INTRODUCTION
Until after World War II, when penicillin became widely available for the first time to the general populace, syphilis and its effects were killing millions and filling untold numbers of chronic hospital beds in the Western World. Syphilis has plagued the West since 1500, when the “Great Pox” pandemic appeared and millions succumbed. The devastation was greater than from “Small Pox”, also a devastating killer. While small pox has been conquered, syphilis has not.
Syphilis was certainly present in Asia, Africa and elsewhere as well. But the scourge of other plagues and ills often masked its effects even to the present day. With early death from famine, diarrhea, parasites, malaria and other diseases, most still with us, the long term severe effects of syphilis, many of which don’t occur for decades after the spirochete attacks, were often masked. Unfortunately, the disease persists despite the availability of antibiotics to treat it.
Like small pox, syphilis too should have been eradicated. Unfortunately, as we all know, this has not occurred. The intransigence of the disease and the unpopularity and difficulty in dealing with it make it similar to HIV disease and AIDS. Both diseases are STDs, sexually transmitted diseases. This means they are diseases basically propagated by non-monogamous sex, sex for pleasure and sex with many partners1,2 and therefore are associated with activities and behaviors considered undesirable by the main stream of most major societies, East and West. Outside Western society, while sex might not be considered in terms of sin, cultural attitudes towards sex nevertheless color reactions to sexually transmitted diseases. In contemporary times the STD of greatest concern is HIV disease and AIDS. Until a vaccine is available and a successful treatment is found, every community will have to directly confront the sexual parameters of this disease to reduce progressive morbidity and mortality.3
The “community” of reference, for the present discussion, may be a neighborhood, a city, state/province or country. The community may also be a social or ethnic grouping, such as “Gays” or Blacks, and immigrants or Islanders. This paper will attend to some broad issues that need consideration in dealing with HIV disease and AIDS.
DENIAL, SHAME AND STIGMA
On a national, community and individual level, the first problems to be dealt with are denial, shame and stigma. Unlike other illnesses which strike by chance, AIDS for most adults, like other STDs, is a “disease of behavior”. Unlike behaviors of an environmental or occupational nature this is a disease associated with pleasure and carries a stigma of immorality. As such, even those who get the disease via a transfusion of contaminated blood, from occupational exposure (as might health care workers) or other non-sexual means often feel the associated shame. They feel compelled to mention how they “innocently” contracted the disease.
Few communities deal openly with sex-related topics. Sex-related subjects are most often kept private. Often there is a reluctance to mention sex in open or in mixed male-female conversation. When sex is dealt with openly it is often in jest or with exaggeration. While the “Gay” community in the United States has lately come to grips with the sexual ramifications of AIDS, it wasn’t until after a dramatic rallying cry was issued and many of the community fell ill or died (Kramer, 1983). And even then it was slow to take hold. Within the Gay community, in America, there was a reluctance to give up hard won sexual freedoms that were newly being enjoyed (Shilts, 1987).
In Africa and Latin America and much of Asia, where the mode of transmission is essentially heterosexual, there too is a reluctance to give up sexual pleasures in service of prevention. And unfortunately even when one wants to discontinue risky sexual practices, one is not always in a position to say “no”. Many individuals, usually women, are often socially powerless to resist, and the community doesn’t interfere with such personal and private negotiations.
Many countries or communities, due to shame and stigma, initially refuse to recognize that AIDS has touched their community. HIV disease was initially linked to homosexual practices, particularly anal sex, and many communities do not want to admit association with such behaviors. As there was reluctance on the part of the homosexual community to accept its role with AIDS in the United States, now the reluctance is seen among the Black and Hispanic communities which, due largely to IDU (injected drug use) transmission – also illegal and immoral – are now being most heavily affected. These groups are slow to rise to the challenge. They deny that homosexuality, drug use or non-marital sex are in their midst. To a lesser extent the same is true for other minorities. They feel they have larger problems to deal with and admission that group members have HIV disease would lead to added discrimination for themselves by the majority population. It will take some dramatic leadership or a significant member’s death to mobilize them. Such certainly happened with the AIDS-related death in the United States of the well known movie actor Rock Hudson (Cantwell, 1986). His death forced the majority of the general population to admit that HIV disease could affect “decent and respected” people.
An example relevant to Asia is available from Hawaii. The earliest disclosed AIDS cases in Hawaii were among Caucasians. This reinforced the general belief that those of Oriental descent (e.g. Japanese, Chinese, Koreans) or those of Island descent, such as Hawaiians, Samoans or Tongans, do not engage in high risk behavior and get HIV disease. Of course they do, but these communities, even now years later, continue to deny the presence of HIV illness among their members. With many, this blindness is associated with any sexual issue. They also don’t generally speak of illegitimate births or non-marital sex and even abortion or divorce. The conservative Christian missionary influence has been strong in discouraging open discussion of sexual activities.
Once the disease hits a community, the reaction is quite varied and seems only slightly related to the community’s state of enlightenment or its views of personal civil rights. Many continue to refuse to admit the prevalence of HIV/AIDS in the country, or they downplay its presence. In 1988, of the 177 countries and territories regularly reporting to WHO (World Health Organization), more than 80% had reported at least one case of AIDS (AIDS, 1989). Unfortunately, in many instances, the number of cases is woefully understated. Consider that in many countries of Africa, such as Uganda and Kenya which are considered to be among the countries presently most devastated by the disease, the official governmental policy was to deny that the disease was a significant health threat. Instead of reporting the actual tens of thousands of cases, they under-reported by factors of 10 or more (Edelston, 1988). This is slowly changing, but the magnitude of the problem in these countries now makes true estimation of the disease’s prevalence difficult.
Certainly prudery wasn’t the only motivating factor in this sham. National pride kept each country from wanting to be seen as the country of origin or locus for the disease, and economic/tourist interests advocated against admitting the size of the problem. But the sexual nature of the illness was part of the hesitancy and shame.
The process of denial, particularly in the early stages of HIV disease, leads the majority of most communities to consider the illness a “foreigners’ disease”. That the disease may enter any community via this route is certainly true. However, members of most every community travel and have contact with outsiders, and they may unknowingly bring back the disease. Foreigners travel and mingle with locals, so no longer is any area safe. Also, many communities, such as Japan and Hong Kong, have for many years imported large quantities of blood products for their hemophilia population. While these products are now extremely safe, the quantities previously imported exposed a sizable proportion of such hemophilia groups, perhaps 30-75%, to HIV contaminated blood products and subsequent infection. These hemophiliacs too have sexual contact with others and can spread the disease (Johnson and Laga, 1990).
Denial of the seriousness of the disease and its potential impact on the community has also prevented most communities from taking steps of advance preparation to protect their population. Efforts toward widespread public education campaigns to warn of HIV infection and to instruct the population how to reduce risk have met with appeals to not raise issues that have not yet surfaced (“Don’t wake the sleeping baby.”). There is also reluctance to take any actions that might lead to public hysteria. There is also a tendency by conservative elements of some communities to prefer not to be specific but talk in generalities: e.g., “Just say no to sex,” rather than “Use a condom and be safe.” Fortunately, in Asia, this reluctance to speak of sex is not tinged with religious guilt so open discussion of the problem will be more readily accepted once such community decisions are made.
BANS, ISOLATION, AND QUARANTINE
Typically, the initial effort of a community is to ban or restrict strangers and foreigners. Several years ago, the United States passed a law making it illegal for any person known to be HIV positive to enter the country as a visitor or immigrant (Ford and Quam, 1987). (Tests prior to entry are not required, but this can be a question at immigration.) This restriction exists despite the admitted estimated presence of some 1,000,000 or more of the U.S.’s own HIV-positive individuals. With the 1990 Sixth International AIDS Conference in San Francisco, groups, organizations and even countries announced they would boycott the meeting unless the U.S. Government changed this policy, since it would make it impossible for many PWAs (persons with AIDS) to legitimately attend. This boycott threat did result in President George Bush modifying the ban to allow HIV-positive individuals into the country for a period of 10 days to participate in this or other meetings. With the original ban back in effect, the 1992 meeting, originally scheduled for Boston, Massachusetts, has been cancelled. It has been rescheduled for the Netherlands. Other countries have similar bans, fearing sexual activity would occur between the visitor and their own members. Bans also occur at a local level. In Japan, for example, many bars and houses of prostitution bar foreigners from entering. Recently (October 1992) a Tokyo hotel refused accommodations for a non-symptomatic person with AIDS.
Another activity often popular is to make illegal certain practices such as prostitution or cohabitation among community members and foreigners. Anti-prostitution efforts are popular since they pick on an already stigmatized class and give the impression of “doing something”. Often prostitutes work outside the law and public scrutiny, so controlling them is difficult. Also, despite the bans and risks, they are often forced by economic conditions to continue their practice.
The contribution of prostitutes to the AIDS situation is actually very much community-dependent, as is the response. In certain countries of Africa, for instance, the role of prostitutes in transmission is high. Longitudinal data from Nairobi, Kenya and Zaire show a rapidly rising prevalence of HIV antibody in cohorts of female prostitutes (from 4% in 1981 to 90% in 1987 in Kenya, and from 27% in 1985 to 50% in 1988 in Zaire). Cameron et al. (Cameron, 1990) estimated that the incidence of female-to-male HIV transmission after a single exposure to a woman in the Nairobi prostitute cohort, 90% of whom were infected, was 8% (Cameron, 1990). In Asia, Thailand, the Philippines and India are known to have high populations of infected sex industry workers.
The contribution of prostitutes to AIDS in Europe and the U.S., however, is less salient. In 1988, HIV positivity among prostitutes in Europe was estimated at <1 % compared with a large multi-center study in the U.S. which found 5% of non-drug using prostitutes were seropositive. Those HIV-positive women were associated with a large number of non-paying partners with whom condoms are not often used (Johnson and Laga, 1990). (The use of condoms with customers has increasingly become widespread in the U.S. among most urban prostitutes. With pimps and friends, however, condoms are often not used. And many prostitutes overlap in life style with the IDU population and its high AIDS risk.)
The low incidence of HIV positivity among American and European and Japanese prostitutes may be changing. In these countries, many foreign women from Asian countries are migrating or traveling, increasingly working as prostitutes and less likely than native women to use condoms.
In countries of Western Europe prostitution is legal, and prostitutes are regularly licensed and tested for STDs including HIV. They also are aware of the protection offered by condoms and more likely to use them. In the US, prostitution is illegal everywhere except in one state, but this doesn’t seem to pose a significant AIDS threat. While there have been calls from some in the general population and from politicians and health care workers for increased surveillance and curtailment of the “availability” of prostitutes, little has actually occurred. And, attention continues to be directed toward the female “seller” rather than the male “buyer”.
In Africa and elsewhere, the situation among prostitutes seems to be getting worse. In some communities, such as in Thailand, the economics of the sex industry is so important to the country, due to “sex tours” and other features of commerce, that until recently AIDS has been ignored to the extent that some estimates report 40% of the sex-industry personnel are HIV-positive (Sittitrai, Brown et al., 1991 (In Press)). And the ramifications for that culture are great, since prostitutes in Thailand tend to move in and out of the “The Life”. After a year or two as prostitutes in the big cities, the women return to their home rural communities and there spread the disease to their new partners.
Preventing cohabitation is more difficult but has been attempted in some restrictive societies, the People’s Republic of China for one. News articles have indicated the P.R.C. has made it illegal for foreigners to sleep overnight at Chinese homes, and they have limited the occasions on which its citizens can meet foreigners. Visitors and students, particularly from Africa, have been kept under scrutiny sufficient to warrant official protest from the students’ governments.
Some countries, such as Saudi Arabia, have required HIV antibody tests before individuals are allowed into the country for work or residence. All of these efforts place the burden on the “outsider” or potentially infectious foreigner to control his or her behavior. It relieves the community member of the responsibility to protect oneself.
India has refused to allow enrollment of foreign students without HIV clearance certificates and insists on the mandatory testing of all visitors who intend to stay more than three months (Moss and Misztal, 1990).
Cuba is one of the few countries that has tested its entire national population and quarantines all those individuals it finds are HIV positive (Moss and Misztal, 1990). It has been rumored that one reason Cuba was reluctant to bring home its troops from Africa is that many of the military personnel were HIV-positive, and the government and Cuba would not be able to quarantine all those that were positive. As a totalitarian government it can do this. Democracies are much more restricted, and few communities actually have the resources for such an action. The United States has an infected population estimated to be more than a million persons. India already has an estimated HIV-positive population of tens of thousands. Brazil too has tens of thousands of individuals with a rate of increase estimated as high as 100% per year (Parker, 1990). But most communities do not even have the resources to test their members to determine who is or is not infected. And such a testing regimen would have to be ongoing and would, due to the tests’ inaccuracy and the disease’s window of non-detectability, be of limited use in any case.
The task of identifying, isolating and quarantining all individuals found to be HIV-positive is immense (aside from the social and ethical costs). Since it is known that AIDS cannot be casually transmitted, the assumption made by the Cuban government is that, without quarantine, sexual activity and transmission of the disease will occur, and this method will keep the remainder of the population safe. HIV-positive individuals are, therefore, separated from their families and friends, and the governmental policy stated is one to protect the general population. Actually, probably every government already has in existence some mechanism by which it can isolate individuals it considers dangerous and potentially liable to spread disease. In the past this has been used for such diseases as tuberculosis, typhoid and leprosy. (This practice of removing sick individuals from society was so widespread for leprosy in old Hawaii that the disease was called “the separating sickness”.) The practice for HIV disease and AIDS, however, has been quite limited. Malaysia has considered the most draconian methods of dealing with AIDS. According to a report in Time, 30 September 1991, “infected individuals would be obliged to carry special identification cards. The press would be permitted to publish the names of patients …, the government proposes building a detention camp similar to a leper colony for those with AIDS.”
DISCRIMINATION
Many countries have increased their discrimination against homosexuality and adulterous relations. In some communities these sexual practices are illegal, in others they are not. Several states in the U.S. retain laws that predate AIDS, maintaining these practices as illegal, but enforcement is spotty and rare. Alone among Western countries, the United States has a law, on the books long before AIDS was on the scene, that homosexuals not be allowed into the country, even as tourists. While enforcement of this law has never been uniformly strict, since the advent of AIDS this has been much more stringently enforced. This is notwithstanding that the U.S. has millions of individuals engaging routinely in same-sex activities, and male homosexuals and bisexuals comprise some 60-70% of the known PWAs in the U.S. (U.S. Department of Health and Human Services, 1991).
Within the United States, each individual state has its own laws regulating sexual activity and health laws regarding HIV disease. To these laws, many states have added laws making it illegal for someone knowingly HIV-positive to have “unsafe sex”4, heterosexually or homosexually. In some states this restriction holds regardless if the partner is informed or not. While the intent might be laudable, this law has the disadvantage of discouraging individuals from voluntarily taking the HIV-antibody test so they can’t be accused of a felony if they are unknowingly HIV-positive and sexually active. Many are similarly reluctant to even take the test, fearing identification as “one who needs the test due to engaging in homosexual or other immoral behavior.
In republics of the former Soviet Union, the Arab countries of the Middle East and Africa and Muslim countries elsewhere, like Indonesia, homosexuality is likewise illegal. This is not true in the P.R.C. (or some other countries), but homophobia and anti-homosexual attitudes are sufficiently propagated by the government that the effect is almost the same. (It might be mentioned that in some of these countries, such as the P.R.C., homosexuality is seen as a sickness and subject to ‘treatment” rather than incarceration.) While the motives behind these homophobic laws are varied, of late their enhanced enforcement, as in the U.S., is in hopes that it will stem the spread of HIV disease. There is no evidence that such laws decrease the incidence of these behaviors. They serve more to drive the behavior underground.
During the 1960s and 1970s a generalized swing toward sexual liberalism and tolerance offered to homosexual and bisexual individuals a greater degree of acceptance than in the past. With AIDS in the 1980s, however, this tolerance has been severely strained. “Gay bashing”, inflicting bodily injury or death to homosexuals is the worst – and fortunately rare – manifestation of this intolerance, but many types of discrimination are more common.
Within almost every community individual discrimination, shunning and such has occurred. This occurs in many subtle ways. The most obvious areas of discrimination are in housing, work and insurance against homosexuals. But also critical is the availability of health care. In the United States, as in many countries, many physicians and particularly dentists have been notably reluctant to deal with HIV-positive individuals (Misztal and Moss (Eds.), 1990; Fazekas, C., Diamond, M., Mose, J.R., & Neubauer, A., 1992). This may affect those individuals self-identified as openly Gay but also, in a more insidious way, by discriminating against all male hairdressers, interior designers, florists and others in occupations stereotypically identified as “Gay”. This homophobia has medical as well as economic and social ramifications. If individuals can’t get insurance, often the establishments they work for also can not be insured.
Another area of discrimination is in the receiving or availability of social services. Many social workers and others apply their own moralistic standards to the people they work with and are less inclined to willingly or assiduously work for those they think sexually wrong or immoral. Even those who work in AIDS research or treatment have come under discrimination.
Among some communities, discrimination follows fundamentalist religious lines. AIDS is seen as a vengeful God’s way of dealing with adulterers, fornicators, homosexuals, promiscuous heterosexuals and others considered “sinners” by such groups. Unlike other diseases such as cancer and diabetes, which is viewed as striking “innocent victims”, HIV disease is seen by these fundamentalists to basically fall upon the “guilty transgressor”. To these bigots, this not only justifies their discrimination but their lack of commitment to treatment, research and prevention education. This discrimination occurs, as well, in countries without the fundamentalist religious overtones. In Japan as in other countries, for instance, the hemophilia-associated PWAs are placed separately and set themselves self-righteously apart from those PWAs who became infected from injected drug use or sexual practices.
MANDATORY TESTING
Many communities are debating mandatory HIV testing to identify infected individuals. The die has, nevertheless, been cast for certain groups. Many countries test their military personnel. In the U.S., for instance, all applicants for military service are tested, and active duty armed forces personnel are tested yearly for HIV antibodies. The stated purpose is to insure a fit and healthy military and a clean blood supply if battle field transfusions are needed. Applicants found positive are refused induction but, in accordance with the long standing policy of the military, individuals on duty found to be HIV-positive are not discharged but given medical treatment as needed and assigned appropriate duty. Thailand does similarly. Interestingly, among many Gay civilians, members of the military have become preferred sexual partners since the required testing seems to portend a low risk encounter. (Before the antibiotic era, virgins and children were similarly preferred for the same reasons and the mythical belief that intercourse with a virgin transferred the disease and released the transmitter of it.) Many communities impose mandatory testing upon convicts, particularly sex offenders.
Mandatory testing of health care workers has become a new focus in some communities. Since the discovery in the United States that one health care worker, an infected dentist, has transmitted the disease to five of his patients, a cry has risen to test all health care workers and make their HIV status known to at least their supervisors. Some are now demanding that if an individual is positive, he or she must inform every patient. So far such testing remains voluntary but encouraged (Centers, 1991). The arguments against the practice are similar to that mentioned above in regard to the Cuban practices. While a call to test health care workers is relatively new, the desire of health care workers to test their patients, or at least all hospital admissions, has been an early response to the epidemic. Indeed, health care workers are at much greater risk than are patients.
Voluntary testing is believed by most enlightened public health experts to be the most effective method of dealing with this epidemic. It reduces the stigma of the disease and allows the individual to seek treatment and observe behavioral practices to reduce the likelihood of transmitting the disease to others. Where possible, testing is often accompanied by education and counseling.
PREVENTION: EDUCATION IS THE VACCINE
Sooner or later, all communities have to deal with the spread of HIV disease within their community. And until a vaccine is developed, education is the “Vaccine”. This education, however, is beset with many moral/ethical considerations based upon sexual parameters. There are adherents for all sides, pro and con, liberal and conservative, on what should be taught, where and how as well as when, and who should do the teaching. Basically these questions parallel those for all education but contain extra concerns associated with sex. The following issues/questions are considered crucial:
- Where does sex education begin and differ from AIDS education?
- What methods are appropriate?
- Is any non-monogamous sex safe? Is there “Safe Sex”?
- Can sex still be seen as pleasurable for itself aside from reproduction?
- Do certain groups need special attention or sheltering?
- How do we balance respect for the disease severity and risk with the pleasurable aspects of sex?
- How explicit can the education be?
- Should there be limits to the advocacy of condoms in regard to age, sex, etc.?
- Should we utilize fear in AIDS education?
Unfortunately, among different communities there has been a tug of war in regard to many aspects of research, so that health care workers, epidemiologists and behavioral scientists and sexologists have had to work hard to convince groups that more sex research is needed both for better education and better epidemiological studies. At first, the Gay communities fought for “no research’; now it is their enemies among the “conservative” population who are against research. The former didn’t want to be considered guinea-pigs, and the latter think it unseemly that questions about one’s private life be asked. A nation-wide sexological study is presently stalled in the U.S. due to such thinking (Booth, 1989), and England almost suffered a similar fate (Wellings, Field et al., 1990).
In some communities long-standing prohibitions against sex education have relaxed and AIDS education is being allowed. Some communities are using public and private facilities to broadcast the messages. Others rely on the standard educational system. Some communities, for instance where Roman Catholicism is strong, do not allow discussion of the use of condoms although they will educate about abstinence (Parker, 1990).
In some countries the government has financed separate non-governmental organizations just to deal with prevention education. One example is The Japanese Foundation for AIDS Prevention. In this manner the government can implement prevention techniques with some degree of insulation from unwanted criticism. Similarly, in many communities private organizations have taken the lead in advocating prevention education. Usually these groups are non-profit and many were formed specifically with prevention education in mind. Others, like commercial publishing houses, supported prevention education as part of their efforts toward community service (Diamond, Ikegami and Thorne, 1988).
ALTERNATIVE SEXUAL OUTLETS AND PRACTICES
In response to fear of AIDS and the increased reluctance to participate in anonymous sex with its concomitant decrease in available sexual outlets, alternative sexual outlets and practices have emerged. These are commercial and non-commercial and variably tolerated. Masturbation has increased both on an individual level and as a group phenomenon. Public masturbation (j.o. = jerk-off) clubs are available in larger cities with major homosexual communities. There are also massage groups and “sensual experiences” of all sorts offered commercially and just as a mutual no-charge “release”. Phone sex has become a popular release among both heterosexuals and homosexuals, males more than females. And pornography of all sorts seems to be emerging in a manner upsetting to many of the general community who see this, not as a substitution, but as a stimulus to even more high risk behavior. Actually many recent pornographic films and magazines and other items are mindful of “safe sex” and model such behaviors. What the future holds in new items and practices remains to be seen.
HYSTERIA AND TRUST. NEW PRACTICES.
One type of community response definitely needs emphasis. Since AIDS is a new disease and much still remains unknown about it, hysteria and distrust abound. In some communities a “we” versus “them” mentality has developed alongside much of the homophobia and discrimination mentioned above. But this facet has a different perspective. This community response says that the government or health agencies (“them”) are not telling the truth (to “us”). The contention is made: “They are down-playing the severity of the disease and the culpability of the Gay community”. The authorities are called into question since this group thinks “they” are trying to protect homosexuals, or that the government just doesn’t want to attend to this matter, preferring to deal with politically safer topics. Others, at the extreme opposite of the spectrum, think that the whole issue is being overblown. Heart disease or cancer, they correctly note, still claim many more lives every year than does AIDS. Why then, they ask, should we emphasize this minor disease? They do not see or understand the exponential curve of this pandemic and the economic and social cost this new disease is imposing.
Another view is equally bizarre. While most Gay and straight sexually active communities have accepted the pronouncements of the health authorities, have adopted and advocated adherence to safe sex practices and advocate a decrease in anal intercourse and any unprotected (non-condom) sex, a small minority group has not. This minority, unconvinced by the data showing that oral sex may be a high risk practice and believing that the health officials are just trying to stifle Gay practices, are down-playing the disease’s threat. Some of them, however, are partially accommodating, by advocating fellatio as a substitute for anal intercourse. How widely this highly controversial change in behavior will spread remains to be seen. In Germany, one Gay AIDS organization produced a poster considering oral sex acceptable as long as one ejaculated outside the mouth.
Another set of ideas has emerged from some communities. At first these ideas seem outlandish, but sober consideration reveals they might have merit. The Gay community has called for the legalization of homosexual marriage. And they and some other groups have also called for the sanctification of plural marriage to stabilize relationships. Not only might such legalization accomplish a decrease in multi-partner sexual exchanges and thus reduce the likelihood of disease transmission, but it would facilitate insurance and other “domestic partner” arrangements. Only Denmark, so far, has legalized homosexual unions.
CONCLUSIONS
The onslaught of AIDS, which has only recently in Asia begun to get the attention it deserves, has forever changed the face of sexual activities throughout the world. Xenophobia has again reared its head, and discrimination and the search for scapegoats are among the first responses to HIV disease. But more realistic and effective responses are emerging. We have seen dramatic reactions in behavior in these past ten years and no doubt will see many more in the years to come. Whether these will include the legalization of homosexual marriage or sanctification of plural marriage to stabilize relationships, or the development of yet unforeseen safe sexual games for non-monogamous sexual dalliances, remains to be seen. Will widespread quarantine provide the answer? Probably not. The path to negotiate this plague will be different for many communities. However, until a vaccine or cure is available, one thing is certain. The changes in the social climate of all communities, large and small, will be mirrored by a great deal of pain and death as the best, most pleasurable and safest path is charted.