Educating about HIV: prevention, impact mitigation and care

Since very early in the epidemic, education has been identified as central to an effective response. Three different kinds of education can be distinguished: education for HIV prevention, education about treatment, and education to prevent or mitigate the negative effects of the epidemic. This article also considers three different contexts in which education takes place: in schools, at the level of specific groups and across society as a whole. Some 30 years into the epidemic, it is vital that the potential of education is more fully recognized and embraced, not only by agencies and individuals with special expertise in the field (although this is essential), but also by everyone seeking to contribute to the ambitious goals of zero new infections, zero discrimination and zero AIDS-related deaths.     

Understandings of risk among HIV seroconverters in Sydney

This paper examines the risk discourses of Sydney gay men who had recently become HIV positive. 92 in depth interviews were conducted eliciting narratives about the incident in which they believed they became infected. The veracity of this narrative was negotiated between the interviewer and participant. Qualitative analysis was performed in order to distinguish different styles of thinking and acting in relation to risk. Two overarching discourses were distinguished that broadly related to the fields of public health, HIV prevention education, social theory and health policy. These we characterise as ‘quantifiable/objectivist’ and ‘social/subjectivist’. The first approach sees risk as objectively knowable through the application of scientific method or reasoned thinking. The second regards actors as culturally embedded in relation to risk, itself a cultural category. The fact that all men in this study became infected demonstrates the potential fallibility of both approaches. HIV prevention strategies need to take account of both the cultural aspects of risk, understanding the embedded quality of everyday cultural practices such as hygiene, and understand these assumptions are often inadequate for preventing HIV infection. Objectivist approaches also entail problems as many men using them felt HIV infection to be inevitable or unavoidable in some circumstances.     

The injection of methadone syrup in New South Wales: patterns of use and increased harm after partial banning of injecting equipment

OBJECTIVE: To describe methadone injectors and the risk practices associated with injecting methadone in New South Wales, Australia. To assess the impact on injecting drug use and risk behaviour of the withdrawal of methadone injecting equipment from government-funded needle and syringe programs. METHOD: Cross-sectional survey, conducted in 1999, of 206 people who had injected methadone at least once in the previous month. Participants were from Central Sydney, West Sydney and rural New South Wales. RESULTS: Of participants who had injected both methadone and other drugs in the previous month (n=162), significantly more reused their methadone injecting equipment compared with those who reused their other drug injecting equipment (60% vs. 28%, p<0.01). There was no significant difference in terms of sharing injecting equipment, with 19% reporting sharing methadone injecting equipment and 14% sharing other drug injecting equipment. However, women were more likely than men to share methadone injecting equipment. Over half of the participants had accessed diverted methadone and a substantial minority reported the use of public spaces for injecting methadone. CONCLUSIONS: Our results suggest that the current policy has led to increased reuse of equipment for injecting methadone. IMPLICATIONS: A range of other possible policy options, such as closer monitoring and dilution of take-home doses, increasing oral doses and implementing trials of injected methadone, may assist to reduce the prevalence of methadone syrup injection and related harms.     

How homosexual men believe they became infected with HIV: the role of risk-reduction behaviors

OBJECTIVES: A range of HIV risk reduction strategies has been described in homosexual men who practice unprotected anal intercourse (UAI), including serosorting, strategic positioning, and negotiating around an HIV-positive partner's viral load. It is uncertain how commonly these behaviors might result in HIV infection. We describe sexual behaviors and associated risk reduction strategies reported by homosexual men in their accounts of their recent seroconversion. METHODS: Homosexual men recently diagnosed with primary HIV infection between 2003 and 2006 were invited to participate in a nurse-administered survey. RESULTS: Among 158 men enrolled, 143 (91%) were able to identify the high-risk event that they believed led to their HIV seroconversion, and this involved UAI in 102 (71%). Among these 102 men, 21 (21%) reported they were certain that the source partner was HIV-negative. Ten men (10%) reported insertive UAI as the highest risk behavior. Of the 21 men who reported knowing the HIV-positive partner's viral load, 9 reported that the man had an undetectable viral load (43%). CONCLUSION: In 38% of the high-risk events involving UAI, infection occurred when the reported risk event involved serosorting, strategic positioning, or intercourse with a man whose viral load was believed to be undetectable.     

Between Individual Agency and Structure in HIV Prevention: Understanding the Middle Ground of Social Practice

When HIV prevention targets risk and vulnerability, it focuses on individual agency and social structures, ignoring the centrality of community in effective HIV prevention. The neoliberal concept of risk assumes individuals are rational agents who act on information provided to them regarding HIV transmission. This individualistic framework does not recognize the communities in which people act and connect. The concept of vulnerability on the other hand acknowledges the social world, but mainly as social barriers that make it difficult for individuals to act. Neither approach to HIV prevention offers understanding of community practices or collective agency, both central to success in HIV prevention to date. Drawing on examples of the social transformation achieved by community action in Australia and Brazil, this article focuses on this middle ground and its role in effective HIV prevention.In 2012, the Joint United Nations Programme on HIV/AIDS (UNAIDS) released a report in conjunction with the International AIDS Conference in Washington, entitled “Together We Will End AIDS,” which included a section entitled “Transforming Societies.”1 At the beginning of this section, communities are placed center stage:

When affected communities help to plan and implement HIV initiatives, the demand for better and more equitable services increases, awareness of societal barriers and harmful gender norms is raised, governments are held accountable for meeting the needs of citizens and services and outcomes improve. This leads to broader social transformation, which is paramount to halt and reverse the HIV epidemic.1^(p58)

A few pages later, Wilson places community at the heart of an effective response, asserting that “nothing has ever happened in HIV that was not driven by the communities most impacted.”1^(p61) Later in the report, the importance of collectives and groups is again made explicit with reference to young people: “Young people have a unique role in reaching out to their peers, particularly in key populations at higher risk of HIV such as young people who inject drugs.”1^(p79)Although community has always played a part in HIV prevention, this explicit UNAIDS attention is welcome because it shifts attention away from an earlier almost exclusive focus on risk behaviors and vulnerable populations. It places socially related individuals that make up these communities center stage and in a manner that highlights agency, and more importantly, as we demonstrate, collective agency.Not all vulnerable populations perceive themselves as distinct communities based on the behaviors that place them and their members at risk for HIV. Nevertheless, the members of these populations all inhabit social worlds that mediate, in profound ways, their ability to confront HIV and AIDS. Heterosexual men and women, gay men, injection drug users, and sex workers are all at greater or lesser risk and more or less vulnerable depending on a host of sociocultural, political, and economic factors. These same people, as members of communities, groups, organizations, or collectives, are those who have acted to protect themselves and others from HIV and AIDS by transforming their own sexual and drug injection practices.Findings from studies around the world have documented declines in HIV transmission, and many of these studies have identified the role of communities, networks, and groups—both those infected with HIV and those affected either directly or indirectly by HIV—as one of the key factors related to the declines. Such evidence is provided for Africa from Uganda,2 Zimbabwe,2–4 Malawi,5 and South Africa.6 It also has come from several countries, including Brazil and Thailand,7–9 and from cities such as New York City; Rotterdam, the Netherlands; and Buenos Aires, Argentina and sites in Central Asia.10 Many of these studies provide rich and detailed accounts of the social and political processes involved in the collective shifts in social practices that preceded declining HIV incidence, and the role of sexual communities, kinship networks, and drug using groups in achieving these outcomes. Although the evidence for effectiveness is not conclusive (and effectiveness cannot be assessed the same way as efficacy using randomized controlled trials or other forms of experimental control),11 evidence is available. Such evidence, framed as a series of steps from HIV prevalence to national policies via measures of HIV incidence, changes in behavior, and HIV prevention programs,12 indicates more or less what has worked in particular settings at particular times. It is clear that collectives, whether they are communities, networks, or groups, are central in terms of advocating, initiating, and implementing change. However, what is not clearly stated is how communities become transformative in their practices.Following Adam’s analysis13 of the ways in which the epistemological framework, which is characteristic of biomedical individualism, bypasses the social, we aim to show how the predominant ways of framing discussion of HIV prevention, in terms of risk or vulnerability, have occluded attempts to understand how social transformation occurs. We also examine how the concept of “social drivers” attempts to offer the conceptual tools for engaging with community responses to HIV. Although such framing does not quite fulfill its promise, it points toward a potentially productive way of understanding social transformation and change. We examine the centrality of collective agency and social practice in social transformation, drawing on examples of shifts in practice in 2 contrasting countries, Australia and Brazil. These cases demonstrate public health’s capacity to engage with collective agency when it takes as its starting point neither risk nor vulnerability, but the collective agency of communities whose HIV prevention efforts are shaped by the specificities of what they value.     

HIV generations? Generational discourse in interviews with Australian general practitioners and their HIV positive gay male patients

The introduction of highly active antiretroviral therapy (HAART) is typically represented as a turning point in the social and medical history of HIV/AIDS, leading to a conceptual division into pre- and post-HAART eras. This paper explores how generational discourse is produced in interviews with general practitioners (GPs) and their HIV positive gay male patients in making sense of this moment and related changes in the Australian HIV epidemic. A theme of ‘HIV generations’ was identified in in-depth interviews with GPs who have HIV medication prescribing rights (based in Sydney, Adelaide and rural-coastal New South Wales) and the HIV positive gay men who attend their practices. In a closer analysis, generational discourse was identified across the interviews with GPs, characterising pre- and post-HAART HIV generations through three main features: treatment histories, socioeconomic status, and modes of survivorship. While generational discourse was less common in the accounts of HIV positive gay men, many of their examples wove together two narrative forms – ‘a different time’ and ‘difference today’ – suggesting that concepts of time and inequity are deeply embedded in these men’s understandings of the HIV experience. Our analysis indicates that generational concepts play a significant role in shaping both professional and ‘lay’ understandings of changes and patterns in the HIV epidemic.     

Sexual practice and understandings of safe sex: assessing change among 18- to 19-year-old Australian tertiary students, 1988 to 1994

Abstract: From 1988 to 1994, first-year students in a large introductory class at Macquarie University completed a questionnaire regarding sexual practice, knowledge of transmission of human immunodeficiency virus (HIV) and understandings of safe sex. Data from 18- and 19-year-old students were analysed to examine changes over time among recent school leavers. Approximately 58 per cent were sexually experienced, young men were more experienced than young women, and both had more experience with regular than with casual partners. The number of partners did not vary over the years, most respondents having had one or two partners. Changes over time were found with respect to condom use, particularly with regular partners. The percentage using condoms 'always' with casual partners was greater, having increased to around 60 per cent. Accuracy of knowledge relating to safety of sexual practices with casual and with regular partners increased over time, particularly with respect to regular partners. While both accuracy of knowledge and safety of practice increased with time, there was no relationship between these two variables in any one year. The findings suggest that there has been normative change with regard to condom use and that this has occurred within a reasonably static and unchanging set of sexual practices. Sex education appears to be one of the factors contributing to this change.     

HIV-related discrimination: a survey of New South Wales general practitioners

Abstract: This study aimed to investigate the correlates of human immunodeficiency virus (HlV)-related discrimination among general practitioners. The survey, conducted in 1993–1994, covered a random sample of 878 general practitioners from six of the 12 New South Wales health areas, augmented by 44 general practitioners from the same areas who were antiretroviral drug prescribers. The response rate was 51 per cent, and the final usable sample was 451. Variables examined were: demographic characteristics, the number of HIV-infected patients, personal contact with people living with HIV or AIDS, personal contact with homosexuals, the degree of anxiety about HIV or AIDS, and the degree of HIV-related discrimination. Discriminatory attitudes among general practitioners decreased as contact with HIV-infected patients (P < 0.001), other people living with HIV or AIDS (P< 0.001), and homosexuals (P < 0.001) increased. Anxiety about HIV or AIDS also decreased as contact increased (P < 0.001). Higher levels of anxiety were strongly associated with higher levels of HIV-related discrimination (P< 0.001). The demographic correlates of discrimination among general practitioners were the same as those found in the wider population. The professional care of people living with HIV and AIDS was concentrated among a small number of general practitioners, many of whom were homosexual. Ten general practitioners were carrying extraordinarily high caseloads of over 200 HIV-infected patients each. Older, heterosexual and male general practitioners are an important target for education campaigns, and the professional care of people living with HIV or AIDS should be encouraged among a wider group of general practitioners.