Beyond the Distinction Between Biomedical and Social Dimensions of HIV Prevention Through the Lens of a Social Public Health

摘要

Developing effective HIV prevention requires that we move beyond the historical but problematic distinction between biomedical and social dimensions of HIV. The current claim that prevention has failed has led to a strong interest in the role of treatment as HIV prevention; however, the turn to “biomedical prevention,” “test and treat,” and “combination prevention” instances pervasive confusions about prevention. These confusions arise from a failure to realize that all HIV prevention interventions must engage with the everyday lives of people and be integrated into their social relations and social practices. We challenge the claim that prevention has failed (illustrating this with discussion of prevention in Australia, Uganda, and Zimbabwe). We explain the enduring appeal of misguided approaches to prevention by examining how 1996 can be seen as a pivotal moment in the history of the global response to HIV, a moment marked by the rise and fall of distinct biomedical and social narratives of HIV. ALTHOUGH SOME RECOGNITION of disease as having a social dimension is arguably one of the cornerstones of public health, how exactly to conceptualize and respond to the social aspects of disease is highly contested. These questions are particularly pressing when it comes to the deeply intimate social practices involved in HIV transmission. Sexual intercourse and the sharing of drug injection equipment are strongly shaped and regulated by cultural and social norms, and preventing HIV transmission demands a deep engagement with the social, cultural, and political factors that produce vulnerability and risk. To be effective, all HIV-prevention technologies, including those that are called biomedical, must engage with the lived world of those at risk for infection. Hence, the contemporary distinction between biomedical, behavioral, and structural forms of prevention functions to cloud our understanding of what effective prevention is and the mechanisms involved in its effectiveness. If one reflects on the history of HIV prevention, two narratives emerge: a biomedical and a social narrative. As noted as early as 1993, these two contesting interpretations contrast individualistic and collective views of disease. 1 The focus of prevention in the biomedical narrative is on the individual members of populations who are understood as rational neo-liberal agents who, when counseled by experts, adopt the prevention technologies advocated or change their behavior to reduce HIV transmission. Within this narrative, failure to do so is interpreted as an individual weakness of some kind or a function of some “vulnerability” occasioned by “social structures” such as poverty or gender. The social narrative, rather than focusing on individuals, is concerned with relations between persons and on how sexual and other practices that place persons at risk for HIV transmission are produced as well as transformed to reduce risk. The focus is on communities and networks and the manner in which these collectives interact with the virus, with biomedicine, and with the state and other institutions and are thus enabled (or not) to respond effectively and sometimes creatively to the threat of HIV and AIDS. We examined the responses of the biomedical and the social sciences to the challenges of HIV prevention—their collaboration and its absence. We argue that the dominant focus of HIV-related discourse and policies has always been biomedical with a particular emphasis on treatment. This has recently been so much so that the insights that social sciences might offer about the social life of the virus, a social life that is integral to its transmission and so to HIV as a medical entity, are occluded. The importance of biomedicine is clearly evident in the Joint United Nations Programme on HIV/AIDS (UNAIDS; 2006) 2 timeline covering the defining moments in HIV from 1981 to 2006 ( see the box on this page ), and this importance has grown since 2006. Joint United Nations Programme on HIV/AIDS timeline Year Twenty-Five Years of AIDS (1981–2006) 1981 Young gay man “diagnosed” with devastating immune deficiency in the United States 1982 Acquired immune deficiency syndrome (AIDS) named 1983 Human immunodeficiency virus (HIV) was identified as the cause of AIDS and the heterosexual epidemic revealed in Africa 1985 Test to detect HIV in infected persons with no symptoms developed—HIV test 1986 Global Network of People Living with HIV/AIDS (GNP+) founded 1987 Global Program on AIDS (World Health Organization) was established in recognition of a global epidemic 1987 First therapy for AIDS—AZT (zidovudine)—developed 1993 In 1991 to 1993, HIV prevalence in young pregnant women in Uganda and in young men in Thailand begins to decrease, the first major downturn in developing countries 1994 First treatment regimen to reduce mother-to-child transmission developed 1996 Comparatively successful antiretroviral treatment (ART) developed 1996 Joint United Nations Progra