The stigma associated with acquiring HIV today is possibly greater than it was a few years ago. Today, in the era of safer sex, some people's reaction, when hearing of someone acquiring HIV, is that such a person "should know better." But consider the analogy between the acquisition of HIV by a person who knows how to protect him or herself and an unwanted pregnancy in a woman who knows how to avoid it. HIV infections and unwanted pregnancies themselves are not comparable--not least because women have worked for years to change the view of pregnancy as an illness--but some of the underlying issues that result in them are.
Efforts to reduce both will be far more successful when we focus on these underlying issues. There are a lot of them, including poverty, substance abuse, lack of education, sex-driven cultural influences, low self-esteem and difficulties in negotiating safer-sex practices between individuals--same- or opposite-sex partners--whose power relationship is not equal.
Perhaps most important, it requires us to be honest and open about sexuality, desire and fantasy. We could start with intelligent sex education in the school, which would help balance the objectified sex fetishism in popular culture.
But talking about sex in an intelligent way is tough, especially for those us raised in families, cultures and religions where sex was simply not talked about except in negative terms. Tougher still is garnering political support for targeted prevention campaigns using explicit or colloquial messages that are proven to be the most effective.
But the consequence of HIV- and pregnancy-prevention policies based, explicitly or implicitly, on a "sex is bad" foundation will, very clearly, lead to more HIV infections and more unwanted pregnancies.
As our knowledge about HIV transmission had grown, we have all adopted our own customized codes of safer sex. Most people concerned about acquiring HIV engage in relative-risk assessment and determine what level of risk they are willing to accept. It is not unlike the relative-risk assessment practiced by many women who do not want to become pregnant. But unlike heterosexuals seeking to avoid pregnancy without the use of contraception-at-the-moment, there is no Norplant, vasectomy or Pill to avoid HIV (or abortion, after the fact).
An obsessive focus on a goal that is unachievable for most people-abstinence--is doomed to fail. But Congress, bowing to the religious right, recently included $50 million for abstinence programs in the welfare "reform" bill which, with required state matching funds, will total almost half a billion dollars in five years. Abstinence is great for those who choose it; families and churches are free to promote it as they wish. But spending scarce resources on this campaign, at the expense of other significantly more cost-effective anti-HIV and family planning programs (half of new HIV infections occur in persons under the age of 25) is an outrage.
If abstinence programs are the priority for Congress, the priority for too many AIDS activists is now on treatment education and access instead of effective prevention. Rather than fight the abstinence campaign, and get those dollars used for programs that work, too many of us have simply focused on other issues.
All the components in our battle against AIDS are vital. But to downgrade the importance of prevention in light of hopeful treatment news is to doom our effort to failure. It is also selfish because the new HIV infections increasingly occur among those who are least able to afford treatment. The hope of the past year is little more than a cruel carrot dangling far beyond the reach of many.
We have enormously complicated prevention issues to face, including the phenomenon of bareback sex ("riding raw"), the question of how viral levels impact a person's infectiousness and a growing resentment by the post-'70s generation, which is sick and tired of hearing about the libertine glory days of almost-unreal sexual excess and now want to taste some of it themselves.
If the past year was marked by extraordinary treatment news, let's work to make the next remembered for extraordinary prevention news, starting with needle exchange, condom distribution in prisons and schools, development of vaginal and anal microbicides, well-funded community-created prevention programs and research on the relative risks of HIV transmission.