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The Social Barriers to Effective HIV Prevention

The Social Barriers to Effective HIV Prevention . Susan Kippax Social Policy Research Centre University of New South Wales Australia. The inexpressible social .

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The Social Barriers to Effective HIV Prevention

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  1. The Social Barriers to Effective HIV Prevention Susan Kippax Social Policy Research Centre University of New South Wales Australia

  2. The inexpressible social “Since the beginning of the pandemic, the focus of discourse and policies throughout the world solely on the medical aspects of the illness, and since the beginning of the South African controversy, solely on the availability of drugs, has made the social issues (both carried and revealed by AIDS) practically inexpressible” (Fassin, 2007, p.189)

  3. Four Sections of the Talk • what constitutes effective prevention • the role of the social and political in effective prevention • the challenges of the inclusion of social and political factors with regard to evidence for effectiveness • a ‘social public health’

  4. Efficacy and Effectiveness • Efficacy: is the improvement in health outcome achieved in a research setting, in expert hands, under ideal circumstances: it measures the individual-level effect of an intervention • Effectiveness: is the impact an intervention achieves in the real world, under resource constraints, in entire populations, and in specified sub-groups of a population Aral & Peterman , The Lancet, 1998.

  5. Two Requirements of Effective Prevention Effective HIV prevention requires: • efficacious tools and technologies, which are then • made available to populations, and taken up by communities and their individual members and made part of their everyday lives

  6. Requirements for Effectiveness Prevention tools • NSP • Condoms • PMTCT • Male Circumcision • Microbicides • PreP/nPEP • Treatment as prevention Provision and promotion • Political support • Mass media • Social marketing • Sex education • Peer outreach/educ. • Community engagement • Counselling

  7. Effectiveness ‘Enablers’ The acceptability & sustained take-up of the technologies is dependent on: • Technologies themselves • Political commitment • Cultural understandings and values • Laws, legal policies and practices • Community mobilisation • Stigma reduction Schwartlander et al. The Lancet 2011

  8. Synergies with Development Sectors • Education • Legal reform • Gender equality • Poverty reduction • Community systems • Employer practices • Health systems Schwartlander et al. The Lancet 2011

  9. Kissing Mutual masturbation Oral-genital sex Vaginal intercourse Anal intercourse Range of more esoteric behaviours Kippax, Current Opinion in HIV/AIDS, 2010 Express/communicate love/build intimacy Reproduce/have a family Casual sex/‘one night stand’ For pleasure/for fun Reaffirmation of one’s sexuality Loss of virginity Sex work Rape Behaviour Practice

  10. Strategies adopted by Gay Men in Sydney (1984/5 - ) • Condom use • Negotiated safety • Poz-poz sex • Serosorting/guessing • Strategic positioning • Reliance on undetectable viral load • nPEP • Treatment of STIs Kippax & Race, Social Science & Medicine (2003); Mao et al. J. STIs (2011)

  11. The Effectiveness of “Treatment as Prevention” hinges on: • Cost • Levels of stigma associated with HIV testing • Feasibility of annual or more frequent testing • Human rights issues • Adherence/ drug resistance issues

  12. Unintended Consequences of “Treatment as Prevention” • Government abandonment of politically difficult HIV prevention technologies such as provision of needles and syringes • Personal abandonment of condoms and other forms of prevention • 100% of funding earmarked for treatment Kippax et al., AIDS Education & Prevention, 2011.

  13. Work of Social and Political Science • Understand how the medium of the social works for and against HIV prevention • Design HIV prevention programmes or interventions that engage with the terrain in which they operate • Make externally valid assessments of their effectiveness

  14. Contingent Outcomes Effectiveness is acontingent outcome of: • the collective activity of a diverse range of actors both human and non-human, including the technologies themselves • scientific practices and clinical services • legal decisions and environments • norms, values, and discourses that animate human behaviour/practice. Race (2011); Haraway (2011); Michaels & Rosengarten (2010)

  15. HIV Prevention Evaluated • Uganda: Low-Beer and Stoneburner, 2003; Stoneburner & Low-Beer, 2004; Hallett et al., 2006; Thornton, 2007 • Zimbabwe: Hallet et al. 2006; Gregson et al., 2006; Halperin et al., 2011 • Australia: Bowtell 2005; Mindel & Kippax (in press) • Brazil, Thailand, .. Global HIV Prevention Working Group, 2006; 2007; and 2008

  16. Models of New Public Health

  17. Effective Prevention • Government provision of prevention tools and public support • HIV prevention programmes that are informed by biomedical, epidemiological and social research • Funding of community-informed, if not community-led, prevention programmes that promote public debate and talk

  18. Conclusions Effective prevention entails developing community capacity and requires that public health address people not only as individuals but as connected members of groups, networks, and collectives who interact (talk, negotiate, have sex, use drugs, …) together.

  19. Conclusions All effective prevention requires people to change practices: need to move beyond the unhelpful distinction between behavioural and biomedical prevention

  20. Effective HIV Prevention Engage with HIV and efforts to prevent it as encountered in life – as • biological and material • information and technological • emotional and affective • social, collective, and institutional

  21. Tribute & Request Please add your voices to the many appeals to Iranian authorities to release Dr. Arash Alaei from prison and allow him to leave Iran. He and his brother were among the pioneers of harm reduction in Iran - a country which adopted and implemented harm reduction early and vigorously - to the great benefit of its people. Sign the petition atIranFreetheDocs.org

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