We knew the facts way back in 1987, but instead of a safe-sex new world order, we got global disaster. Reported cases of AIDS in countries both rich and poor skyrocketed -- not doubled or tripled, but increased tenfold or more. Health care systems -- even in the most developed nations -- are taxed to the limit, and sympathy for people with HIV is in short supply. After a decade of promoting compassion, many governments have settled for simply scaring the hell out of their citizens and, when that fails, jailing them or leaving them to die. In India, for example, one town used the AIDS memorial quilt not as a rite of remembrance but as a safe-sex campaign: "Don't become part of the quilt," organizers warned. What's to be done?
Just as there will never be a magic bullet for HIV, so we will never have a single strategy for preventing its transmission. The solution isn't to throw up our hands in despair, but to dig in our heels and learn what we can from the decade since the World Health Organization, the Red Cross and activists first carried safe-sex projects out into the world. What scientists are observing about this wily new virus is mirrored in what prevention activists are discovering about the age-old domain of sex: It works differently in each person's body. We've learned that ideas that seem impossibly conservative in one culture appear radical and sexy in another. For example, campaigns to promote monogamy have generally been frowned upon or deemed homophobic in the U.S. Yet that was the message behind a provocative Indian campaign that featured Kamasutra-like illustrations with the slogan "Many positions with one are better than one position with many." History, not hormones, determines how desire and pleasure are experienced. Culture decides how variations in sexuality are molded to the requirements of safe sex.
A truth: Safe sex is all about the science of HIV transmission. Fair enough, if safe sex is defined narrowly as specific techniques that block the virus' passage from body to body. But beings are more than just bodies, and the attitudes and meanings that we attach to safe sex (and that influence why we start and stop practicing it) are at least as important as the science. Prejudices about our own and others' sexuality turn out to be just plain wrong.
Officials in the developing world often remark that Americans' interest in sex is a product of our consumer society and high standard of living. The poor in their own countries may have as much sex as anyone, but the effort to prevent STDs, it is said, seems insignificant to them in the daily grind of poverty -- sweatshop workers tend not to have time to make sex safe. A similar attitude has made safe sex education among the so-called hard-to-reach poor in the U.S. appear futile. This attitude is mistaken.
Vera Paiva does AIDS prevention among slum dwellers in São Paulo, Brazil. There, young men and women have no private spaces for sex, much less safe places to talk about sex. In constant danger of getting caught by families or police, the youths have refined the art of quick sex in cars or while leaning against lampposts. They know about HIV transmission, but they can't afford the condoms touted as their salvation. Are these young people less motivated to fight for condoms than for food, housing or higher wages? Not a chance. Paiva helped the youths organize for better health care, ongoing access to condoms and freedom from harassment for having sex. Far from seeing sex as a frivolous diversion from their dire economic conditions, these youths see it as central to their ghetto world. So safe sex is central to their quest for a better life.
But prevention programs have only rarely proved so unifying. In some U.S. cities, different approaches to safe sex have evolved into a virtual apartheid between negative and positive gay men. Contrary to prevailing advice, which generally advocated "a condom every time," positive and negative men began in the mid-'80s to part ways over the meaning of safe sex. This was an enormously consequential shift. Safe sex was increasingly experienced as a limit on sexual expression: If not punishment, then a serious compromise. With the HIV-antibody test readily available, both negative and positive men began to wonder whether it might be easier simply to have condomless sex with partners of like status. But their reasons for doing so already differed. For positive men, sticking to their own offered the hope of mutual understanding and group identity akin to coming out; for negative men, refusing sex with positive men was a way of avoiding both HIV and the now-odious discipline of safe sex.
With no consensus on how or when to disclose HIV status, same-status partnering wasn't workable. By the late '80s, gay men calculated their risk using a different set of beliefs. Some thought it was the positive man's responsibility to reveal his status, on the assumption that anyone who didn't was negative. Others thought that if a partner didn't demand a condom when he was being penetrated, he was indicating he was positive. In this way, gay men presumed they were following the advice to "know your partner." This emphasis on asking and telling created the illusion that sexual encounters were risky only when you didn't talk.
In the past year, gay and straight newspapers alike have spewed dozens of personal confessions by individuals who have had unsafe sex in bathhouses or with anonymous partners. Meantime, we go on ignoring the real stumbling block in current prevention programs, gay or straight. What is it? The warm, wonderful bond that many view as a source of well-being and some consider the only safe harbor in an epidemic of incurable STDs: The Couple. Why? Most everyone uses condoms with partners whom they consider casual; most everyone stops using condoms when they "fall in love."
Today, HIV testing is routine; safe sex is not. Instead, many gay men and a growing number of heterosexuals make sexual decisions based on nothing more than hunches about each other's status. So men and women are becoming infected in the very relationships they had hoped would keep them safe. But the psychological dynamic, especially for gay men, is different from in the early years, when no one could know who was infected. Instead of "Was it him?" and "Was it me?" gay men now think, "I should have known better" or "I shouldn't have trusted him." This is personally devastating. It is also tearing at the heart and soul of gay communities.
In 1978 the United Nations came to a landmark consensus that individual health could be achieved only at the community level, through primary prevention and education. The famous "health for all by the year 2000" statement presented a broad view of health but had little to say about sexuality. Compelling as the idea is, we can't "stop AIDS!" until there is "safe sex for all": Not just to save marriages in fact or form, but for everyone, regardless of the shape of their desires and pleasures.
As we approach the millennium that once held so much promise, we know we inhabit a world full of trouble. We know we have in common the need for a global response to AIDS -- for treatment and prevention. We also know our sexualities are extremely diverse, and so local approaches to safe sex must be flexible. Our shared bond is not the similarity of sexual drives but the amazing variety with which we express them. Our goal should not be producing a uniform kind of safe sex and punishing those who fail to abide by it, but rather understanding the infinite ways that sex can become safe for everyone by the year 2000.