PAPER: Beyond the Distinction between Biomedical and Social Dimensions of HIV Prevention
Beyond the Distinction between
Biomedical and Social Dimensions of HIV
Prevention
REFERENCE
Kippax,
S., & Stephenson, N. (2012). Beyond the distinction between biomedical and
social dimensions of HIV prevention through the lens of a social public
health. American journal of public health, 102(5),
789-799.
MY SUMMARY
Interestingly this paper, an
argumentative paper, describes how many HIV prevention program focuses on
biomedical prevention approach, like PMTCT service, ART, Prep/PEP (pre-exposure and post-exposure
prophylaxis, VCT,
and male circumcision, not focus on behavioral and social transformation
approach, like delaying sexual practice, using condoms, or being faithful to
their partners. The current meta-analysis, systematic-analysis and other
experimental publications seem to focus on the effectiveness and efficacy of
biomedical prevention approach and consider the failure of ‘behavioral
prevention approach’, therefore all of this lead to global funders focus on
much on biomedical prevention rather than behavioral approach.
The authors argue that the approach of
‘test and treat’ or ‘treatment as prevention’, like VCT or ARV treatment or provider-initiated testing or PMTCT service the numbers
increase the number of early detection of HIV in high-risk or low-risk
population that seems to offer benefits for HIV-positive results to further be
treated with ARV and prevent HIV transmission, but not for HIV-negative results
to engage them to change their high risk behaviors. In addition, stigma and
discrimination are other challenges for accessing HIV test and for accessing
ARV treatment for new HIV-positive persons. Therefore, the authors “argue that all
prevention requires that people change their social practices, changes that
cannot be effectively sustained unless they are supported by broader social
transformation” (p.791). In other words, there is “failure”—by muting research and interventions into the social
life of HIV, into the specificity of relations between people, viruses, and
institutions that enable or prevent transmission” (p.796).
To sum up, social
transformation that relates to community empowerment is important element to
sustain both biomedical prevention and behavioral prevention approach to
sustain all HIV prevention and treatment programs to be engaged “with the
everyday lives of people” and to be integrated into their social relations and
social practices” (p.789), including social
norms- moral, taboos, laws and beliefs . For instance, how HIV-positive persons or
HIV-negative persons to change their behaviors, not to have multiple partners,
to adhere the long-life ARV treatment or access PreP, or to keep using condoms
by considering social norms in their everyday life. In their final conclusions,
they added “social and biomedical scientists can
best contribute to understanding prevention in the real world by engaging with HIV
and efforts to prevent it as they are encountered in life—as biological and
material, as information and technological, as emotional and affective, as
social, collective, institutional” (p796).
ABSTRACT
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.
CONCLUSIONS
Notwithstanding
the recent attention to the social drivers of the epidemic and discussion of
social impact,69 we have argued that increasing
biomedicalization is distorting prevention efforts. We go beyond
describing the rise of biomedical prevention to offer an explanation of it in
terms of what many believe is a failure in HIV prevention. HIV prevention has
not failed—at least not everywhere. Where it has stalled it is possible that
the linking of prevention to testing in the context of the roll-out of
treatment in 1996 and the concomitant positioning of prevention as a private
matter in the clinic may have played a role in that “failure”—by muting
research and interventions into the social life of HIV, into the specificity of
relations between people, viruses, and institutions that enable or prevent
transmission. The more recent turn to treatment for prevention and
treatment as prevention is likely to reinforce this positioning
of HIV as an exclusively biomedical matter. Social transformation is difficult
if not impossible to achieve in the clinic.
We are not
trying to defend behavioral and structural approaches or to discount biomedical
ones. Rather—whether prevention programs or interventions advocate delayed
sexual initiation, the use of condoms, clean needles and syringes,
microbicides, or PrEP or PEP—we
argue that all prevention requires that people change their social practices,
changes that cannot be effectively sustained unless they are supported by
broader social transformation. The latest in technological innovation, “test
and treat” or “treatment
as prevention,” also requires
changes in practice that can only be
sustained if they are supported by widespread
social change: annual HIV testing for those who test HIV-negative
and, for those who test HIV-positive and accept treatment, a lifelong regimen
of drugs, many of which have short- and long-term side effects. The
challenges to the effectiveness of test and treat are the same as for any other
prevention technology: they concern the kinds of relationships between people
and things that are involved in the provision, acceptability, adoption,
sustained use, and unintended consequences of any prevention technology or
tool. How are countries, which at present cannot afford to treat
those who are in need of treatment, going to find the extra funding (and at a
time when there is broad anticipation that budgets for global health will
shrink)?70 Regarding acceptance and
adoption: how do those advocating treatment as prevention propose encouraging
people to test and to test regularly? Although in the context of
provider-initiated testing the numbers of people being tested has increased,
there continue to be very many who are not being tested and many with reason.71 The
evidence that increased testing normalizes testing and reduces stigma
associated with HIV is not clear: at least two studies, one in South Africa72 and one in the United
States,73 demonstrate that HIV-positive
status continues to be associated with stigma and discrimination.
And how do those advocating treatment as prevention propose encouraging all
those who test positive to embark on a lifelong regimen of treatment?
Not only is
it essential to ensure provision, acceptability, adoption, and sustained use of
HIV-prevention strategies, but also an absence of unintended negative
consequences is necessary for there to be an effective response.
One possible unintended consequence of the promotion of test and treat is that
it could make harm reduction measures such as the establishing of needle and
syringe programs even more politically difficult to roll out in countries that
have to date resisted them (some of which have rapidly growing epidemics at the
moment). Governments may well use test and treat to justify their reluctance to
provide needle and syringe programs. And
what of the optimistic HIV-positive men and women on treatment who believe that
they can engage in unprotected sexual intercourse with impunity? Or what of the
relieved person who infers from his or her negative HIV test result that a
degree of unsafe behavior is not that risky after all? Or of governments that
fear that promoting anything that might challenge existing gender relations or
that might involve them in being explicit in their dealings with sexuality is
unlikely to get them re-elected? And, perhaps most important of all: how are
those who advocate treatment as prevention going to convince governments and
countries not to put all their HIV funding into treatment? Although treatment is essential for those
in need of it as treatment, if it is going to play an effective role in
preventing HIV transmission across a population, then social and political
research on its effectiveness as a prevention strategy is needed.
We have
framed our argument about HIV prevention in terms of a biomedical narrative
that has shaped much of the field of HIV prevention in problematic ways, and a
social narrative that has often been marginalized and muted despite its
potential to yield insights about effective prevention.
However, we see this opposition as one that has arisen historically and one
that needs to be contested now as did Fee and Krieger in 1993.74 Researching HIV prevention
today demands that social scientists engage with HIV prevention without
invoking a nature or culture distinction that supposedly describes how a virus
is encountered by humans.75 Social and biomedical
scientists can best contribute to understanding prevention in the real world by
engaging with HIV and efforts to prevent it as they are encountered in life—as
biological and material, as information and technological, as emotional and
affective, as social, collective, institutional.
IMPORTANT
KEY POINTS IN THE PAPER
·
The
intervention mostly focuses on biomedical approach compared to behavioral
approach
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. P.789
We witnessed the development
of prevention of mother-to-child transmission (PMTCT) and, more recently,
microbicide gels based on antiretroviral treatments such as tenofovir, and
preexposure and postexposure prophylaxis (PrEP and PEP) also derived from
treatments. P.791
they claim that in
populations where a substantial proportion of people living with HIV is on
ART, p.791
It would now almost
certainly include the development of interventions such as PrEP and PEP and
“test and treat” (all based on antiretroviral therapy) as well as male
circumcision. P.791
In recent trials,
microbicides have been found to be 39% efficacious in preventing the sexual
transmission of HIV from men to women,7 male circumcision 55%
to 60% efficacious in preventing the sexual transmission of HIV from women to
men,8 and, depending on the
level of drug adherence, PrEP has been shown to be 44% to 73% efficacious in
preventing homosexual transmission.9 p. 791
Evidence indicates that the
application of PEP lowers the likelihood of occupational HIV transmission13 and PEP is provided in
many countries for both occupational and non-occupational exposures. P.791
“In response to HIV, people,
as members of communities and networks, have modified their sexual and drug
injection practices in ways that enable them to remain gay, masculine, married,
Hindu, and so on. As many researchers46 have pointed out,
the most powerful influences on human sexuality, for example, are social norms—morals, taboos,
laws, beliefs—that regulate and govern its
expression. Practices are socially produced.” P.791
The appeal of biomedical prevention technologies
also rests on misunderstandings over what effective prevention actually entails as well as
more specific confusions over what counts as biomedical prevention. For
example, whereas some researchers29 classify condoms as a
biomedical prevention technology, others30 typically categorize
condom use as a behavioral strategy although they rarely if ever refer to PrEP
use or microbicide use as behavioral strategies. The problem is not whether condoms should be included under
the rubric of biomedical
or behavioral prevention; all these technologies or
tools—whether termed biomedical or behavioral—have to be adopted and, with the
exception of male circumcision, their use sustained. Any prevention
strategy—which by necessity involves relationships between different entities (e.g.,
PrEP or condoms and people, and people and information)—can be meaningfully
said to be biomedical and behavioral and indeed structural. They
all require modifications to behavior or practice but, more importantly, they
all require the active engagement of peoples and communities: the social,
cultural, and political dimensions of sexual activity and injection drug use
are paramount. Although analytically distinct, effective prevention requires that
biomedical technologies, behavioral strategies, and social structures are not
treated as separate entities. PrEP or condoms or sterile needles can
only become effective if prevention strategies tackle the contexts that fail to
support people's appropriation of these tools into their sexual and injection
practices, including the contexts that position the technologies such that they
fail to prompt any action on the part of the people who might fruitfully use
them. P. 791
Nowhere is this more evident
than with the advent of successful treatments in 1996, when voluntary
counseling and testing (VCT) was unrolled on a massive scale globally and
prevention increasingly attached to testing and confined to the clinic.
The clinic's position as the center stage for prevention efforts was further
reinforced by the prioritization of treatment by global HIV funders as
exemplified by the US President's Emergency Plan for AIDS Relief (PEPFAR) and WHO's “3
by 5” initiatives.32 p. 793
However, neither testing nor counseling, imparting advice on preventing
transmission, offer much potential to contribute to transforming social
relations, and there is growing evidence that, although counseling in the context of HIV testing
influences the sexual practices of those who are found to be HIV-positive, it
has little if any impact on those who test HIV-negative.33 p. 793
Social relations and their
transformation are the bread and butter of change. What these three countries
developed was a “social vaccine” that produced social transformation. P.796
·
How the
biomedical approach assumed as a good prevention approach for HIV transmission,
this assumption misguided the conclusion of the future policy for HIV. The
failure to differentiate between biomedical approach and prevention approach
should be defined.
The enthusiasm rests in part
on what is seen by many as the failure of what has been termed behavioral prevention—delayed
sexual initiation, reduction in number of sexual partners, and condom use, and
the use of sterile injection equipment—to distinguish it from biomedical prevention. P.
792
To be clear, we are not
mounting a critique of HIV treatment successes in the shape of ART but rather of
the manner in which the success of ART has swamped prevention efforts.
Not only has prevention moved to the clinic, but also the need to continue to
invest in and develop HIV prevention efforts has become sidelined and,
gradually since 1996, prevention in many countries has become almost
indivisible from treatment.40 Indeed, as we have
noted previously, there is a growing number of biomedical scientists arguing
that treatment is prevention.
The “prevention failure”
line has gained strength from the hundreds of inappropriate experimental evaluations
of HIV-prevention interventions. The evaluations are
inappropriate in the sense that the same methods are used to assess
effectiveness as are used to assess efficacy.41 They are misguided
attempts to experimentally assess real-world effectiveness and, not
surprisingly, the results of a number of meta-analyses focusing on those
evaluation studies that meet strict criteria of rigor in biomedical research
indicate that the majority of prevention initiatives evaluated have
inconclusive or flat results.42 Most recently,
researchers conducting a systematic review of randomized controlled trials for
prevention of sexual transmission of HIV concluded that “almost 90% of
[randomized controlled trials] of interventions for prevention of sexual
transmission of HIV have delivered flat results.”43(p631) Not
only do these studies falsely reinforce the view that HIV prevention has
failed, but they have also led to a mistaken attempt to differentiate biomedical from other forms of prevention. P.794
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