Governing a World with HIV and Aids

The pandemic is not out of the danger zone, but apocalyptic predictions about the collapse of armies, state crises, and a vicious interaction between HIV/AIDS and violent conflict — especially in Africa — have not come to pass. Careful analysis gives far less cause for pessimism than many imagined would be possible even half a decade ago.

AIDS patient Elimas Mokola at home, Lusaka, March 2007.<br>Antonin Kratochvil/VII/Corbis

In a debate on why Africa’s HIV/AIDS epidemic had not (yet) led to political crisis, Peter Baldwin (University of California, Los Angeles,) pointedly asked, “Why would one expect it to do so in the first place?” His specific point was that illness “has never been the source of political action.” His wider point was that the HIV/AIDS pandemic is being successfully managed, so it does not pose a political threat. It was a rebuttal to alarming predictions that the HIV/AIDS pandemic spelled political crisis for weak states. A seminal report in 2000 by the U.S. National Intelligence Council (NIC) concluded that “the persistent infectious disease burden is likely to aggravate and in some cases, may even provoke economic decay, social fragmentation and political destabilization of the hardest hit countries in the developing world.”

The history of the last decade has resolved the debate between those who predicted the collapse of armies, state crises, and a vicious interaction between HIV/AIDS and violent conflict, especially in Africa. These calamities did not come to pass. In retrospect, the predictions appear to be an example of a misplaced apocalyptic prediction that projected existing trends in Africa into the future in an uncritical manner, and underestimated the resilience of African societies and states. However, this conclusion obscures the ways in which militaries, conflicts, and governance have actually influenced the course of HIV/AIDS epidemics, and vice versa.

Forecasting Doom

Epidemic disease has rarely been the cause of endogenous political crisis. Indeed if we examine the political histories of Europe in the fourteenth century, the demographic cataclysm of the Black Death warrants only passing mention. We can trace the indirect consequences of syphilis and cholera on European armies and trade, but neither led directly to revolution or the collapse of regimes. The great influenza pandemic of 1919 passed off with minimal political impact.

On the other hand, disease and hunger have been handmaidens to state collapse in the face of an aggressor. When the European conquistadores introduced new infections to immunologically naïve Native American populations, the epidemics that followed left the great pre-Columbian empires weak and vulnerable. The sequence of famines, epizootics, and epidemics that devastated much of China, India, and northeastern Africa in the 1880s was also a prelude to imperial conquest. Disease has also been a challenge to sustaining and deploying armed forces, with armies historically losing several men to infection for every one killed or wounded in combat. Emperor Napoleon Bonaparte’s stomach ailment that kept him away from personally commanding the French army at the Battle of Waterloo may have determined the result. Insofar as illness has altered the course of military history, it has also determined the fate of nations.

The collapse of the Soviet Union sparked a flurry of interest in the links between health crisis and state crisis. In the late 1970s, the rising infant mortality rate in the USSR sparked debate in America over whether this was real or an artifact of poor statistics. Some scholars argued that the rise was not only real but was an important signal marking the bankruptcy of the Soviet system. In contrast to silence from the Central Intelligence Agency, demographers and public health specialists saw a crisis coming. Policy interest in health and life expectancy indicators was reinforced when the U.S. State Failure Task Force (SFTF) found that the best model for predicting state failure used three variables: openness to trade (lack of), democracy (lack of), and infant mortality. The infant mortality factor was taken as a “broad measure of living standards and quality of life,” but it is nonetheless striking that among seventy-five potential proxies for well-being that were tested, this was one of the three that stood out.

The SFTF sprang from the mainstream of American political science in its quantitative methods and liberal-democratic values. The four kinds of state failure of concern to the SFTF were revolutionary wars, ethnic wars, mass killings (genocides or politicides), and adverse or disruptive regime changes (involving extended periods of disorder and excluding ‘routine’ coups d’etat or orderly government changes). A different political science tradition would have resisted placing episodes of revolutionary transformation in the same category with genocide, ethnic war, and anarchy. Moreover, the indicators used for defining state collapse, and subsequently state fragility, are all at a high level of aggregation, measuring only limited dimensions of state crisis.

More significant than the incipient collapse of weak states, was the impact of the prediction itself on the policies of major powers, and especially the U.S. The HIV/AIDS pandemic had already badly shaken the confidence of Western governments and health establishments, which assumed that epidemics of fatal infectious diseases had been consigned to history. Laurie Garrett’s The Coming Plague (1994) popularized these fears. This built upon a deepening disorientation in Washington, D.C., about what new security threats might be looming. In February 1994, Robert Kaplan’s article “The Coming Anarchy,” subtitled “How scarcity, crime, overpopulation, tribalism, and disease are rapidly destroying the social fabric of our planet,” reportedly so disturbed President Bill Clinton that he ordered it to be faxed to every American embassy around the world.

Two years later, as part of a broadening in the focus of national intelligence to cover topics such as humanitarian emergencies and the environmental crises as well as assessments of missile threats and the military capabilities of China, Clinton requested that the NIC focus on the threats posed by emerging and resurgent infectious diseases. In January 2000, the NIC reported on the subject and, in the same month, the historic UN Security Council debate on HIV/AIDS was held at the initiative of the United States.

The NIC report contributed to a minor avalanche of publications on how disease in general and HIV/AIDS in particular might undermine militaries, states, democracies, and international peace and security. These publications shared two main features. First, little empirical evidence was presented, but rather deductions were made from anecdote and selective historical comparison. Second, they tended to make worst-case assumptions, arguing from ‘may happen’ to ‘will happen,’ and rarely examined how factors might act in the opposite direction. The unfolding of the food crisis in southern Africa in 2002–03, unexpected during peacetime, also led to the fear that HIV/AIDS would contribute to ‘new variant famine.’ The NIC itself then upped its predictions of disaster, forecasting a ‘second wave’ of HIV/AIDS in Russia, India, and China, which would surpass in numbers (though not prevalence rates) the generalized epidemics in Africa.

Very little social science literature was concerned with resilience or lack of impact. A rare example is the demographer John C. Caldwell who in 1997 noted that in hard-hit countries, “Life goes on in a surprisingly normal way. There has not even been any very marked change in sexual behaviour, and society is not dominated by government demands that there should be. There is no paranoia and little in the way of new religious or death cults. In some ways it is very impressive.” A more influential contrary view came from some economic analyses that indicated modest impacts or even an increase in per capita GDP as the epidemic reduced unemployment.

As this debate gathered momentum, the center of gravity of U.S. foreign policy abruptly switched to the ‘Global War on Terror.’ Concern with HIV/AIDS and state crisis was folded into this. Three weeks after the September 11 attack Tony Blair, the British prime minister, spoke at the Labour Party conference, linking social crisis to state failure to terrorism: “We are realizing how fragile are our frontiers in the face of the world’s new challenges.” One principle of the war on terror was that no territory should be left ungoverned and hence prey to terrorist takeover or hideout, while the ‘one percent doctrine’ required the U.S. to deal with even the smallest contributory factors to the risks of terrorism. The logic was that U.S. security entailed confronting HIV/AIDS.

The responses of the countries considered at risk of HIV/AIDS-related crisis were diverse. Africans tended to see the epidemic as one misfortune and stress among many, not as a grave political threat. This is illustrated by the relatively low priority given to HIV/AIDS in public responses to opinion surveys. Some governments simply denied the problem for as long as they could. Others’ efforts were focused principally on designing programs that could attract international funding and policies that would win them international credit. President Yoweri Museveni in Uganda, following his early domestically-initiated HIV/AIDS efforts, became adept at using HIV/AIDS to polish his image abroad. A number of militaries, including South Africa’s, took prompt and vigorous steps. Botswana’s President Festus Mogae was the most alarmist, repeatedly saying that his country’s very existence was at stake.

Fears over the implications of the epidemic impelled the UN Economic Commission for Africa to set up the Commission on HIV/AIDS and Governance in Africa (CHGA) in 2003. Over the course of its work, it stepped back toward a measured assessment of the impacts and risks, concluding “that African governments and societies could surmount the challenges of governance and development posed by HIV and AIDS.” This writer also concluded that HIV/AIDS was not causing political crisis in Africa, and critiqued (among others) his own earlier writings as having been unduly pessimistic.

Two of the biggest countries of concern in the ‘second wave’ of HIV/AIDS were Russia and China. In due course, each came to see the epidemic as a threat, in its own distinct way. The Russian government is concerned about the declining health of its adult male population, including both the population from which it recruits its soldiers and those soldiers themselves. On this basis, President Vladimir Putin announced in April 2006 that HIV/AIDS was a national security issue, and he would increase HIV/AIDS spending twentyfold.

China, concerned with its standing in the world, sees HIV/AIDS as prominent among infectious diseases that pose a threat to its national image, and consequently a national security issue. China’s belated response to the 2003 SARS epidemic was heavily criticized at home and abroad, while quarantine measures hit the country’s exports. Less tangible but perhaps more serious was the Chinese leadership’s fear that their country would be seen as a global source of disease. Taking a long view, the leadership resolved that secrecy was not an option, and that the effective management of the HIV/AIDS epidemic, including measures such as harm reduction for injecting drug users, was in its national interest. China has acted accordingly.

In 2008, the U.S. NIC revised its assessment of the security implications of infectious diseases. Gone were the predictions of social crisis and state collapse in Africa and the predictions that hyperendemic HIV would become common in Asian populations. Rather, the focus shifted to a wider spectrum of diseases, including chronic diseases and accidents, and their economic impacts. For example, the report notes that poor health is costing Russia an estimated 1 percent of GDP annually—and this may rise to as much as 5 percent by 2020—and conversely notes that reduction in disease burden contributes to economic growth. The governance impacts of health, it suggests, are “less pervasive,” and it cites examples of how mishandling of health issues can undermine a government’s credibility, such as Thabo Mbeki’s stand on AIDS and China’s dithering over SARS. It also refers to contrary cases, in which organizations such as Hezbollah in Lebanon or Hamas in Palestine have provided basic health care, enabling them to building a political base. In terms of military readiness, the report points to the poor health status of army conscripts in Russia and North Korea, but also revisits the NIC’s earlier fears about how HIV/AIDS would undermine military capabilities in sub-Saharan Africa, suggesting both that the risks had been overstated and the responses effective.

Perhaps most significantly, the 2008 NIC report concludes with a section entitled “Health as Opportunity: A new look at a successful paradigm.” Global health, it suggests, is a fruitful field for diplomacy, including effective engagement with rising powers, reconstruction and stabilization, smoothing relations with adversaries, easing north–south tensions, and advancing economic development. The earlier pessimism had given way to optimism that efforts such as the President’s Emergency Plan for AIDS Relief (PEPFAR) could become one of the U.S.’s major sources of global influence.

Even though the HIV/AIDS pandemic, including its broader impacts, may not have materialized as feared, HIV/AIDS has had global social and governance consequences. Among them is PEPFAR itself, which surely would not have been established and placed under the authority of the Department of State, were it not for the fears outlined above.

The essential background to this reassessment is the downward revision of estimates for the global numbers of people living with HIV. New HIV infections, having accelerated at a faster rate than anyone expected in the 1980s and 1990s, had crested and begun to fall (slightly) earlier than had been anticipated. Models for global HIV incidence indicate a peak in new infections in the early 2000s. This downward revision had several components. The most important was that the concentrated epidemics in Asia and eastern Europe were not developing into generalized epidemics, so that even the lower-end estimates made by the NIC in 2002 were proving overstated. In Africa, only South Africa and some of its immediate neighbors were sustaining hyperendemic HIV, and most countries were registering declining HIV rates.

Armies, Law Enforcement, and HIV/AIDS

The issue of HIV prevalence in armies has been the subject of a number of ‘factoids’—claims that are so regularly cited that their original provenance becomes obscure and their slender empirical basis becomes overlooked. Prominent among these is the claim that HIV rates among soldiers are typically two to five times higher than among civilians, and that this ratio can be many times higher still during conflict, a claim repeated in at least ten publications.

In fact, data indicate that this is rarely the case. One reason for this is that infantry armies commonly recruit from a population category with low HIV, namely young rural men. The biggest study of HIV prevalence among recruits was conducted using HIV screening data from the Ethiopian army, which showed low HIV levels. Comparable data were collected in Swaziland. However, HIV prevalence among soldiers increases with time in service and appears to do so more rapidly than among civilian peers .

Sub-Saharan armies moved promptly to respond to the threat posed by higher than normal rates of incapacity and death. Armies are designed with an element of redundancy built in, especially at lower ranks, so they can withstand attrition during war. They are also ready to implement command measures that violate individual human rights, in this case mandatory testing and exclusion of those found to be HIV positive from enlistment, promotion, specialist training, or deployment—all measures that reduce HIV prevalence among the ranks, albeit by displacing the problem elsewhere. Because they are incompatible with human rights standards and contradict national (civilian) HIV policies, many militaries have kept quiet about these practices. Court cases in Namibia and South Africa, both of which found military discrimination on the basis of HIV status to be unlawful, have exposed this gap. It presents military commanders with a dilemma, as their own medical analysis and interpretation of command responsibility often determines that they practice such discriminatory policies.

This poses a particular dilemma for UN peacekeeping operations, which are highly visible and expected to conform to international norms, but are also wholly dependent on the readiness of troop-contributing countries to provide the forces, often in short order. The UN’s HIV testing policy for uniformed peacekeepers is that the sole medical criterion for deployment and retention is ‘fitness for duty,’ based on clinical criteria rather than HIV sero-status. While holding up the standard of exclusively voluntary confidential counseling and testing, the UN also recognizes that many countries, including most of its major troop-contributors, have a mandatory HIV testing policy and do not deploy HIV-positive personnel; and the UN respects these national policies.

The story for police services is similar. Senior police officers also felt stigmatized by casual allegations of high levels of HIV in their ranks, an especially problematic claim because of the day-to-day interaction between police officers and the general public. This led to even greater opacity than among armies, and more obstacles to researchers. As a result, even limited data are not available, and the issue of HIV/AIDS within law enforcement services remains neglected.

An emerging agenda concerns how law enforcement influences the trajectory of the epidemic itself. This is the most compelling, if little studied, example of how governance can determine HIV/AIDS. In many countries in the world, HIV transmission is concentrated among groups which are criminalized or stigmatized, or is associated with practices that infringe the law. Examples include injecting drug users (IDUs), sex workers and their clients, gay men and individuals with variant sexual identities, and illegal immigrants. Those most vulnerable to HIV may be offenders, victims, or the socially excluded. Examples include survivors of rape and other forms of sexual and gender-based violence and exploitation, trafficked women, and street children. In one way or another, the principal point of contact with the authorities for most of these people is the police officer. It follows that law enforcement and policing practices can be a major influence on the course of the epidemic, either for good or ill.

Challenges for the police occur in situations in which the law and widely held social norms come into conflict with public health principles and human rights. The most acute examples concern harm reduction technologies and methods such as methadone substitution and needle exchange for IDUs. These are prohibited in many countries yet are an HIV prevention intervention of proven efficacy. In the best cases the individual police officer has much discretion. In some countries, police officers turn a blind eye to their obligations under the law, knowing that it would be counterproductive and wasteful to try to enforce prohibitions. They prefer their discreet tolerance of harm reduction to go unnoticed in the public realm, because they fear that populist politicians would demand zero tolerance of prohibited activities. In other instances, such as China, the authorities recognized the efficacy of harm reduction measures and implemented them rapidly at scale, with measurable success. Increasingly, international HIV/AIDS policymakers are taking seriously the challenge that HIV transmission through IDUs can be prevented entirely, and that this requires the universal adoption of harm reduction technologies and practices, which in turn demands the worldwide decriminalization of drug use.

Policing practices concerning sex workers provide another example. In some countries, possession of a condom is taken as evidence of participation in illegal sex work, complicating HIV prevention efforts. In other countries, the police themselves regulate commercial sex work, including the sexual exploitation of underage girls and trafficked women, operating simultaneously on both sides of the law. This poses acute dilemmas for HIV/AIDS advocates and policymakers, who want instinctively to respond both to the abuse of women and girls and to the threat of HIV—priorities that might not always be fully aligned.

HIV/AIDS During Traumatic Social Transitions

The assertion that armed conflict contributes to inflating HIV levels was a standard assumption at the turn of the millennium. This derived in part from circumstantial evidence suggesting that the movement of Tanzanian military brigades through Uganda in 1979 had contributed to the first unfolding of the epidemic in east Africa, and military bases in Namibia and South Africa had been local epicenters for HIV. A meeting of experts convened by the U.S. Institute of Peace in 2001 reached a consensus that “Although some might question the significance of AIDS as a contributor to conflict, no one denies the role of conflict in the spread of the virus.”

This claim has since been convincingly challenged, using data that show that refugees do not have elevated HIV rates in comparison to host communities, and that conflict is often accompanied by a suppression of HIV rates. The common ground among the various studies is that the implications of conflict and displacement for the epidemiology of HIV vary greatly according to circumstances, and the effects are not as dramatic as was earlier anticipated. Increasingly, scholarly and policy attention focuses on the post-conflict period, as one in which HIV risks may increase because of population mobility and mixing, while HIV/AIDS services may be neglected in favor of other priorities.

The shift in focus from war as such, to the specific forms of social disruption and change associated with war, or with the transition from war to peace, provides a more productive line of inquiry. At a macro level, Nathan Paxton of Harvard University has examined the impacts of transition on HIV. He used a dataset that included 162 countries over the period 1990–2006. He found that rapid economic growth had no significant impact on HIV prevalence, but that major political transitions from authoritarianism to democracy were associated with an increase of about 0.9 percent. Paxton found that interstate war had no statistically significant effect on HIV prevalence, but that internal war was associated with a suppression of HIV prevalence by about 1.7 percent. (Note that this does not mean that war pushes HIV prevalence down but rather that rates would have been higher were the country not at war).

The social implications of conflict do not end with a peace agreement. The processes of disarmament and demobilization of former combatants, the return of refugees and displaced people, the opening up of areas that were isolated during conflict, and the winding down of humanitarian assistance are all disruptions in their own ways. There are numerous historical examples in which demobilizing soldiers contribute to different forms of violence. Post-conflict periods can witness dispossession of villagers’ land as well-connected entrepreneurs move in, and the sudden creation of boom towns associated with new economic opportunities, government centers, and aid efforts. In addition, the psychological effects of conflict and trauma, among combatants and civilians alike, can endure long into the post-conflict period. All these can reconfigure vulnerabilities to HIV.

One conclusion from these studies is that researchers and policymakers have been asking the wrong questions and looking in the wrong place. Casting the analysis at the level of ‘conflict’ as such misses the significance of the different kinds of conflict, the groups involved, and the varied forms of interaction among them. Aggregation to the level of an entire conflict-affected population is less useful than looking at specific groups, times, and places. The concept of a ‘crisis’ or ‘emergency’ may be useful for marshaling an immediate humanitarian response, but it does not help shape an appropriate analysis for HIV/AIDS or a response to the epidemic.

HIV/AIDS and State Crisis

One of the most compelling claims in the January 2000 NIC report was that the HIV/AIDS epidemic threatened state crisis and collapse. It has not happened. Moreover, Tony Barnett of the London School of Economics and Political Science argues that, based on analysis across large datasets, the lack of any relationship between HIV/AIDS and state failure is sufficiently robust to allow for a strong conclusion to be drawn—that it is not going to happen.

There is a limiting case: Swaziland, a very small country, economically dependent with weak governance, which is facing hyperendemic HIV. Swaziland has been described as a long-wave social crisis, in which daily mortality rates now exceed the levels conventionally used by humanitarian agencies as their thresholds for identifying an emergency. Swazi citizens face a chronic reduction in living standards. Barnett points out, however, that a very small nation such as this cannot be taken as a model for larger states. His review includes studies of Manipur and Nagaland, northeast India and the Papua region of Indonesia, both of which have the highest HIV rates in their countries, and a comparative study of the South Pacific. There is no possibility that localized HIV/AIDS crises in parts of India or Indonesia could destabilize the states in question or threaten their overall prosperity, and despite a debate in Australia about possible ‘Africanization’ of the South Pacific epidemic, any similarities are superficial, and the prospects for these countries of resembling Swaziland are remote.

Barnett also modifies his conclusion with respect to local government. Until very recently, the political impacts of HIV/AIDS had been studied only at national level, and there was very little interest in what it might mean for local institutions and their performance and accountability. The largest study of this type to date is a study of twelve municipalities in South Africa. It finds measurable adverse impacts of the epidemic on various aspects of local government. It found a consistent pattern of elevated death rates among councilors aged between twenty-nine and forty-two, raising the prospect of some communities lacking any elected councilors and therefore being unrepresented. Strains are intensified by increased AIDS-related absenteeism and lower productivity among staff. Researchers Kondwani Chirambo and Justin Steyn noted high level of stigma around AIDS among councilors and found only one councilor openly living with HIV, from among a sample of 3,895.

It is notable that HIV/AIDS has not become a major political issue that determines the outcome of elections, even in South Africa which has had the combination of hyperendemic HIV, a president who denies the link between HIV and AIDS, and a powerful activist movement. Public opinion surveys indicate that HIV/AIDS is rarely a priority for electorates. In line with the observations by the late sociologist Carolyn Baylies and by Peter Baldwin, it appears that AIDS is regarded as a personal misfortune rather than being the occasion for political outcry. There is a striking contrast with the way in which food crisis is commonly the focus of political mobilization, and the relative political apathy over HIV/AIDS.

Although HIV/AIDS has not become an issue in adversarial politics, it has become an important element of governance in many sub-Saharan countries, especially with a proliferation of civil society organizations. This is primarily because of the innovation of the international HIV/AIDS leadership in promoting a human-rights based approach. This approach has its origins in the early leadership of the AIDS movement among gay men in America, many of them gay rights activists, and the human rights framework for health pioneered by the late Jonathan Mann at the World Health Organization. Not only has this led to an emphasis on the individual’s right to privacy and the strictly voluntary nature of HIV testing, but it has also contributed to the high-level participation of civil society organizations and representatives of people living with HIV and AIDS in international organizations including UNAIDS and the Global Fund to fight HIV/AIDS, TB, and Malaria. The HIV/AIDS pandemic has marked a new era for the governance of international public health, characterized by epidemiological individualism and pressures on African governments to conform to a liberal civil society-based framework for disease management.

In modern history, the measures implemented to control infectious diseases have often had a greater governance impact than those diseases themselves. To give just one example, European colonial powers’ efforts to prevent the spread of cholera and other communicable diseases along trade routes, including the sanitary management of the Muslim Hajj, were instrumental in imperial penetration of the Middle East. We can see a similar pattern in the case of HIV/AIDS, from the health diplomacy of the U.S. to the ways in which national governments, from Africa to China, have adjusted their governance strategies in response to the unique place occupied by the pandemic in global perception and aid institutions.

Peter Piot, former Executive Director of UNAIDS, arguing in support of an ‘exceptional’ strategy for HIV/AIDS policy and programming, has noted that the international response has been an important factor preventing stigma and discrimination. It has also contributed to the consolidation of liberal governance in aid-dependent countries in Africa. The 2008 NIC report, with its stress on the strategic benefits of ‘medical diplomacy’ for the U.S., sees this as one of the major, if unanticipated, outcomes of the pandemic. In looking at possible frameworks for its institutional response to the challenge of managing climate change, the UN has debated the merits of the ‘UNAIDS model’ as a model for how to engage a wide range of non-governmental stakeholders, in such a way that the technical policy demands of a response are made compatible with democratic values and human rights. The rise of public health diplomacy and participatory governance for global public goods may be one of the most significant impacts of the HIV/AIDS pandemic. The public health arguments in favor of promoting harm reduction technologies are now beyond dispute, and it is possible that the next historic contribution of HIV/AIDS to global governance will be in the field of decriminalizing drug use.

The Long Wave of HIV/AIDS

The analysis above gives far less cause for pessimism than many imagined would be possible even half a decade ago. This is far short of claiming that the pandemic is out of the danger zone or that the instruments are at hand for overcoming it. At the Toronto conference of the International AIDS Society in 2006, Piot insisted that “tragically, the end of AIDS is nowhere in sight.” He felt obliged to make this statement because of the optimism implicit in some of the conference speeches, to the effect that the combination of pharmaceutical technology and huge increases in funds meant that twenty-five years after the human immunodeficiency virus was first isolated, the world had turned the corner on the HIV/AIDS pandemic. Shortly afterward, Piot initiated the aids2031 project, intended to look ahead another quarter century to anticipate how the pandemic might unfold over this period, and what might be done to ensure that international commitment to tackling HIV/AIDS remained undiminished.

The combination of the scaling back of UNAIDS’s estimates for global HIV infections, evidence for prevalence plateauing or declining in Africa, and the huge increases in resources available for HIV/AIDS since 2002, might make it appear that optimism should be the order of the day. However, Piot’s caution is precisely in order. The demographer Roy Anderson has modeled it as an event lasting 130 years. Some of the most prominent scholars of HIV/AIDS insist the pandemic is a ‘long wave event.’ While HIV/AIDS may not be leading to dramatic crises, long-wave suppression of life chances and development prospects is probable in hyperendemic countries.

The setbacks in the search for a vaccine are a salutary reminder that there may not be a ‘cure’ for AIDS in the foreseeable future. While the ‘second wave’ fears have not materialized, dangers such as extremely drug-resistant strains of HIV, or secondary epidemics associated with the TB pandemic or the worldwide increase in injecting drug use, mean that constant epidemiological and virological vigilance will be required for the indefinite future.

In conclusion, the HIV/AIDS pandemic can no longer be considered an extraneous factor in social functioning or governance. The impacts of the epidemic have been absorbed into social and political systems, while the national and international institutions and initiatives set up in response to the disease have themselves become an integral part of governance. However, vital issues remain unresolved—for example, whether militaries can legitimately practice mandatory testing and selective exclusion of the HIV positive, and whether it will be possible to make harm reduction the guiding principle for law enforcement services toward injecting drug use. While the feared relationships between HIV/AIDS and conflict and state fragility have not transpired, in both cases the epidemic compels reconsideration, not only of specific policies, but of the basic frameworks on which policy is made.

This essay was originally published in The Socioeconomic Dimensions of HIV/AIDS in Africa, edited by David E. Sahn and published by Cornell University Press. The Cairo Review expresses gratitude to Mr. de Waal, Mr. Sahn and the Cornell University Press for allowing the essay to be included in the Cairo Review.

Anderson, Roy. 2003. Keynote Address. Report of the Scientific Meeting on the Empirical Evidence for the Demographic and Socio-Economic Impact of AIDS, Durban, 26–28 March.

Baldwin, Peter. 2007. Comment on AIDS and Power.>

Barnett, Tony. 2009. Synthesis Paper: HIV/AIDS and State Fragility. ASCI, Synthesis Paper.…papers/ASCI%20Synthesis%20Paper%20State%20Fragility

Baylies, Carolyn. 2002. The Impact of AIDS on Rural Households in Africa: A Shock Like Any Other? Development and Change 33: 611–32.

Caldwell, John C. 1997. The Impact of the African AIDS Epidemic. Health Transition Review 7 Suppl. 2: 169–8.

Chirambo, Kondwani, and Justin Steyn. 2008. AIDS and State Fragility: The Challenge of Increased Deaths among Local Councillors in South Africa. ASCI Working Paper no. 25.

Commission on HIV/AIDS and Governance in Africa, Securing our Future, the Report of the Commission on HIV/AIDS and Governance in Africa, Addis Ababa, UNECA, June 2008.

de Waal, Alex. AIDS and Power: Why There is No Political Crisis—Yet, London, Zed Books, 2006.

AIDS, Security and Conflict Initiative, AIDS, Security and Conflict: New Realities, New Responses, New York, SSRC, September 2009.

Garrett, Laurie. 1994. The Coming Plague: Newly-Emerging Diseases in a World Out of Balance. New York: Farrar, Straus and Giroux.

Kaplan, Robert. 1994. The Coming Anarchy. Atlantic Monthly 273(2): 44–77.

Paxton, Nathan. 2009. Rapid Politico-Economic Transitions and HIV/AIDS: An exploratory analysis. New York: aids2031, New York.

Piot, Peter. 2008. AIDS Exceptionalism Revisited. Lecture at the London School of Economics, 15 May.

Alex de Waal is a program director of the Social Science Research Council, an advisor to the African Union Peace and Security Department, a senior fellow of the Harvard Humanitarian Initiative, and a director of Justice Africa in London. His academic research has focused on issues of famine, conflict, and human rights in Africa. He has served as adviser to the African Union mediation team for the Darfur peace talks (2005–06) and the African Union High-Level Panel on Darfur (2009) and Sudan (2009–2010). He was awarded an OBE in the British New Year’s Honours List of 2009, was on the Prospect/Foreign Policy list of one hundred public intellectuals in 2008, and the Atlantic Monthly list of twenty-seven ‘brave thinkers’ in 2009.