Thirty years ago the emergence of HIV/Aids among the homosexual population of San Francisco came as a devastating blow to an already stigmatised segment of the population. As an educated group of people wishing to protect themselves and their privacy from public knowledge of an infection which was poorly understood and untreatable, they fought for a human rights approach to testing.
While some wanted to define the infection as a public health issue - like tuberculosis, polio and many other notifiable diseases - the human rights approach was deemed to be the most appropriate world-wide and indeed the best way to prevent double stigmatisation and to avoid driving the disease underground. It should not be disputed that much was gained through this approach.
Serious scientific and financial commitment to finding out more about the disease, both medically and socially, has been rewarded by the development of antiretroviral drugs (ARVs) that have turned HIV infection from a fatal disease into a chronic condition that can be successfully and affordably treated.
Extending the quality and duration of the life of individuals for many decades is of individual and public benefit. We now know that effective treatment makes an additional impact on public health by reducing viral loads and thus the potential to infect others.
Prevention of mother-to-child transmission has been another victory. In the wake of such advances, pre- and post-exposure prophylaxis are becoming effective, and soon there may be a highly effective microbicide gel (that could empower women to prevent infection) and even a vaccine.
Successes in extending treatment to 1.4 million of the six million HIV- positive persons who will need ARVs in South Africa, and the possibility of reducing infectivity by starting drug treatment earlier in the natural history of the infection, make it clear that while doing all possible to improve the lives and health of those who are positive, reducing the number of new infections among the over 40 million who are HIV negative in South Africa should also be a high public health priority.
Encouraging more people to be tested is based on the benefits of knowing that one is HIV positive - access to early treatment with ARVs and hence the opportunity for prolonged survival, reduction in the infective risk one poses to others, and the opportunity to work with others to reduce stigma and to facilitate the community solidarity required for so many aspects of dealing with this pandemic.
Several courses of action have the potential to increase the number of people tested. The first is to intensify educational and social activities to encourage more people to volunteer for testing and counselling.
Taking counselling and testing into schools poses additional challenges - logistically and in terms of how to deal with the results.
More imaginative approaches to increase testing, including various incentive mechanisms, could perhaps be more successful. Which ones work, and for how long, are as yet unknown. Research is needed to provide an evidence base for effective and acceptable action.
Attempts to reduce infection through influencing sexual relations have received a high profile. As sexual relations are among the most sensitive, complex and powerful of all human interactions and are permeated by power relations, great difficulty could be anticipated in achieving change.
Encouraging late sexual debut and discouragement of intergenerational sex are admirable goals, but not easy to achieve. Limiting sexual relations to a life-long single partner also has great potential for stemming the pandemic, but is unlikely to be sufficiently accepted.
Acknowledgment of multiple sexual partners as a "norm", and accepting the inevitability of sequential partners (already widespread) as less risky than having multiple partners simultaneously, has had some impact. …