Ambitious treatment efforts and smart prevention programs are, of course, not inherently at odds. But especially in an era of fiscal constraint, these two goals could come into conflict. The result, wasteful in dollars spent and lives diminished, would represent only the latest misjudgment by powerful donor nations such as the United States, which still struggle to understand the root causes of an epidemic that has spread most widely in weaker, poorer nations.
In Africa, the most important cause of the epidemic is sexual cultures in which it’s not unusual for people to have more than one partner in the same week or month. Sound strategies for stemming the spread of HIV would pay particular attention to those places where Africans themselves — in nations such as Uganda and Zimbabwe— have reversed the epidemic and saved millions of lives by changing sexual behavior.
Failing to address this is a bit like targeting lung cancer mainly through more chemotherapy, while doing little to curb high smoking rates.
HIV was born in a remote central African forest near the beginning of 20th century, amid the disastrous intrusions of Western colonialism. Broad social changes — the rise of cities, the undermining of traditional values, the creation of modern transport routes — helped spread a host of sexually transmitted diseases. No one knew it at the time, but HIV was among them.
The growth of sex work is often cited as the key element of the epidemic. But even more consequential was a shift away from traditional polygamy — common across much of Africa but scorned by Christian missionaries — toward more informal relationships. In these, men often had one wife but maintained secretive and less permanent relationships with other women. And with their husbands often spending months at a time working at far-off mines, plantations or factories, wives increasingly took sex partners outside of marriage.
The changing sexual mores alarmed colonial officials, who worried about the future of the workforce as birth rates plunged from the ravages of syphilis and chlamydia. In the Belgian Congo, a levy was imposed on all single women to encourage monogamous, Christian-style marriages. Instead, a new, freewheeling sexual culture took hold, one efficient at spreading disease.