| Abstract: | 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. |
