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From No. 1, Vol. XLVIII, ¡°HIV/AIDS The Fourth Decade¡±, 2011

In the beginning, the AIDS epidemic struck like a thief in the night -- suddenly, terrifyingly, and deadly. At first, there were a few cases of a rare malignancy, Kaposi's sarcoma; then came the appearance of Pneumocystis pneumonia; and finally a plethora of opportunistic infections including systemic candidiasis, cryptococcal meningitis, and Mycobacterium avium-intracellulare -- all rare diseases associated with this new mysterious, unknown, and unnamed spectre.

Infectious disease doctors had been predicting that mankind would completely conquer all infectious diseases, and that these ancient plagues would be eliminated at the end of the twentieth century. In just one generation from Alexander Fleming's discovery of penicillin, the scientific community was able to develop antibiotics and antiviral medication to treat most of the world's known infectious agents. Suddenly, out of Africa came a new infectious disease heretofore unknown and deadly. Society had just experienced and conquered Legionnaire's disease and toxic shock syndrome, and most of us felt that the identification and elimination of this new scourge would occur quickly and decisively. None of us anticipated that 30 years later we would still be battling one of the most lethal infectious agents known to man.

As with every epidemic, this one went through the four seminal stages of societal response:

First, as always, was denial. Some countries, such as South Africa, denied that AIDS was even happening. Most countries, such as Saudi Arabia and Japan, felt it was something only happening to other people, and would not happen to them. But, of course, with every epidemic, it did happen to them.

Then came blame: it was the fault of gay men; it was the fault of promiscuity; it was God's punishment for immoral behaviour. Some people thought that it would never happen to them because they did not have "those kinds of people" in their society. To their surprise, they did have those kinds of people, and it did happen to them.

Inappropriate legislation always follows a new epidemic. As one of the countries first and hardest hit by the epidemic, the United States passed laws to exclude HIV-positive individuals from entering the country -- a classic case of closing the barn door after the horse has bolted. United States Senator Jesse Helms championed legislation which prohibited American scientists, paid for by the United States Government, from attending international meetings dedicated to understanding and treating the disease.

And finally, as in all epidemics, society lost faith in its institutions. Suddenly the American people found that the Food and Drug Administration was not doing its job to bring life-saving drugs to those in critical need of these treatments. Institutions that had been established to address this very type of catastrophe were thwarted by bureaucracy, ignorance and fear.

The Centers for Disease Control and Prevention were supposed to identify new diseases and take immediate action to ameliorate the spread of a new risk to society. These efforts were totally crippled by the Reagan Administration, which treated this disease as a criminal problem, rather than a medical one. The National Institutes of Health were supposed to devote funds to seek new treatments for emerging diseases: it took congressional investigations years of advocacy to remind them of their mandate. Blood banks in America were staffed by physicians who were hired extensively to protect the nation's blood supply. Instead, these blood bank physicians joined hands and for four years denied that "those kinds of people" would even come to blood banks to donate blood. As a consequence, 28,000 Americans were infected with HIV through transfusion, and untold numbers of foreign haemophiliacs were killed by the export of American blood products.

Thirty years later, we have treatments for HIV, but the United States still has 56,000 new infections every year. Education and prevention programmes remain unchanged since the early 1980s, and are woefully inadequate. The United States Congress has vowed to cut funding even for the meagre education programmes that exist. Annually, 27 per cent of all new cases of HIV infection occur in women -- a harbinger of a heterosexual epidemic still in its infancy.

To stop the AIDS epidemic in the United States, we need to acknowledge that the entire society is at risk and take the appropriate steps to stop the spread of this fatal disease. Everyone who comes into contact with the health care delivery system should be tested for HIV and other sexually transmitted, and potentially fatal, diseases. When an individual tests positive, he or she should be educated and offered life-saving medications, which have the additional societal benefit of reducing the transmission of the disease and, eventually eliminating infections from society. Finally, public health authorities should follow up with those individuals who are known to be positive and who are not taking antiretroviral medications, to educate and persuade them of the need to protect themselves and their intimate contacts.

Is there a lesson in this sordid history? Yes. The lesson is that social and political activism by individuals who clearly see a threat is essential in mobilizing local and regional governments to respond. Governments are necessary, indeed essential, and yet they are always mired in tradition. They suffer from the notion that the way we have always done it is the way it should always be done in the future. History has shown us, over and over again, that this approach will lead to disaster, and will change only if clear thinking, progressive individuals stand up and speak out.

How many men died in World War I because the generals were unwilling to acknowledge that warfare had changed? How many civilians have died in Iraq and Afghanistan because the military failed to acknowledge that carpet bombing and killing women and children cannot win a guerrilla war? Why did people die from HIV-tainted blood? Because the blood banks were certain that their procedures were fail-safe and immutable. We will never win the war against HIV/AIDS by employing the same tired tools that have failed us in the past. We must stand up, speak out, and demand meaningful and compassionate government action.