After the Exception: HIV/AIDS Beyond Salvation and Scarcity

Abstract: Access to treatment for HIV/AIDS became a flashpoint for global justice struggles in the late 1990s. An expanding international response, premised to a significant extent on the idea of HIV/AIDS as an exceptional global problem, has since delivered treatment, care and prevention to growing numbers of people. HIV/AIDS exceptionalism, however, has increasingly been questioned, many aspects of the response have been critiqued and donor funding has started to decline. I argue that, having been framed as an exceptional humanitarian emergency, the question of HIV/AIDS as a global problem is increasingly located within a discourse of scarcity. Tracking the growing entanglement of global HIV/AIDS relief with neoliberal governmentality and the emergence of something I term therapeutic neoliberalism, I argue that the shift from a rationality of salvation to one of administration poses new challenges for global health activism. Questioning the discourse of scarcity remains essential to an alternative global health agenda.     

Wealth alone does not buy health: Political capacity,democracy, and the spread of AIDS

Although there have been have numerous studies on AIDS documenting its mortality, its epidemiological features, and its relationship to poverty and development, few studies have systematically analyzed how political factors and policies may help curtail the spread of AIDS. In this paper I consider how a variety of domestic factors influence HIV infection rates across countries. I argue that states with higher state capacity are better able to reduce the spread of the HIV/AIDS epidemic. Moreover, I argue that while strong autocracies can implement efficient policies with fewer constraints, democracies tend to be more responsive to the needs of the population and can be more efficient in curtailing the spread of HIV/AIDS. I empirically evaluate the hypotheses using a cross-sectional time-series sample of 117 countries. The empirical results indicate that greater state capacity indeed appears to help curtail HIV/AIDS infection rates.     

Privileging prevention,gendering responsibility: an analysis of the Ghanaian campaign against HIV/AIDS

This article focuses on the discourses around HIV/AIDS in the national Ghanaian ‘Stop AIDS Love Life!’ public health campaign, within non-governmental HIV/AIDS publications, and the Ghanaian national print media. I have used critical discourse analysis to interpret and deconstruct a range of these social texts collected between June and September of 2001 and 2003 in and around Greater Accra, Ghana. I argue, firstly, that these discourses are shaped by an international politics of funding for HIV/AIDS that privileges prevention through behaviour change over treatment action under the premise that prevention is a more cost-effective option for the Global South. I critique this stance, highlighting the emerging possibilities for integrated prevention–treatment efforts in resource-poor settings such as Ghana. Secondly, I argue that the discourses around HIV/AIDS presented in prevention campaign materials powerfully construct normative and gendered subjectivities with assigned roles and responsibilities. The fight against HIV/AIDS is constructed as a national project in which an idealized, and often very young, female citizen is positioned as educator, volunteer, carer and protector of herself and society. This discursive coding of responsibility places the many burdens of HIV upon some of the most vulnerable in society, ignoring the structural constraints of gender, generational and economic inequality. I conclude my paper by arguing that efforts to reduce transmission rates, stigma, and the burden of care for those living with HIV/AIDS in Ghana must integrate both preventative efforts and treatment action. Where prevention campaigns are utilized I suggest that these must recognize the limitations of behaviour change initiatives that primarily target women and acknowledge the gendered constraints faced by those very subjects identified as responsible for the protection and education of the nation.     

AIDS Activism in Pakistan: Diminishing Funds,Evasive State

This article draws on a year of ethnographic fieldwork in the HIV/AIDS sector of Pakistan at the moment of rolling back a World Bank‐financed programme. Classified by UN agencies as at ‘high risk’ of a generalized HIV epidemic, Pakistan has an epidemiology driven by injecting drug use, and a Penal Code and Islamist legislation which criminalize non‐therapeutic drug use and extra‐marital sex. In recent years, a sharp increase in the numbers of registered HIV‐positive people has necessitated a shift from HIV prevention among ‘high risk groups’ to the provision of care to those living with HIV/AIDS. The rolling back of external funding, which was further compounded by the effects of devolution on the Ministry of Health, created challenges for AIDS activism in Pakistan, as reflected in the everyday lives — and deaths — of the patient‐activists and their community‐based organizations. This article recounts the story of one such aspiring AIDS activist caught in multiple dilemmas emanating from these macro‐processes. This story throws light on the limitations of the complex agency of actors in development, and shows how the shifting loci of power from the state to non‐state entities in the global neoliberal order impacts the provision of vital services like HIV prevention and AIDS control.     

‘Facing it Together’: Early Caregiving Responses to Vancouver's HIV/AIDS Epidemic

This article utilises oral history interviews with long-term survivors and caregivers in Vancouver, British Columbia to foreground the importance of gay men's early HIV/AIDS caregiving work. Caregiving was essential to the health and resilience of Vancouver's gay community and served as a political response to homophobic discourses that demonised gay men and devalued the lives of people living with HIV/AIDS. This analysis of the practical and political significance of HIV/AIDS caregiving demonstrates that historians must find better ways to recover the often-untold histories of men's caregiving and domesticity and appreciate their significance to the success of social movements.     

HIV/AIDS and security

The UN and its associated agencies have been among the most important players in increasing global AIDS awareness. But the intervention of the Security Council has been critical in securitizing HIV/AIDS. Moreover, the claims made by the Security Council have set the agenda for the subsequent debate on HIV/AIDS as a security issue. This article examines these claims—that HIV/AIDS poses a risk to internal stability, national security and peacekeepers, and that conflict is a vector for the spread of the disease. It argues that the evidence is less clear cut, more complex and case sensitive than the original claims suggested. Moreover, the causal links between HIV/AIDS and insecurity appear less robust. It concludes that the case made by the Security Council was somewhat speculative, while the snowballing of subsequent pessimistic thinking led these concerns to a position of orthodoxy that now appears less assured. HIV/AIDS remains a tragedy and a human security issue; whether it is a national security issue is more problematic.     

Ryan White CARE Act Title I Funding Priorities and Unmet Service Needs in Baltimore, Maryland

The analysis presented in this paper explores the similarities and differences between the services selected as priorities for funding by the Baltimore Ryan White CARE Act Title I Planning Council during the first 2 years of the program in this metropolitan area, and services perceived by HIV/AIDS service providers and people living with HIV/AIDS to be unmet needs. The data used for these analyses were collected as part of a study to assess the implementation and impact of the CARE Act legislation in the Baltimore eligible metropolitan area( EMS ). This project includes three interrelated components: (a) a case study of the legislatively mandated Planning Council, (b) a survey of providers representing HIV/AIDS service organizations, and (c) a qualitative field study of the perceptions of people living with HIV/AIDS about the service delivery system. Taken together, the data from these three sources describe the similarities and differences among these three groups involved in HIV/AIDS care in Baltimore, in terms of their perceptions of services needed by people living with HIV / AIDS. The conclusions drawn from this study can be used to strengthen needs assessments in Title I-EMAs throughout the United States.     

Securitising HIV/AIDS in the Xinjiang Uyghur Autonomous Region

For the People's Republic of China, the localised HIV/AIDS epidemics in the Xinjiang Uyghur Autonomous Region are emerging as threats to those persons affected by the disease, but also to the stability of Xinjiang. This article examines the HIV/AIDS epidemic in Xinjiang and considers the impacts it may have on human and political security. The authors argue that due to its remote location and the religious, cultural and ethnic diversity of its population, and current political situation, Xinjiang poses difficult obstacles to effective programs in tackling HIV/AIDS, and the pandemic has disproportionately affected the minority nationalities in the region compared to their Han counterparts. If the HIV/AIDS pandemic among minority nationalities in Xinjiang continues to grow, it has the potential to further weaken social cohesion there, as well as Uyghur human security. Therefore, a HIV/AIDS pandemic in Xinjiang could tip the balance in terms of ethnic and regional stability.     

Great Ancestral Women: Sexuality,Gendered Mobility,and HIV among the Bamu and Gogodala of Papua New Guinea

Faced with a potentially devastating epidemic of HIV/AIDS in Papua New Guinea (PNG), sexuality and mobility have become a focus of national research and prevention programs. In Gogodala and Bamu communities in the Western Province, gendered mobility and sexuality intersect with ancestral narratives that form part of a wider series of Hero Tales found in the southern regions of PNG and Irian Jaya. In this paper we highlight the way these stories detail the travels and activities of female ancestors – known as Sagalu among the Bamui and Sawiya among the Gogodala. We outline the way such ancestral figures are now linked to understandings of contemporary STIs such HIV/AIDS as well as gendered mobility and sexuality more generally. Among the Bamu such links are sometimes directly asserted, with Sagalu represented as the origin if not cause of a uniquely defined variant of HIV/AIDS. Among the Gogodala, however, HIV/AIDS is predominantly understood as something external to the Gogodala and unrelated to ancestors like Sawiya. To explain this difference we note that, historically, Gogodala women have been less mobile and less transactable than their Bamu counterparts who have continued to enact unique understandings of the intersection of heterosexual marriage, gendered mobility, and illness. We argue that the mobility and sexuality of gendered ancestors is salient to understanding these contemporary enactments and their potential implications in light of the HIV epidemic in PNG.     

HIV,AIDS and security: where are we now?

HIV/AIDS is one of the greatest single causes of death and suffering on the planet. Over the last decade the societal impact of HIV/AIDS has been widely discussed in terms of national and international security. This article assesses the securitizing move and suggests that HIV/AIDS was only partially securitized at best and both the political consensus and strength of evidence were overestimated. It argues for greater nuance in our understanding of the link between HIV/AIDS and security, and the effects of its securitization, suggesting that neither is straightforward, and both are subject to case sensitivities.     

Towards a jus in bello of Guerrilla Warfare

Abstract

Pentecostalism is the fastest growing form of Christianity in developing countries. Paralleling Pentecostalism's growth has been the HIV/AIDS pandemic. This paper examines how post-apartheid South Africans are responding to the conflicts born of the HIV/AIDS crisis. Fieldwork conducted in 2005 shows that Pentecostals who were not involved in efforts to address HIV/AIDS saw the church's mission as almost exclusively spiritual in nature. Pentecostals who were engaged in HIV/AIDS-related work were more likely to have an integrated worldview and to see the church's mission as relevant to the physical world. Beliefs about removing racism from the church and sin as structural as well as individual were also associated with this integrated worldview. These insights lay the foundation for constructing a Pentecostal social ethic for addressing HIV/AIDS.     

Impact of the Ryan White CARE Act on the Availability of HIV/AIDS Services

This article assesses the extent to which the availability of HIV/AIDS services in the Baltimore and Oakland eligible metropolitan areas (EMAs) increased after receipt of funding under Title I of the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act. Survey data on the availability of HIV/AIDS services in each EMA were collected from samples of organizations at two points in time: 1 year before (1991) and 1 year after (1993) the Oakland and Baltimore EMAs received their first installments of CARE Act Title I funds. Cross-sectional and longitudinal analyses of the data were performed to assess changes in the availability of HIV/AIDS services. The results showed that after CARE Act Title I funding became available, the availability of ambulatory medical and social support services in the Baltimore and Oakland EMAs increased. However, the way service availability increased varied significantly, reflecting differing opportunities and constraints present in each community. In Baltimore, the increase in the availability of HIV/AIDS services was due largely to the creation of new organizations that used Title I funds to provide services (system expansion). In Oakland, relatively few new organizations were created, but existing organizations added new HIV/AIDS services (service line expansion). Our data also indicated that in both EMAs the majority of HIV/AIDS organizations receiving Title I funds expanded the capacity of their existing services to meet growing demand.     

“Dissemination as Intervention”: Building Local HIV Competence through the Report Back of Research Findings to a South African Rural Community

Abstract: What ethical obligations do researchers have to research informants in marginalised communities in serious distress? Our “dissemination as intervention” exercise reported research findings back to a South African rural community—using a dialogical approach which sought to strengthen participants’ confidence and ability to respond more effectively to HIV/AIDS. Nine workshops were conducted with 121 people. Workshops provided opportunities for participants to start developing critical understandings of the possibilities and limitations of their responses to HIV/AIDS, understandings which constitute a necessary (though obviously not sufficient) condition for further action. Workshops alerted participants to the valuable role played by local HIV/AIDS volunteers, facilitating reflection on how local people might better support the volunteers. These discussions served as the impetus for the establishment of a three‐year community‐led intervention to further these goals.     

HIV/AIDS and development: failures of vision and imagination

As early as the mid-1990s the US Bureau of the Census was making dire predictions as to the effect of AIDS on life expectancy, infant and child mortality and population size and structure in a number of AIDS affected countries. Despite this it was not until 1997 that the United Nations began to consider HIV/AIDS as a development issue. This article looks at how the international community (still) fails to take HIV/AIDS into account in setting development goals. The article argues that this myopic view means that in 2015, when we assess the development goals, we are certain to have 'failed' in a number of countries and, therefore, that a new realism in target setting is imperative. There is a need to understand better the impact of the disease by taking into account that it is a long-wave event with a complex current and future impact. Sustained equitable development will be essential in dealing with this impact.     

Navigating the AIDS industry: being poor and positive in Tanzania

This article shows how poor people living with HIV/AIDS in Tanzania navigate a myriad of actors, agencies and organizations to obtain the aid they need to survive. It focuses on community-based organizations which establish networks of care through which people obtain care, treatment and financial support. A case study of a roadside town in Tanzania illustrates that these community-based networks of care — essential to the survival of many — are partly the product of the AIDS industry, which encourages the establishment of community-based organizations and voluntary service delivery rather than more formalized systems of care. Community-based organizations, however, are so poorly supported that they often deploy self-destructive strategies. The need to strategically navigate the AIDS industry creates tension and even conflict among HIV-positive activists, the people they represent and the wider community, which undermines rather than strengthens community-based interventions. Whilst the AIDS industry promises inclusion of HIV-positive people in the response to HIV/AIDS, it succeeds only partially, with the result that it may potentially do more harm than good.     

Research on human subjects,exploitation, and global principles of ethics

Abstract

In 1997, 5.8 million people became infected with HIV, 30.6 million people were living with HIV/AIDS, and infection was running at about sixteen thousand new infections a day, of which more than 90% were in low income countries. Against this background the urgency and importance of the fight against HIV/AIDS can scarcely be exaggerated. While a cure for AIDS remains elusive research to discover more effective treatment and possible vaccines is vital. It is at this crucial moment that moral criticism has emerged of some of the most promising research towards treatments and vaccines for HIV/AIDS. This criticism has focused on, and purports to be justified by, the major current international principles and protocols on the ethics of research on human subjects. If this criticism is valid and no better ways of prosecuting successful research on AIDS can be found, the consequences, as the figures above indicate, are truly bleak. This paper will attempt to provide an appropriate framework for assessing the ethics of research on human subjects generally and in doing so will assess the relevance and force of the major ethical criticisms that have been levelled at current research on human subjects in the context of HIV/AIDS therapy and vaccines.     

Reproduction rates in multiregion modeling systems for HIV / AIDS

The persistence of HIV/AIDS has seen a revival of academic interest in the development of modeling systems to assist understanding the population dynamics of this infection. Moreover, it has become increasingly recognized that a key component of these systems for interpreting disease prevention is their reproduction rate, which provides an indication of whether an epidemic might start in a community described by a particular set of epidemiological characteristics. The properties of these rates have been explored in detail for models of a single risk behavior but not for multiregion formats that allow for the transfer of infection between geographical units. Therefore, in this paper I derive reproduction rates for a multiregion HIV/AIDS model together with their associated critical thresholds that estimate the minimum population of susceptibles necessary for an epidemic to begin. These statistics are interpreted for a simplified global setting representing regional variations in the potential onset of HIV/AIDS. In the discussion I examine the potential applicability of these results to understanding HIV/AIDS prevention.     

Localizing HIV/AIDS discourse in a rural Kenyan community

This paper examines the effectiveness of multimodal texts used in HIV/AIDS campaigns in rural western Kenya using multimodal discourse analysis (Kress and Van Leeuwen, 2006; Martin and Rose, 2004). Twenty HIV/AIDS documents (posters, billboards and brochures) are analysed together with interview data (20 unstructured one-on-one interviews and six focus groups) from the target group to explore the effectiveness of the multimodal texts in engaging the target rural audience in meaningful interaction towards behavioural change. It is concluded that in some cases the HIV/AIDS messages are misinterpreted or lost as the multimodal texts used are unfamiliar and contradictory to the everyday life experiences of the rural folk. The paper suggests localization of HIV/AIDS discourse through use of local modes of communication and resources.     

Epilogue: Homegrown in PNG — Rural Responses to HIV and AIDS

ABSTRACT A three‐years‐long, multi‐sited, multi‐method study conducted throughout Papua New Guinea by the Institute of Medical Research revealed a staggering prevalence of sexually transmitted disease (STD) that threatens an already fragile political‐economy and health services delivery system. Logistics, methodological complexities, and political and especially religious sensitivities hampered conduct of such research. Extremely little HIV social research has been allowed to inform interventions or serosurveillance protocols. Well‐ intended but ill‐conceived international initiatives have promoted a normative AIDS paradigm that misconstrues HIV transmission risk, incites greater fear, increases stigma, and promotes anti‐condom rhetoric. This collection ‘HIV/AIDS in Rural Papua New Guinea’ presents a sustained series of ethnographically based accounts of rural responses. In this epilogue I situate the importance of those responses in a discussion of the great divide between the lived realities of HIV infection and AIDS related suffering on the one hand, and the discursive practices and policies of media, public health, international donors and NGOs on the other.     

Patterns of Vulnerability to AIDS Impacts in Zambian Households

Using household data from Northern Zambia, this article looks at HIV/AIDS impacts on different aspects of people's access to food. The findings draw particular attention to the variances in vulnerability among households burdened by illness and orphans that are headed by men, women and the elderly. It is argued that vulnerability levels to HIV/AIDS impact differ substantially among households and implicitly expose the underlying causal conditions that enable or disable people in their responsiveness. Households affected by HIV/AIDS cannot be treated as a homogeneous group and understanding the differences in vulnerability can play an important policy role in designing targeted support.