From brothel to boardroom: prospects for community leadership of HIV interventions in the context of global funding practices

The empowerment of marginalised communities to lead local responses to HIV/AIDS is a key strategy of funding agencies' globalised HIV/AIDS policies, given evidence that disempowerment is a root source of vulnerability to HIV. We report on two multi-level ethnographies at the interface between HIV prevention projects for sex workers in India and their funding environment, examining the extent to which the funding environment itself promotes or undermines sex worker empowerment. We show how the 'new managerialism' characteristic of the funding system undermines sex worker leadership of HIV interventions. By requiring local projects to conform to global management standards, funding agencies risk undermining the very localism and empowerment that their intervention policies espouse.     

Deconstructing the Portrayals of HIV/AIDS Among Campaign Planners Targeting Tribal Populations in Koraput,India: A Culture-Centered Interrogation

This article deconstructs the portrayal of HIV/AIDS in the tribal dominated district of Koraput, India, among program planners, service delivery personnel, nongovernmental organizations (NGOs), etc. who plan, implement, and evaluate HIV/AIDS interventions targeting tribal communities in the region. Drawing upon postcolonial and subaltern studies approaches, we critically examine the ideological assumptions that circulate in the dominant discursive spaces among campaign planners and implementers who target HIV/AIDS among the tribal population in Koraput, India. Based on our critical examination, we suggest guidelines for engaging with program planners and implementers through health communication pedagogy informed by the culture-centered approach.     

Counting results: performance-based financing and HIV testing among MSM in China

In this paper, I examine the use of performance-based financing to scale-up HIV testing in men who have sex with men, or MSM, by global health initiatives in China. This mechanism, which ties financing directly to the achievement of targets and indicators, assures that measurable results are produced from health interventions and accounts for financial spending. On the one hand, its adoption into HIV programming in China articulates with broader shifts in global health that place currency on particular forms of evidence. At the same time, performance-based financing reshapes how HIV interventions are carried out and what counts in these programmes. The suturing of financing to outputs directs what gets counted and how, and as a consequence leads to the production of measurable results as an end in and of themselves. Based on 22 months of ethnographic research carried out in China, I explore the effects of this mechanism and, in doing so, ask what gets left out in the pursuit of evidence. In particular, I demonstrate how the demand for outputs undermines HIV prevention in MSM, thus risking the very lives these interventions are intended to save.     

Deconstructing the portrayals of HIV/AIDS among campaign planners targeting tribal populations in Koraput, India: a culture-centered interrogation

This article deconstructs the portrayal of HIV/AIDS in the tribal dominated district of Koraput, India, among program planners, service delivery personnel, nongovernmental organizations (NGOs), etc. who plan, implement, and evaluate HIV/AIDS interventions targeting tribal communities in the region. Drawing upon postcolonial and subaltern studies approaches, we critically examine the ideological assumptions that circulate in the dominant discursive spaces among campaign planners and implementers who target HIV/AIDS among the tribal population in Koraput, India. Based on our critical examination, we suggest guidelines for engaging with program planners and implementers through health communication pedagogy informed by the culture-centered approach.     

‘We can’t do that here’: negotiating evidence in HIV prevention campaigns in southwest China

Disease prevention and health care delivery, areas traditionally governed by the nation state and local communities, are increasingly being inhabited by ‘mobile sovereigns’ who carry a global currency of prevention strategies and treatments grounded in the universal standards of scientific evidence. Drawing on ethnographic evidence from research conducted on HIV in southwest China, this paper examines the impact of evidence-based science on the effectiveness of global health programming. It interrogates the intentions of global health partnerships and how the balance of power waged between those with money, science, and technical expertise, and those seeking assistance and resources, influences global health programming. Ultimately, the paper demonstrates the disconnect between the demand for a system of universal standards developed on the basis of scientific evidence and an appreciation for the local context, which shapes the way these standards should be modified for effective implementation of global health programs.     

Emerging dynamics of evidence and trust in online user-to-user engagement: the case of ‘unproven’ stem cell therapies

Abstract

This article explores the ways in which patients and their families (hereafter referred as ‘users’) share and evaluate disease-specific evidence via online communities. The aim is to understand what this user engagement in healthcare and knowledge production reveals about society’s shifting perceptions of trust in the institutions of ‘evidence-based medicine’ (EBM) such as regulators, bioethicists and scientists and the implications for EBM. To do this, I use the case of experimental stem cell therapies (eSCTs). ESCTs are commonly labelled in academic literature as ‘unproven’, a label that frames their lack of conclusive clinical evidence as unsafe, inefficacious and thus unethical when clinically used. Despite this framing, users engage with other users to share and evaluate all available evidence for themselves, including on-going clinical trial and experiential evidence to build trust for and undertake eSCTs. Increasingly, this user engagement with evidence takes place in online communities that range from user-created and user-run Facebook pages to user-to-user discussion forums on healthcare provider sites or blogs with little if any provider-input in conversations. In this paper, I draw on a sample of these user conversations to show the complex and unpredictable ways in which what counts as evidence and how trust is built for it are shifting. In so doing, I reflect on the shifting relations between the institutions of EBM and society for greater control over evidence that lies at the heart of the evidentiary basis of public health policies.     

Dhandha, dharma and disease: traditional sex work and HIV/AIDS in rural India

This paper discusses the results of two ethnographic studies with female sex workers in rural areas of Karnataka and Rajasthan, India. In particular, we focus on women whose socio-economic status, and religious and occupational practices, are part of sex work systems that have historical precedents such that they can be termed "traditional" sex workers. The approach taken in the ethnographic work was informed by current critical approaches in medical anthropology and public health. The paper argues that in the context of an expanding HIV/AIDS epidemic in rural areas of India, understanding the historical and structural factors that operate to perpetuate female sex work as a culturally "sanctioned" occupation is critical if interventions intended to reduce the risk of HIV transmission are to succeed. We conclude that interventions designed to empower women collectively in these communities that are consistent with cultural traditions are needed to lead to healthier sexual behaviours and reduced risk of HIV/AIDS infection.     

The influence of health knowledge in shaping political priorities: Examining HIV/AIDS knowledge and public opinion about global health and domestic policies

Abstract

Public opinion polls have historically indicated that the US public favours domestic over global priorities. It is not known what influence health knowledge has in shaping public opinion about domestic and global health policy. This study examines how knowledge of HIV/AIDS is related to the rated importance of domestic and global health issues. Participants were recruited to participate in an electronic survey (N = 995) and were predominantly White (86.3%), married (61.9%) and female (71.8%). HIV/AIDS knowledge was significantly associated with both domestic (β = 0.12, p < 0.05) and global health (β = 0.14, p < 0.01) priorities after controlling for sociodemographic variables. In addition, global health was found to act as a mediator between HIV/AIDS knowledge and perceived importance of domestic issues. Study findings suggest that those with greater HIV/AIDS knowledge rate global health issues higher, which in turn affects ratings of more domestic issues. This research has implications for ways to gain support for implementation of public health policy through increasing health knowledge.     

The 'third wave' of HIV prevention: filling gaps in integrated interventions, knowledge, and funding

There is growing optimism in the global health community that the HIV epidemic can be halted. After decades of relying primarily on behavior change to prevent HIV transmission, a second generation of prevention efforts based on medical or biological interventions such as male circumcision and preexposure prophylaxis--the use of antiretroviral drugs to protect uninfected, at-risk individuals--has shown promising results. This article calls for a third generation of HIV prevention efforts that would integrate behavioral, biological, and structural interventions focused on the social, political, and environmental underpinnings of the epidemic, making use of local epidemiological evidence to target affected populations. In this third wave, global programs should deliver HIV prevention services together with cost-effective interventions for reproductive health and for tuberculosis, malaria, and other diseases. Additionally, new efforts are needed to address gaps in HIV prevention research, evaluation, and implementation. Increased and sustained funding, along with evidence-based allocation of funds, will be necessary to accelerate the decline in new HIV infections.     

Chronicity,crisis, and the ‘end of AIDS’

In biomedical, public health, and popular discourses, the ‘end of AIDS’ has emerged as a predominant way to understand the future of HIV research and prevention. This approach is predicated on structuring and responding to HIV in ways that underscore its presumed lifelong nature. In this article, I examine the phenomenon of HIV chronicity that undergirds the ‘end of AIDS’ discourse. In particular, I explore how the logic of HIV chronicity, induced by technological advances in treatment and global financial and political investments, intensifies long-term uncertainty and prolonged crisis. Focusing on over 10 years of anthropological and public health research in the United States, I argue that HIV chronicity, and subsequently, the ‘end of AIDS’ discourse, obscure the on-going HIV crisis in particular global communities, especially among marginalised and ageing populations who live in under-resourced areas. By tracing the ‘end of AIDS’ discourse in my field sites and in other global locations, I describe how HIV chronicity signals a continuing global crisis and persistent social precarity rather than a ‘break’ with a hopeless past or a promising future free from AIDS.