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Addressing Publics Positively: Some Developments in HIV Prevention

Serosorting Enjoy AZT

Earlier on Savage Minds, I asked about contemporary shifts in the symbolism and sociality of HIV/AIDS — a global epidemic. The question concerns me as someone who found himself along with other members of ACT UP, in the early mid-90s, in places like the parking lot of the Astrodome yelling at delegates to the Republican National Convention about funding for healthcare. It concerns me as someone who, in the late mid-90s, was employed as a professional ethnographer (!) tracking social knowledge related to sexual risk in San Francisco. These days, I am interested in the meaning of HIV and the ways in which that meaning is mediated and manifested specifically through what might be called technologies of public persuasion, whether they are relatively complex, such as social marketing campaigns (on the left above), or fairly simple, such as political protest posters (on the right).

A pointed exchange of sorts in the pages of Anthropology News last fall highlights the role that anthropologists are playing in ongoing efforts to respond to–and shape–the HIV/AIDS epidemic and its meaning today. An initial article (read: puff piece) lauded the research of Ted Green, who has worked closely with the Bush administration on its AIDS strategy. Green has embraced ‘risk elimination’ programs for HIV prevention — especially those that (according to Green) primarily prioritize abstinence and partner reduction over condom use and education. By his own account, this represents a paradigm shift in thinking on HIV prevention:

Green believes that the transformation of his maverick and unorthodox ideas into official US policy has been nothing short of groundbreaking.

The article works hard to place Green gingerly in between ‘fashionable academic anthropology’ and the conservative government he apparently works with quite closely, despite being a Democrat (we read of him on a private trip to Africa with CEOs of major pharmaceutical concerns and top Bush administration officials). Green sees Uganda’s famous ‘ABC’ approach as reflecting an ‘indigenous’ Ugandan response to AIDS, and apparently he emphasizes the need for HIV/AIDS agencies to take into account local perspective(s). His political party affiliation notwithstanding, Green’s research is embraced by the right wing of the political spectrum.

Douglas Feldman and Tom Boellstorff each published sharp letters in response to the AN piece.While Feldman details the failures of Bush’s policies, Boellstorff criticizes Green’s notion of ‘risk elimination’ and his simplistic model of indigenous point of view. Boellstorff writes:

Green’s notion of ‘indigenous prevention models’ is rooted in an incorrect understanding of cultural relativism. The notion of ‘the indigenous’ upon which Green relies, and which was disproven by ‘fashionable academic anthropology’ a couple decades ago, presumes a singular ‘indigenous perspective’ and ignores inequality and culture change. What if the supposed ‘indigenous worldview’ is that women are inferior, or homosexuality a foreign import? What appear to be ‘indigenous worldviews’ may be shaped by colonialism, reflecting the values of, say, Victorian England.

As it happens, the question of ‘indigenous’ models for prevention is on the minds of the gay men of San Francisco. A risk reduction strategy known locally as ‘serosorting,’ a prevention model that ‘organically’ emerged within SF’s gay sexual subculture, has received the imprimatur of municipal health authorities. Serosorting consists principally in sex partners disclosing HIV status and then sticking to partners of the same status. One of the main reasons for this ‘sorting’ is so that men can engage in what is known as ‘unsafe’ sex while reducing the actual risk of transmission from a positive man to a negative one.

Here, indeed, is a paradigm shift in prevention. Boellstorff and Feldman intimate that Green’s (and by extension, the U.S. government’s) picture of Ugandan policy performs a problematic slippage between local (‘Ugandan’) emphases and U.S. derived conservative imperatives, so that what Green trumpets as ‘groundbreaking’ prevention is actually U.S. conservative ideology in disguise. But in San Francisco, a government agency is openly embracing local forms through which people negotiate risk. The idea is not without it’s detractors. I bullet some considerations:

  • In the U.S., efforts are underway nationally to ‘normalize’ HIV and HIV-testing. Health agencies and companies are looking for ways to streamline testing so that more people will get HIV tests, resulting in greater awareness of sero-status and therefore more informed decision making with regard to sexual risk. Last year, Washington, D.C., authorities announced a plan to get all residents over age 14 tested. Last year, San Francisco authorities briefly rescinded the requirement that city clinics obtain written consent for HIV tests. (The requirement was later re-affirmed.)
  • Continued federal funding for state administered AIDS programs under the Ryan White Care Act was tied to the surveillance of infected individuals through “names reporting.” In order to obtain federal funding for AIDS care, states were and are forced to abide by the order that the names of those who get an HIV+ test result are reported to the CDC. AIDS agencies that had previously strongly opposed such measures were forced to reassess their stances.
  • The California Supreme Court ruled in July that a person may be held liable in civil court for infecting someone even if s/he did not know at the time of the encounter that s/he was positive. In a complicated decision positing the existence of ‘constructive’ (versus ‘active’) knowledge of infection, the court argued that anyone who had ever engaged in high risk sex should, essentially, know and reveal that s/he could be a carrier on the basis this sexual history or else be held liable for possible transmission.
  • The AIDS crisis became newly fashionable, as celebrities, fashion designers, musicians, corporations, and others took up the cause of the epidemic in Africa. It became possible for wealthy white Westerners to appear in awareness advertising proclaiming, “I AM AFRICAN.” It became possible to imagine that using a red American Express charge card was an act of empathetic human kindness:American Express

These are just big developments that spring to mind — I’m sure there are others and I invite commentary.

If every articulation of knowledge also entails the exercise of power, we here have a set of knowledge-power relations fraught with an exceedingly complex tangle of interests, motives, fears, desires, each of them imaged and elicited through sophisticated semiotic technologies (laws, television ads, fashion, hyperlinks). Knowledge of HIV-status might be positioned as a form of self-care for a community under siege, an ethical imperative that promotes both health and eroticism. At the same time, however, knowledge may come at the expense of increased surveillance. ‘Normalization’ of HIV testing — and the dictate that one know oneself as a subject of HIV (regardless of status) — has all the marks of what we have so fondly come to understand as ‘governmentality.’ Persons emplace themselves on a leveling grid (the postive/negative diagnostic) that subsequently structures their rights, their senses of self, their potential pleasures. Spectres of confinement and incarceration, prosecution and persecution, haunt this self-knowledge that is simultaneously state knowledge. Bodies appear both more robust (medicated) and more fragile (infected), and the lives of the marginalized are metonymized as the cause/consequence of policies that reinscribe their marginalization. Residents of Washington, D.C. are told that HIV testing is a ‘prevention strategy’ — but they are not also told that they will be guaranteed care and treatment in the event that they are sick.

No wonder that some see silence on HIV as a way of resisting, or of relaxing, the tangles of conduct and coercion (and, yes, care) that comprise positive publics. Some activists in San Francisco, for example, are calling for a moratorium on social marketing campaigns directed at gay men. And silence too is a semiotic technology, possibly even a persuasive one. Silence too may be a semiotic technology of a ruthlessly simple kind — especially in worlds where we are incited and seduced, over and over, and in manifold ways, to know ourselves through a virus.

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Strong is Thomas Strong, lecturer in the department of anthropology at the National University of Ireland Maynooth.

6 thoughts on “Addressing Publics Positively: Some Developments in HIV Prevention

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    Strong says:

    Anyone running across this should also see the following article:

    Technology and Affect: HIV/AIDS Testing in Brazil. By: Biehl, João; Coutinho, Denise; Outeiro, Ana Luzia. Culture, Medicine & Psychiatry, Mar2001, Vol. 25 Issue 1, p87-129

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    Strong says:

    A spat has broken out between Gabriello Rotello and Andrew Sullivan regarding the current state of the AIDS/HIV epidemic among U.S. gay men. Rotello’s recent post at Huffington Post links to Sullivan and responds. The dispute partly concerns the idea of ‘sero-sorting’ as a prevention strategy, which I comment on in the above item.


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    Ted Green says:

    I only read the first couple of para’s attacking me for breaking the silence about AIDS. If the writer cares about evidence rather than maintenance of a multi-billion dollar industry, he/she will have to eventualy face facts:
    African AIDS is not like American AIDS. African AIDS is not caused or driven by poverty, gender inequality or social/civil strife. Nor is one “protected” by using American or any other condoms. What a cruel hoax on Africans.

    All the popular things the major donors fund: condom social marketing, treatment of STIs, and VCT are about as effective in Africa as Bush’s war policy is in Iraq. Or Israel’s policy of “fighting terror” is in Palestine.

    The writer can atack me personally all he wants, but his/her faith-based consensus approach to AIDS will continue to have no effect in Africa. I suggest the writer begin with looking at recent DHS data for SSA, then check at some recent studies:

    Gregson S; Adamson S; Papaya S; Mundondo J; Nyamukapa CA; Mason PR; Garnett GP; Chandiwana SK; Foster G; Anderson RM. (2007) Impact and process evaluation of integrated community and clinic-based HIV-1 control: A cluster-randomised trial in eastern Zimbabwe PLOS MED. 4: 545-555;

    Quigley M, Kamali A, Kinsman J, Kamulegeya I, Nakiyingi JS, et al. (2004) The impact of attending a behavioural intervention on HIV incidence in Masaka, Uganda. AIDS 18: 2055–2063

    Sherr L et al. Voluntary HIV testing in rural Zimbabwe – what is the uptake, impact on sexual behaviour and HIV incidence 3 years later? Third South African AIDS Conference, Durban, abstract 46, 2007.

    Matovu JKB et al. Voluntary HIV counselling and testing acceptance, sexual risk behaviour and HIV incidence in Rakai, Uganda. AIDS 2005, 19: 503-511.

    Increased prevalence of HIV: Not a casualty of war

    Prevalence of HIV infection in conflict-affected and displaced people
    in seven sub-Saharan African countries: a systematic review
    Paul B Spiegel MD, Anne Rygaard Bennedsen BSc, Johanna
    Claass MD, Laurie Bruns MA, Njogu Patterson MD, Dieudonne
    Yiweza MD and Marian Schilperoord MA.
    The Lancet 2007; 369:2187-2195, DOI:10.1016/S0140-6736(07)61015-0

    Remember: truth usually wins in the end. Ad hominen attacks do not.


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    Strong says:

    Hi Ted, Thank you for your comment! I do not see how this post can be construed as an ‘ad hominen’ attack. I point to an article in Anthropology News that *celebrated* your work (although I gesture to the lack of dissenting voices in the piece) and to letters by other experts who disagree with you. If you had read the whole post, you might see that the dispute in AN served as a segue for talking about some developments in HIV prevention in the US *not* in Africa. Indeed, this post is not about prevention per se, but how messages pertaining to prevention shape what HIV/AIDS means.

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    Edward C Green says:

    The author or Webmeister wrote of my response “I do not see how this post can be construed as an ‘ad hominen’ attack.”

    Well, I guess not, if calling someone a fashionable conservative who flies around with drug company CEOs is considered a complement–to a left-wing, get-out-of-Palestine-and-Iraq-Today anthropologist.

    To understand the difference between an indigenous response to AIDS rather than a corporate Euro-American commodities-driven response, you only need follow the money, as they say.

    My view on these matters aims to empower people– individuals–to take some control of their destiny. It is patronizing in the extreme to think that we social engineers, we Grandiose Planners from Washington, Geneva, and London know what is best for the World’s poor, including in AIDS matters. Or to patronizingly dismiss behavior change efforts as of no use because “we” know poor people have no control over economic forces or their male hormones.

    Indeed, the position I argue is “bad for business,” since it questions the need for multi-billion dollar AIDS programs based on expensive drugs, medical devices, and—most of all—expensive “technical consultants” like myself and my friends and colleagues. Surely challenging Big Business, Big Pharma, Big Consulting is not conservatism as we usually know it. It seems more like democracy, but the real thing and not what Bush & Cheney promote with shock-and-awe ordnance in the Middle East.

    The annual cost of the world’s first clear AIDS success story was almost embarrassingly low. [for a calculation of cost of original program:
    “The population of Uganda was estimated at 22,459,000 in 2000 by the United Nations Economic Commission for Africa, an annual average increase of 2.5 percent from the 1995 population of 19,689,000” So, estimate 18.9 mil for 1990. Low-Beer in Financial Times:
    “One of the best kept secrets in HIV is that the critical Ugandan programme cost only $21,676,000 over five years.”

    So divide the 5 year cost by 5 = 4,335,200 expense per year, = 23 cents per person per year (or nearly half that if we only consider ages 15-49
    (Ref. Daniel Low-Beer, “Personal view: ‘This is a routinely avoidable disease’.” Financial Times; Nov 28, 2003)

    What does the Merk-USAID-Gates Foundation-Kaiser Foundation-Bono-fundraising AIDS prevention programs of Botswana and South Africa cost? Somewhere in the many hundreds of dollars per person, per year. Forget pennies, this is Science!

    Yet unlike Uganda’s original program, these expensive programs have not worked.

    This may be difficult to process through the conventional lens of American conservatism –liberalism polemics. If so, I suggest abandoning attempts to understand this as an American. But it ought to at least be clear that the Big Business approach to AIDS prevention (the approach that has had success in Thailand and Cambodia but never in Africa) is not the one I have been promoting since 1993.

    Postscript: Alas, the Big International Donors have effectively stripped Ugandan AIDS prevention of the elements that made it effective in the period 1986-95 (perhaps because no US commodities were involved? Putting a lot of White Folks out of business?). Multi-partner sex and HIV prevalence are again on the rise in Uganda. The Corporate West seems to have prevailed in the end, I am sorry to say, with the help of well-meaning US activists who thought they were on the right side of this issue…

    -Ted Green

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    Strong says:

    Hi again, and thank you for your response. You make a great point about how serious thinking about HIV and AIDS defies the easy orthodoxies of either a (U.S.) liberal or conservative sort, especially as these impinge upon politics in other countries. I appreciate your taking the time to comment further. Stepping away from the question of whether promoting condoms is a magic bullet for preventing HIV-transmission in all places, there is another question that doesn’t cleave easily along left (anti-market, say) and right (anti-welfare, say) lines and this pertains to making lifesaving drugs available to people who already have HIV.</p><br /><br /><br /><br /><br /><br />
    <p>First, it’s possible that these drugs might never have been developed. The story of _how_ they were developed is complex, and it crisscrosses divides between science, the market, and activist communities, as “Steven Epstein”:http://books.google.fi/books?id=kZOso0FMsrMC&dq=&pg=PP1&ots=CVfs5PeVP-&sig=usiJxZVKphfWK83n3xsETL_riUA&prev=http://www.google.fi/search%3Fclient%3Dfirefox-a%26rls%3Dorg.mozilla%253Aen-GB%253Aofficial%26channel%3Ds%26hl%3Den%26q%3Dimpure%2Bscience%26meta%3D%26btnG%3DGoogle%2BSearch&sa=X&oi=print&ct=title has shown. I remember many arguments with other AIDS activists in the early 1990s about whether our clarion call for “more (state) funding” for AIDS research was the best way to hasten the development of lifesaving treatments. Some argued that the market, and naked financial interest, would be the most effective forces for getting the drugs developed. Of course, it is worth remembering that ACT UP and other AIDS activist organizations, including ACT UP’s Treatment Action Group, were operating in an extremely hostile environment, in which getting _anyone_ (including US Presidents) even to _talk_ about AIDS was something of an accomplishment. Yet, the ostensibly radical politics of a group like ACT UP were sparked by the personal efforts and passionate rhetoric of “Larry Kramer”:http://en.wikipedia.org/wiki/Larry_Kramer who combined moral outrage at the disgusting neglect of HIV by politicians and others with a more practical outrage about the sex habits he imputed to the gay male community. Likewise, “Randy Shilts”:http://en.wikipedia.org/wiki/And_the_Band_Played_On crossed over and between easy left/right orthodoxies in his majesterial and still vital history of HIV and AIDS in America.</p><br /><br /><br /><br /><br /><br />
    <p>OK, so the development of ARVs, as well as HIV prevention tactics, in the _US_ represents a history that can’t be reduced to platitudes about left and right. So what about today, right now? I mean, we now HAVE the means to save millions of lives through anti-retroviral drugs that are extremely expensive. What are the politics involved? There are issues concerning intellectual property rights and finding ways to speed production of the drugs in poor countries, for example. If commercial interest in part provided the motive for development of drugs, would relaxing the property laws that make that interest profitable undermine the system that generated them (the drugs) in the first place?</p><br /><br /><br /><br /><br /><br />
    <p>I think the best writing and thinking on this problem, and its politics, is by an anthropologist! His name is “Joao Biehl”:http://www.princeton.edu/main/news/archive/S17/06/97S70/index.xml?section=featured and he sensitively and complexly portrays the ways in which Brazil has made ARVs available. However, it is worth pointing out that “Jean Comaroff”:http://www.publicculture.org/articles/volume_19_number_1/beyond_bare_life_aids_bio_politi has recently criticized Biehl for being insufficiently attentive to and critical of the commodity-form that anti-HIV treatment takes today. So does promoting ARVs constitute a kind of commodity fetishism, where the drug in contemporary global orders is a kind of ur-Commodity because it weds capital’s interest in profit to the state’s biopolitics? I am _thinking_ about this stuff and these disputes in relation to research I want to do and I haven’t made up my mind, basically. My writing on this blog that pertains to HIV is an effort to sketch a set of ill-formed ideas that are nascent and inchoate. But as AIDS-HIV morph from a terminal syndrome in every instance to a potentially chronic disease, it will be important for us to re-think all the old analyses, their politics, and the way they inform the way we perceive the epidemic <em>today</em>. I really think this is vital today, because so much of the culture of HIV continues to be ruled by debates that were relevant to the 1980s and 1990s. </p><br /><br /><br /><br /><br /><br />
    <p>So yes, you are absolutely right when you write: “This may be difficult to process through the conventional lens of American conservatism–liberalism polemics,” a statement you make regarding Uganda, but that can be extended to a number of situations, including oddly enough the US itself.</p><br /><br /><br /><br /><br /><br />
    <p>OK. I do think that you are imputing to this post an ‘attack’ that simply isn’t there, and it could have something to do with the snarky tone attributed to most writing on the web. (I do not imply that web writing is not often snarky.) If anything, the main thing criticized in the sections of this post that bother you is an article in Anthropology News that failed to consult other anthropologists who hold different views about HIV prevention, some of whom replied with letters to the publication. The post does not say that conservatism is fashionable; it does say that the article positions you carefully (‘gingerly’) _between_ (as in: not in either camp) academic anthro and conservative politics. I frankly do not know enough about the Ugandan situation to say very much at all about it: which is why this post is not about Uganda, nor about your work, but rather about some shifts in thinking and action around HIV that are going on in the US.</p></p></p></p></p></p></p>

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