms of future challenges, what we do about AIDS depends on how we look on the epidemic-as a mere disease, a failure to respect religious codes, an outcome of differentials in sexual behavior and sexual decision-making between men and women, a human rights issue, or another tragic correlate of poverty and deprivation, to name but a few of the paradigms that have evolved since the start of the epidemic. It is illusory to think that these competing paradigms can ever be reduced to a single world view. The overlaps, such as between the human rights and the poverty paradigms, and even the frank contradictions, for example between biomedical and religious models, mirror the complexities of real life. Sometimes we are at a loss even to understand why a particular community has been successful in lowering transmission. Humility will help us avoid the straitjacket of AIDS orthodoxy and narrow-minded political correctness.
Nevertheless, there do appear to be some universally applicable principles. One is the need for the simultaneous use of multiple approaches that can work together. Another principle is never to lose sight of the epidemic's disproportionate focus on individuals and communities already facing other health, social, and economic challenges, such as women, young people, sexual and ethnic minorities, refugees, drug users, and economically disadvantaged populations. It is no coincidence that more than 90 percent of all new infections now occur in the developing world. An expanded response from the industrialized countries is essential today but also tomorrow, as more effective drugs, HIV barriers, and hopefully vaccines are developed and access by people in the developing countries becomes an ever-greater moral imperative.
As people increasingly demand to know their HIV infection status, a further challenge will be to provide them with voluntary counseling and testing. This can open the way to new ways of coping with the epidemic. Counseling and HIV testing, followed by mutual agreement and trust by the partners to protect each other from HIV, may become the standard prelude to a long-term relationship, with or without procreation. It might be particularly useful in communities where any prospective partner has a high likelihood of being infected, such as parts of Africa where 20 percent of 20-year-olds have HIV. A related challenge will be to offer more effectively tailored support for the real needs of people diagnosed with HIV infection, not only their right to nondiscrimination in areas such as housing, employment, and travel, but their right to care and their needs for intimacy during the decade or more that they can expect to live with the virus.
In conclusion, the worldwide HIV/AIDS epidemic has become a permanent challenge to human integrity and solidarity. Given the scale of suffering, given the proven effectiveness of several approaches, and given the prospect of furthering other human goals through the fight against AIDS, an expanded response makes ethical and practical sense. Instead of letting AIDS turn back the clock, let us use our response to the epidemic to turn humanity's clock ahead.
Peter Piot, a Belgian physician and microbiologist, is executive director of the Joint United Nations Programme on HIV/AIDS (UNAIDS), headquartered in Geneva, Switzerland. A co-discoverer of Ebola virus in 1976, he later launched and expanded a series of collaborative projects on AIDS in Africa. This essay was written in collaboration with Suzanne Cherney of UNAIDS.
