However, crisis responses tend to be short-lived and limited to localised territories. It is thus not surprising to note difficulties encountered in responding to slow-moving epidemics such as HIV. Not only do people have difficulties perceiving such a long-lasting process, but established institutions are generally not designed to respond to longer-term systemic situations. This is due to factors such as territorial mandates (both spatial and sectoral) and personal ambitions that lead many people to sacrifice the common good for short-term personal gains.

When HIV was identified 20 years ago, it was first perceived to be a disease limited to gay or drug-addicted people. However, it did not take long for those working in the international arena to wake up to the fact that we were facing a global pandemic; in response, a Global Programme on AIDS was established under WHO. In contrast, the reaction of many national governments was both to acknowledge and deny this global dimension by attempting to control the movement of perceived potential HIV carriers so that HIV/AIDS presumably would not get a solid foothold in their own countries. Eventually, more and more governments began to recognize that, despite their previous claims, their own populations harboured HIV – the "few cases" were no longer limited to foreigners or national citizens who had been abroad. They admitted that the virus was moving across borders and that containment efforts at border entry points could not address the actual pattern through which HIV was spreading within countries.

Failed containment strategies

In South-East Asia, several countries attempted containment strategies, juggling with contradictions such as requiring HIV tests for visa approvals for students or migrant workers, but not for diplomats or tourists. In these cases, politics or business interests opposed public health interests. A well-known exception to this approach was Thailand, which responded to the HIV threat by reducing the vulnerability of those who could be in contact with "outsiders" (e.g., the 100% condom use strategy in brothels), reconciling both business and public health interests.

Nowadays, national AIDS programmes in that region are aware that there are new opportunities for the spread of HIV infection because of the increasing economic integration of their countries. For example, improved roads and transport infrastructure for Asian highways, coupled with economic disparities, are making zones of economic growth and opportunity irresistible destinations for millions of people. The forces of development are reshaping the societies and economies of the region. It is within such a context that national responses to HIV/AIDS must prevent the epidemic from spreading out of control.

Multisectoral collaboration

Economic integration is accompanied and fuelled by the movement of millions of people across international borders in search of economic opportunities. Communities and households are exposed to forces that overwhelm traditional resilience systems and create new vulnerabilities, leading to greater risks of exposure to HIV infection. For example, traditional crops can become impossible to market if rural farmers cannot compete with lower-priced agricultural products coming in from other areas. This results in out-migration and possible sex work to gain an income. In order to respond proactively to these new challenges, health-based strategies need to build partnerships with other development sectors as allies both in- and outside of the country (Figure). The boundaries that must be broken down are both administrative and geographic in nature; they also include boundaries between sectors.

From such a perspective, national AIDS programmes should encourage development sectors, such as agriculture, public works, law enforcement and the military, to reduce vulnerabilities and strengthen community resilience. For example, when a new road links rural communities to towns, young women may leave villages to engage in sex work while young men leave to find jobs in the cities, especially in construction but also in the sex trade. The agricultural sector can help communities prevent this by introducing income-generating crops for the new markets opened up by the improved road networks: young women and men may thus have other options than the sex trade.

Such a strategy demonstrates the need to shift away from dealing mainly with "high risk groups", such as sex workers, drug users or migrant workers, to adopting a systems approach, in which programmes link the origin, transit and receiving communities of mobile people. They can then begin to address the different vulnerabilities of people who pass through the different communities and of people who interact with them. For example, a rural farmer's wife who stays behind to look after children and elderly family members, while her husband goes to town to seek employment during the idle farm season, would be at risk of HIV infection if her husband has unprotected sexual relations in town. If sex workers or migrant workers are targeted in isolation, other vulnerable populations, like the farmers' wives, are ignored and only a partial response to HIV vulnerability is developed.

An enabling environment

To move effectively into broader HIV/AIDS strategies, national responses need an enabling environment to negotiate with other countries and with multiple sectors within the country. Contrary to what many people think, this goal is achievable, as shown in South-East Asia. On 5 November 2001, a Summit of the heads of State of the Association of South-East Asian Nations (ASEAN) adopted a Declaration in which they decided to "intensify and strengthen multi-sectoral collaboration involving all development ministries and mobilising… a wide range of non-governmental organizations, the business sector, media, CBOs, etc." They also resolved to "strengthen regional mechanisms… to support joint regional actions…to reduce the vulnerability of mobile populations to HIV infection…and promote innovative inter-sectoral collaboration to effectively reduce socio-economic vulnerability and impact…"

The formal language of the Declaration expresses awareness at the highest political levels of the need to be pragmatic by expanding actions beyond health strategies while joining forces regionally. The Declaration also represents a statement of commitment to support activities in this new direction. The ASEAN countries and the People's Republic of China have developed a regional strategy to reduce mobility-related HIV vulnerabilities. They agreed to collaborate not only through national AIDS programmes, but also through Ministries of Public Works and Transport, Ministries of Labour, Ministries of Rural Development, and NGOs. Such collaboration utilizes the expertise and networks of each partner. The challenge is now in implementation!