Tackling the new AIDS denialism

In 2008, a 25-year old Finnish man called Aki Hakkarainen was sentenced to ten years in prison on five counts of aggravated assault. He was required to pay damages of R500,000 to each of his victims. His crime was having passed on the HI virus through unprotected sex, without disclosing his status.

It was not the first case of criminal HIV infection in Finland. The first such case dates back 15 years, to 1997, when Steven Thomas was convicted in Helsinki of 17 counts of attempted manslaughter for infecting women with HIV. He was sentenced to 14 years in prison.

Both cases followed the same trajectory: a woman complained to the police about having become HIV-positive through unprotected sex with a man who did not disclose his status. The police tracked down the suspect, established that he knew he was HIV-positive, and published his photograph in the media in order to locate anyone else who might also have had unprotected sex with him. Other women then came forward and gave the evidence that secured the convictions.

A similar case is currently unfolding in Canada, after Edmonton police arrested a 17-year-old girl on charges of aggravated assault after she had sex with two men without disclosing her status. The police issued a public safety warning, and released the girl's name, photograph and personal details. This led to a third complainant coming forward. The girl's case is currently before the courts.

These cases are by no means unique. In fact, almost half the countries that have signed the European Convention of Human Rights have prosecuted and convicted people for having unprotected sex, knowing they were HIV-positive, without disclosing their status. There are similar examples as far afield as New Zealand, Australia and the United States (where a person can also be prosecuted for donating infected blood). 

These accounts sound shocking in the South African context, where we have a different response to the AIDS pandemic. We tend instinctively to feel that the rights of the accused in the above examples were grossly violated. What about their privacy? How could their photos have been published in the papers? What about the stigma? Wouldn't that discourage others from being tested? Wouldn't it merely drive the pandemic underground, making it more difficult to beat? How could society have so grossly failed a 17-year-old girl?

These are valid questions, but they are not the only ones.

We must also ask ourselves the harder questions that arise from the "List of countries by HIV/AIDS adult prevalence rate" published on-line by Wikipedia. Why does South Africa have the largest HIV-positive population in the world? Why have most other countries, including extremely poor ones, succeeded in containing or beating this disease?

In her brilliant book The Invisible Cure on the HIV pandemic in Southern Africa, Dr Helen Epstein provides the meticulously researched, scientific answer: The root cause of our AIDS crisis is the entrenched culture of multiple concurrent sexual partners, aggravated by inter-generational sex. She describes this as the "Aids Superhighway". And, she concludes, the only countries in Africa that have turned the AIDS pandemic around, are those that have focused on partner reduction. Of particular interest is Uganda's "zero grazing", the name given to the policy to promote sexual fidelity.

Says Epstein: "If the network of concurrent relationships serves as a superhighway for HIV, partner reduction would be like a sledgehammer, breaking up the highway into smaller networks and destroying the "on ramps" - the casual relationships that let HIV onto the superhighway in the first place. In theory, condoms could have created "road blocks" on the superhighway, if only people used them consistently. But most condom use in Africa is inconsistent, especially in the longer-term relationships in which so much HIV transmission takes place."

Epstein notes that the HIV rate in Zimbabwe and Kenya began to decline in the late 1990s. "Rates of condom use had been increasing throughout the decade, but it was not until rates of multiple partnerships began to decline that the HIV rate in these countries also fell." During the same period, "in such countries as Botswana, South Africa and Lesotho, where no partner reduction occurred and where condoms were emphasized as the main method of prevention, HIV rates rose. In all three countries, condoms were used more frequently than in Uganda, where the HIV rate was falling."

In South Africa we remain in deep denial about the core problem. We have focused on condom distribution and free treatment, because these interventions shift the responsibility away from the individual, onto the state. Anyone who dares raise the issue of personal responsibility - the "Be Faithful" component of the ABC prevention trilogy - has been dismissed as a moralising prude at best, or an unconstitutional populist, at worst.

I should have seen it coming when I raised various "personal responsibility" proposals during a recent Health Summit in the Western Cape.

As usual, Twitter provided an interesting feedback channel. Some tweets were so disgusting, they are unprintable.

But here is a small sample of the rest.

Said @Lo_Dee: "U r white. We are groomed for polygamy. Go say that in bloody Europe."

And @Levinborn added this gem: "Outrageous! Hahaha you think u can police individual sexual activity?"

And @LegoTrip added: "Keep your laws off my penis!"

I think it is fair to assume that none of these Twits would hesitate to demand free anti-retrovirals if they were diagnosed HIV-positive. That is, if they ever bothered to get tested. These are the kind of people who reject the "nanny state" when it reminds them of their responsibilities, but demand that the "nanny state" address all their "rights". For free.

Of course, the last thing on their minds are the rights of others. Or the cost of their behaviour to society. I doubt whether these narcissists ever give a thought to the thousands of people with unpreventable conditions, who forego treatment because the state cannot afford everything. And when this obvious point is raised, it evokes angry indignation!

It is this attitude that results in the international AIDS statistics in Wikipedia's comparative table. It is this attitude that puts so many women and men at risk. It is this attitude that costs South Africa billions of Rands each year. And it is this attitude that must change.

The question is: How?

What we have done up to now certainly isn't working. The extent to which we have brought AIDS under control is through free access to medication, not behaviour change.

When I ask myself why other rights-based countries have beaten or limited the AIDS pandemic, I come to the following conclusion: they are managing to remove the stigma against people living with HIV, while stigmatising the behaviour that spreads HIV. This distinction is important.

People living with HIV must be able to lead full, stigma-free lives, and get the treatment they need to do so. At the same time it is fair to require everyone to know their status, and to avoid situations that involve the direct exchange of bodily fluids with others. This applies to bleeding wounds, blood donation and sex.

While this precaution applies to everyone, people who are HIV-positive have a particular duty to disclose their status in situations where others could be at risk. No-one can be assumed to have had consensual sex in a situation of non-disclosure.

Does society have the right to prescribe this? Most rights-based democracies seem to think so.

We must begin by challenging the pre-modern notion that unprotected sex with multiple, inter-generational concurrent sexual partners is a cultural right. It is not. In a modern urban context, it wreaks social devastation. It drives the teenage pregnancy rate, entrenches poverty, spreads disease, destroys families, produces unwanted and neglected children. It is one of the reasons that good parenting is a rarity. It is a key reason why our health system is so overburdened. It must stop. It is not merely a moral issue. It is a developmental issue. And we shouldn't pussy-foot around the subject.

It is not surprising that the only Cabinet Minister who has raised this matter (very tentatively) so far is Trevor Manuel, Minister in the Presidency responsible for long-term planning. He understands that this is a core development issue; that if we do not change this behaviour we cannot meet our national development goals. He broached this subject when he told a Parliamentary Committee meeting this week: "We must focus attention on people taking responsibility for their actions, and I don't want to pontificate, but this is especially so in the area of their sexual conduct."

Well, frankly, it is time to pontificate a whole lot more.

Lest there is any misunderstanding, I have said it before and I will say it again: the Democratic Alliance will continue, where we govern, to provide the most advanced, free treatment to everyone who tests positive for HIV/AIDS (yes, even the Twits quoted above.)

But I also believe it is fair to require everyone to take a regular HIV test (free) and accept responsibility for preventing risk to others. If they do so, they are entitled to live a stigma-free life as valued contributors and role-models in our society. If they don't, they must be prepared to face criminal charges. 

When we move out of denial and get this distinction right, we will beat HIV/AIDS in South Africa.

This article by Helen Zille first appeared in SA Today, the weekly online newsletter by the leader of the Democratic Alliance.

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