Beyond the Distinction Between Biomedical and Social Dimensions of HIV Prevention Through the Lens of a Social Public Health

Abstract

Developing effective HIV prevention requires that we move beyond the historical but problematic distinction between biomedical and social dimensions of HIV. The current claim that prevention has failed has led to a strong interest in the role of treatment as HIV prevention; however, the turn to “biomedical prevention,” “test and treat,” and “combination prevention” instances pervasive confusions about prevention. These confusions arise from a failure to realize that all HIV prevention interventions must engage with the everyday lives of people and be integrated into their social relations and social practices. We challenge the claim that prevention has failed (illustrating this with discussion of prevention in Australia, Uganda, and Zimbabwe). We explain the enduring appeal of misguided approaches to prevention by examining how 1996 can be seen as a pivotal moment in the history of the global response to HIV, a moment marked by the rise and fall of distinct biomedical and social narratives of HIV.

ALTHOUGH SOME RECOGNITION of disease as having a social dimension is arguably one of the cornerstones of public health, how exactly to conceptualize and respond to the social aspects of disease is highly contested. These questions are particularly pressing when it comes to the deeply intimate social practices involved in HIV transmission. Sexual intercourse and the sharing of drug injection equipment are strongly shaped and regulated by cultural and social norms, and preventing HIV transmission demands a deep engagement with the social, cultural, and political factors that produce vulnerability and risk. To be effective, all HIV-prevention technologies, including those that are called biomedical, must engage with the lived world of those at risk for infection. Hence, the contemporary distinction between biomedical, behavioral, and structural forms of prevention functions to cloud our understanding of what effective prevention is and the mechanisms involved in its effectiveness.

If one reflects on the history of HIV prevention, two narratives emerge: a biomedical and a social narrative. As noted as early as 1993, these two contesting interpretations contrast individualistic and collective views of disease.¹ The focus of prevention in the biomedical narrative is on the individual members of populations who are understood as rational neo-liberal agents who, when counseled by experts, adopt the prevention technologies advocated or change their behavior to reduce HIV transmission. Within this narrative, failure to do so is interpreted as an individual weakness of some kind or a function of some “vulnerability” occasioned by “social structures” such as poverty or gender. The social narrative, rather than focusing on individuals, is concerned with relations between persons and on how sexual and other practices that place persons at risk for HIV transmission are produced as well as transformed to reduce risk. The focus is on communities and networks and the manner in which these collectives interact with the virus, with biomedicine, and with the state and other institutions and are thus enabled (or not) to respond effectively and sometimes creatively to the threat of HIV and AIDS.

We examined the responses of the biomedical and the social sciences to the challenges of HIV prevention—their collaboration and its absence. We argue that the dominant focus of HIV-related discourse and policies has always been biomedical with a particular emphasis on treatment. This has recently been so much so that the insights that social sciences might offer about the social life of the virus, a social life that is integral to its transmission and so to HIV as a medical entity, are occluded. The importance of biomedicine is clearly evident in the Joint United

Nations Programme on HIV/AIDS (UNAIDS; 2006)² timeline covering the defining moments in HIV from 1981 to 2006 (see the box on this page), and this importance has grown since 2006.

Joint United Nations Programme on HIV/AIDS timeline

Year	Twenty-Five Years of AIDS (1981–2006)
1981	Young gay man “diagnosed” with devastating immune deficiency in the United States
1982	Acquired immune deficiency syndrome (AIDS) named
1983	Human immunodeficiency virus (HIV) was identified as the cause of AIDS and the heterosexual epidemic  revealed in Africa
1985	Test to detect HIV in infected persons with no symptoms developed—HIV test
1986	Global Network of People Living with HIV/AIDS (GNP+) founded
1987	Global Program on AIDS (World Health Organization) was established in recognition of a global epidemic
1987	First therapy for AIDS—AZT (zidovudine)—developed
1993	In 1991 to 1993, HIV prevalence in young pregnant women in Uganda and in young men in Thailand  begins to decrease, the first major downturn in developing countries
1994	First treatment regimen to reduce mother-to-child transmission developed
1996	Comparatively successful antiretroviral treatment (ART) developed
1996	Joint United Nations Programme on HIV/AIDS (UNAIDS) formed
1997	Brazil becomes first developing country to provide ART through its public health system
2001	United Nations General Special Session on AIDS (UNGASS) is held in recognition of growing global concern
2001	Global Fund to Fight HIV, Tuberculosis, and Malaria established
2001	The 3 by 5 Initiative of the World Health Organization (3 million people on ART by 2005) developed
2004	Global Coalition on Women and AIDS launched

Source. Joint United Nations Programme on HIV/AIDS, 2006 Report on the Global AIDS Epidemic. Geneva, Switzerland: UNAIDS, 2006.

Although some attention is paid to policy initiatives, such as the formation of UNAIDS, and to two moments in the formation of civil society organizations, the timeline is clearly focused on HIV as a medical challenge. The timeline presents the development of HIV testing and treatment technologies as the history of HIV: the HIV test in 1985, the first therapy for AIDS—AZT—in 1987, the far more successful antiretroviral therapy (ART) in 1996, the provision of ART in Brazil through its public health system in 1997, and the “3 by 5 Initiative” of the World Health Organization (WHO; 3 million people on ART by 2005) in 2003. Only two entries directly refer to prevention. And although there is mention of the formation of two global networks of HIV-positive people in 1986 and 2004, there are no milestones regarding in what these groups, or indeed any groups, participated. Nor is there any mention of what their participation achieved. People are interpolated in the timeline through an illness identity rather than any capacity for collective action or grass roots mobilization. The social issues (both carried and revealed by AIDS) have been rendered “practically inexpressible.”³

Our interest is to understand the appeal of the biomedical approach, and particularly treatments as used in prevention. This appeal rests on a misguided notion that it might be possible to bypass the challenges of actually engaging with the social practices and relations involved in HIV transmission by deploying so-called “biomedical technologies.” One result is that the mainstay of the global HIV prevention response is being increasingly marginalized in global, international, and national prevention policies (i.e., efforts are being diverted from the pressing need to understand what social and cultural factors produce HIV vulnerability and risk and, hence, what constitutes effective prevention). Effective prevention requires addressing the relationships between people, the virus (HIV), treatment drugs, and biomedical and other prevention technologies, and other efforts to reduce risk. We develop this point, together with an account of how our approach to social practices cuts across the familiar division in the field of HIV between behavioral and structural prevention—and an underlying division between nature and culture, or between a virus and the human agents involved in transmitting it.

BIOMEDICAL NARRATIVE OF TREATMENT SUCCESS

The HIV test in 1985 and the 1996 development of ART (sometimes referred to as highly active antiretroviral therapy [HAART]) are watersheds in the history of HIV—in particular, both are essential to successful treatment. The success of treatments fueled attempts to develop biomedical prevention technologies. We witnessed the development of prevention of mother-to-child transmission (PMTCT) and, more recently, microbicide gels based on antiretroviral treatments such as tenofovir, and preexposure and postexposure prophylaxis (PrEP and PEP) also derived from treatments. Most recently a number of researchers⁴ associated with the WHO have proposed that treatment in and of itself is prevention and proposed a prevention strategy, “test and treat,” which involves testing all adults every 12 months and starting persons diagnosed with HIV on ART immediately. On the basis of mathematical modeling, they claim that in populations where a substantial proportion of people living with HIV is on ART, the population viral load is lowered and, thus, the risk of HIV transmission in that population is reduced. No doubt, if the UNAIDS timeline were brought up to date, it would not only continue to illustrate the central position of treatment in the HIV/AIDS official history but also how, since the development of successful treatment of HIV in 1996, prevention has been increasingly “biomedicalized.” It would now almost certainly include the development of interventions such as PrEP and PEP and “test and treat” (all based on antiretroviral therapy) as well as male circumcision.

Although PMTCT is highly efficacious and effective,⁵ the remainder of the previously mentioned prevention technologies have only medium impact under experimental conditions or their efficacy has been demonstrated only under very particular conditions. Furthermore, little if anything is known about their effectiveness,⁶ that is, their “impact … in the real world, under resource constraints, in entire populations.”^6(p33) In recent trials, microbicides have been found to be 39% efficacious in preventing the sexual transmission of HIV from men to women,⁷ male circumcision 55% to 60% efficacious in preventing the sexual transmission of HIV from women to men,⁸ and, depending on the level of drug adherence, PrEP has been shown to be 44% to 73% efficacious in preventing homosexual transmission.⁹ Although not as efficacious as condoms, which are 80% to 94% efficacious in preventing the sexual transmission of HIV,¹⁰ these prevention technologies are either being implemented, as, for example, male circumcision, which has been rolled out in a number of southern African countries,¹¹ or efficacy trials are ongoing and planned, as, for example, for PrEP and microbicides, and guidelines being developed for their implementation.¹² Evidence indicates that the application of PEP lowers the likelihood of occupational HIV transmission¹³ and PEP is provided in many countries for both occupational and nonoccupational exposures.

“The HIV test in 1985 and the 1996 development of ART (sometimes referred to as highly active antiretroviral therapy [HAART]) are watersheds in the history of HIV—in particular, both are essential to successful treatment.”

Finally, turning to “test and treat” as a prevention strategy: although there is evidence that, under very strict conditions, use of ART within heterosexual serodiscordant relationships considerably lowers the risk of HIV transmission (i.e., ART is efficacious as prevention¹⁴), there are conflicting results with regard to test and treat as an effective population strategy. One study in British Columbia¹⁵ has shown that the treatment of drug users is related to a slowing of the HIV epidemic in that population, whereas some others have not shown the same relationship.¹⁶ Still others¹⁷ have queried the ecological nature of the association that Montaner et al. found between increased numbers of individuals on treatment, declines in viral load, and declining new HIV diagnoses in British Columbia, thus questioning the validity of the British Columbian study as a population-based cohort study. Furthermore, some have questioned the assumptions of the model arguing that it is unlikely that the very strict conditions of the model can be met under most real-world conditions.¹⁸ Notwithstanding the controversy surrounding the test and treat strategy, many¹⁹ have called for its immediate implementation. British Columbia has implemented a large pilot project,²⁰ and China²¹ and South Africa²² have taken up the call, and implementation is promised or under way.

Not only do these biomedical prevention technologies—with the exception of PMTCT and treatment as prevention—have partial efficacy and many agencies such as the Centers for Disease Control and Prevention (CDC)²³ recommend their use be “combined with existing prevention measures,” but, with the exception of PMTCT, it is far too early to assess their long-term effectiveness. Effectiveness is not gauged by the success of a particular individual in employing a prevention tool but by establishing “the far-reaching population effects of applying interventions” to a very large number of individuals.^24(p270) So, why the appeal? Why do these concerns and the related controversy of these biomedical technologies not dampen the obvious enthusiasm for biomedical prevention?

The enthusiasm rests in part on what is seen by many as the failure of what has been termed behavioral prevention—delayed sexual initiation, reduction in number of sexual partners, and condom use, and the use of sterile injection equipment—to distinguish it from biomedical prevention. After 1996, many in public health became concerned that HIV prevention was failing and, notwithstanding recent evidence of declines in HIV-transmission rates, UNAIDS²⁵ estimated that there are 2.6 million new HIV infections each year, and that, for every two people placed on ART, three to four more people become infected. It seems that the challenges of HIV prevention have not been met. There has been a range of responses: some²⁶ arguing that failure is linked to both disappointing biomedical interventions (i.e., vaccines) and unsatisfactory results of interventions that rely on behavior change, with others²⁷ noting that condom use, delay of sexual initiation, and male circumcision are not effective enough as none of these measures reduces risk sufficiently to halt the pandemic in sub-Saharan Africa, and still others²⁸ arguing—either implicitly or explicitly—for a shift in prevention priorities from the behavioral to the biomedical strategies.

The appeal of biomedical prevention technologies also rests on misunderstandings over what effective prevention actually entails as well as more specific confusions over what counts as biomedical prevention. For example, whereas some researchers²⁹ classify condoms as a biomedical prevention technology, others³⁰ typically categorize condom use as a behavioral strategy although they rarely if ever refer to PrEP use or microbicide use as behavioral strategies. The problem is not whether condoms should be included under the rubric of biomedical or behavioral prevention; all these technologies or tools—whether termed biomedical or behavioral—have to be adopted and, with the exception of male circumcision, their use sustained. Any prevention strategy—which by necessity involves relationships between different entities (e.g., PrEP or condoms and people, and people and information)—can be meaningfully said to be biomedical and behavioral and indeed structural. They all require modifications to behavior or practice but, more importantly, they all require the active engagement of peoples and communities: the social, cultural, and political dimensions of sexual activity and injection drug use are paramount. Although analytically distinct, effective prevention requires that biomedical technologies, behavioral strategies, and social structures are not treated as separate entities. PrEP or condoms or sterile needles can only become effective if prevention strategies tackle the contexts that fail to support people's appropriation of these tools into their sexual and injection practices, including the contexts that position the technologies such that they fail to prompt any action on the part of the people who might fruitfully use them.

So, whereas the researchers referred to previously invoke the future of prevention as “combination prevention” (i.e., bringing biomedical, behavioral, and structural tools together), we argue that the initial efforts to separate them were misguided: their separation prevents us from identifying HIV-prevention strategies that are and are not working. Although combination prevention illustrates a growing acknowledgment of the need to examine how biomedical technologies or prevention tools, such as microbicides, are advocated and promoted to ensure that their use is sustained, concerns about adoption and use are typically reduced to ensuring the provision of the prevention technologies and the use of testing and counseling as a vehicle for their promotion and uptake. In general, issues concerning sustained use of the technologies are ignored once efficacy is demonstrated. For example, the issue of the effectiveness of PrEP and treatment as prevention is reduced to the “implementation challenges” of HIV testing and adherence whereas the structural and behavioral aspects of prevention interventions are positioned separately.³¹ In this way, the need to continuously engage with the social aspects of prevention is, if not sidelined, positioned as complementary and not integral to prevention efforts.

Nowhere is this more evident than with the advent of successful treatments in 1996, when voluntary counseling and testing (VCT) was unrolled on a massive scale globally and prevention increasingly attached to testing and confined to the clinic. The clinic's position as the center stage for prevention efforts was further reinforced by the prioritization of treatment by global HIV funders as exemplified by the US President's Emergency Plan for AIDS Relief (PEPFAR) and WHO's “3 by 5” initiatives.³² However, neither testing nor counseling, imparting advice on preventing transmission, offer much potential to contribute to transforming social relations, and there is growing evidence that, although counseling in the context of HIV testing influences the sexual practices of those who are found to be HIV-positive, it has little if any impact on those who test HIV-negative.³³ Although these findings about VCT's limited impact led to a focus on “positive prevention,” which carries with it the risk of undermining the notion of shared responsibility for HIV transmission, dividing communities and increasing stigma and discrimination, particularly in the context of increasing criminalization of HIV transmission,³⁴ the counseling of HIV-negative persons continues as a major prevention strategy in many countries. It might be suggested that VCT's lack of a preventive impact on HIV-negative people may be a function of the difficulties of overwhelmed health systems or poor counseling, but the evidence mentioned previously, coming from a wide range of countries, suggests otherwise. Other researchers³⁵ modeling the likely population outcomes of expanded HIV screening and antiretroviral treatment in the United States have concluded that even substantial expansion of HIV screening and treatment programs is not sufficient to markedly reduce the HIV epidemic in the United States without “additional interventions that halve risky sexual and needle-sharing behavior [emphasis added].”^35(p786)

In the absence of wide-scale population HIV prevention education, counseling in the context of testing privatizes knowledge and is unlikely to have any sustained effect on the understandings of sexual activity, injection drug use, and associated risks. Indeed, positioning prevention in the clinic gives governments the excuse to draw back from HIV itself, the excuse not to have to deal with the difficulties of publicly addressing populations about sexual activity and drugs, and the excuse not to train teachers and those in contact with the young to raise issues in connection with HIV transmission. Health promotion and HIV prevention education should not be limited to health systems; a multisectoral response that engages with and builds on legal reform and educational and employment practices is needed.

“In response to HIV, people, as members of communities and networks, have modified their sexual and drug injection practices in ways that enable them to remain gay, masculine, married, Hindu, and so on. As many researchers⁴⁶ have pointed out, the most powerful influences on human sexuality, for example, are social norms—morals, taboos, laws, beliefs—that regulate and govern its expression. Practices are socially produced.”

Recent evidence indicates that prevention successes in Uganda and Zimbabwe occurred before counseling and testing were rolled out,³⁶ whereas Botswana's early prevention response, which was dominated by testing and counseling until 1997, was comparatively ineffective.³⁷ In 1997, there was a marked shift in the Botswana government response from tackling HIV as a health issue to tackling it as a development issue that needed a multisectoral response, and HIV incidence dropped by more than 25% between 2001 and 2009.³⁸ As was noted earlier,³⁹ when counseling and testing becomes the dominant or sole prevention intervention, the public and collective voice is excised and the social is rendered inexpressible.

To be clear, we are not mounting a critique of HIV treatment successes in the shape of ART but rather of the manner in which the success of ART has swamped prevention efforts. Not only has prevention moved to the clinic, but also the need to continue to invest in and develop HIV prevention efforts has become sidelined and, gradually since 1996, prevention in many countries has become almost indivisible from treatment.⁴⁰ Indeed, as we have noted previously, there is a growing number of biomedical scientists arguing that treatment is prevention.

The “prevention failure” line has gained strength from the hundreds of inappropriate experimental evaluations of HIV-prevention interventions. The evaluations are inappropriate in the sense that the same methods are used to assess effectiveness as are used to assess efficacy.⁴¹ They are misguided attempts to experimentally assess real-world effectiveness and, not surprisingly, the results of a number of meta-analyses focusing on those evaluation studies that meet strict criteria of rigor in biomedical research indicate that the majority of prevention initiatives evaluated have inconclusive or flat results.⁴² Most recently, researchers conducting a systematic review of randomized controlled trials for prevention of sexual transmission of HIV concluded that “almost 90% of [randomized controlled trials] of interventions for prevention of sexual transmission of HIV have delivered flat results.”^43(p631) Not only do these studies falsely reinforce the view that HIV prevention has failed, but they have also led to a mistaken attempt to differentiate biomedical from other forms of prevention.

SOCIAL NARRATIVE OF PREVENTION SUCCESS

HIV prevention has not failed and there are more or less effective HIV prevention interventions. The more effective prevention interventions engage with the social existence of the virus and with the kind of relations within which HIV becomes embroiled. The social narrative does not try to augment individuals’ capacities but focuses on the relations between them, the norms that regulate such relations and the social practices that constitute them, and the ways in which groups and communities as well as institutions respond to external forces. The social approach, which we call a “social public health,”⁴⁴ moves beyond a reliance on individual capacities or indeed social structures or drivers as separate entities, and recognizes that individual capacities are intimately tied to the enabling (or disabling) character of social norms, practices, and institutions, which are, in turn, understood to be transformed or modified by community mobilization and social movements. Processes of individual and social change are linked, and, within the social sciences, HIV prevention is understood in terms of enabling communities and, indirectly, their individual members, to develop HIV-risk reduction strategies by changing their sexual and injection practices or adopting HIV-prevention technologies.⁴⁵

In response to HIV, people, as members of communities and networks, have modified their sexual and drug injection practices in ways that enable them to remain gay, masculine, married, Hindu, and so on. As many researchers⁴⁶ have pointed out, the most powerful influences on human sexuality, for example, are social norms—morals, taboos, laws, beliefs—that regulate and govern its expression. Practices are socially produced. The social transformation that has occurred at the level of community, network, and group in response to the threat of HIV, has been shaped by particular local conditions and contexts: it is rarely homogeneous across or within countries. Furthermore, it has generally occurred slowly. There is evidence from HIV prevalence and incidence figures and from behavioral surveillance that there have been and are HIV prevention successes—albeit achieved slowly, confined to a number of countries, and, within these countries, uneven.

Early evidence⁴⁷ in the form of reductions in HIV diagnoses from Uganda, Senegal, Thailand, Brazil, and Australia has indicated changes in HIV-related risk practices. The Global HIV-Prevention Working Group⁴⁸ documented HIV prevention successes in a number of countries—including these countries and also including Western Europe, parts of sub-Saharan Africa, and the United States.⁴⁹ The evidence demonstrates that, to different degrees in different places, the adoption of condom use, delayed sexual debut, and partner reduction were effective. Recently, a UNAIDS working group⁵⁰ identified HIV prevalence declines of 25% or more between 2000 and 2008 in women aged 15 to 24 years attending antenatal care clinics in some countries most heavily affected by HIV—Botswana, Côte d'Ivoire, Ethiopia, Kenya, Malawi, Namibia, and Zimbabwe—together with changes in sexual practice as assessed by population-based surveys undertaken repeatedly between 1998 and 2008. Clearly there have been many achievements in curbing the epidemic and these provide a body of evidence about what works. There are also countries and regions⁵¹ that continue to show disturbingly high HIV incidence figures or increases in HIV incidence. Social change is slow and patchy, because success stories involve change in social relations and social practices. There is not one explanation compared with the biomedical narrative where success or failure is typically attributed to the efficacy of the technology involved. Engagement with the local and the particular are the essence of the social take on HIV prevention.

In countries such as Switzerland, Australia, Thailand, Brazil, Uganda, and Zimbabwe, effective prevention is marked by the building of genuine partnerships among government, affected communities, public health, and researchers. It is supported by a “social public health,” where prevention is characterized by combining government funding of and support for community-informed, if not community-led, prevention programs and health promotion that are informed by social, epidemiological, and biomedical research. Effective prevention entails developing community capacity⁵² and requires that public health responses address people not only as individuals but also as connected members of groups, networks, and collectives who interact (e.g., talk, negotiate, have sexual intercourse, use drugs) together.

We take three documented cases of successful prevention—Australia,⁵³ Uganda,⁵⁴ and Zimbabwe⁵⁵—to illustrate what contributed to the success of HIV prevention. Although the epidemics have been patterned differently in each of these countries and each country supported somewhat different prevention programs, they each achieved social changes that supported and enabled people to adopt condoms for sexual intercourse, delay sexual initiation, reduce the number of sexual partners, and, where they were provided, use sterile needles and syringes for injecting illicit drugs.

Australia, Uganda, and Zimbabwe

Compared with the response of countries in Western Europe and North America, Australia's response was robust.⁵⁶ Between 1983 and 1985, HIV spread rapidly in Australia where some 4500 people were infected—mainly men in the gay communities in Sydney and in Melbourne. Over the next few years, it became apparent that the majority of transmissions were (and continued to be) among gay men, and HIV incidence declined.⁵⁷ Recently, increases in HIV transmission were noted in two states, but evidence indicated that these increases occurred in states where there was a marked decline in HIV prevention funding.⁵⁸ A similar story unfolded in Uganda between 1986 and the mid-1990s and, although there are some current concerns about an upturn in HIV transmission rates among young married people, the Ugandan story continues to be one of success compared with other countries in the region.⁵⁹ And, in Zimbabwe, the estimated adult prevalence in 1997 of 29% fell to 16% in 2007.⁶⁰

In Australia, before public health acted, members of the early affected communities began to act to prevent transmission of HIV: gay men began to use condoms as early as in 1983, and injection drug users began to clean their needles with water and bleach before needle and syringe programs, which distributed sterile needles and syringes to injection drug users, were set up in 1985, first in Sydney and then elsewhere in Australia.⁶¹ Essentially the government built on the quick action by communities at risk and funded communities in the form of AIDS Councils to provide HIV-prevention education. The response was primarily one of partnership—among governments, communities, researchers, educators, and those working in public health—and has remained so. In Uganda, researchers⁶² qualified the favored explanation that Museveni's good political leadership led to changes in sexual relationships and argued that

[T]he [community] response preceded and exceeded HIV interventions. Ugandans managed their epidemic, took credit for success, and national and international policy provided support, rather than the other way around. HIV policy was developed and prevention started in the villages, and political and public health interventions built on this.^62(p182)

In both countries, political openness and support went hand and hand with community involvement in social change. Although in Zimbabwe the evidence is not as clear, as researchers noted, “it appears that the motivation for behaviour change largely arose endogenously from within the population.”^63(p5) Furthermore, community-based activities were intensified following the establishment of the National AIDS Council in the late 1990s.

Researchers documenting the HIV prevention successes also referred to an essential characteristic—namely talk, and informal interpersonal communication within families and groups. For example, researchers identified how Ugandans talked with each other about AIDS such that AIDS became part of the stuff of social relations between people, not only between sexual partners, but also between generations, and not only between seemingly HIV-negative people, but also between positive and negative people involved in relationships of care. In all three countries, HIV-prevention programs and information, funded and supported by government and donors, were provided by community organizations via gay communities and injection drug user networks in Australia; churches, school and youth programs, and workplaces in Zimbabwe; and churches, labor and employer organizations, nongovernmental organizations, and other community-based organizations in Uganda.

Other social factors were noted as central to the decline of HIV including the importance of high levels of education and high levels of marriage in Zimbabwe as well as the severe economic and political crises in that country,⁶⁴ the bounded nature of the sexual networks in Uganda compared with those in South Africa,⁶⁵ and, in Australia, the political advocacy skills of gay community members, learned in their fight for gay liberation, were clearly important.⁶⁶ We acknowledge these factors—and they differ from country to country—but there is little doubt that HIV-prevention efforts have been successful and relatively sustainable because they arose from community and are of community. That such responses are of community is evident in the particular response; in Australia, gay men did not abstain from sexual intercourse or reduce the number of their partners—they used condoms; in Zimbabwe, although condom use was important, reduction in number of sexual partners seems to be the mainstay of the decline in HIV; and, although there is some dispute, delayed initiation of sexual intercourse, reduction in numbers of sexual partners, and condom use all seem to have played a vital part in the successful Ugandan response.

The negative finding that counseling and testing contributed comparatively little to the decline in HIV in all three countries is also evidence for the importance of public talk and discussion of the role of social relations and social practices in HIV prevention. At points before effective treatment, testing was actively opposed by the largest AIDS Council in Australia because it was believed that testing was likely to divide communities into those who were HIV-positive and those who were not.⁶⁷ And, as noted earlier, researchers⁶⁸ documented that VCT programs were unlikely to have contributed significantly to HIV incidence decline in Zimbabwe or Uganda as these programs were scaled up only after the declines in HIV in these two countries. Social change requires a public voice—not one confined to the talk between doctor (or nurse) and patient in the clinic. A social public health engages with people not only as individuals but also as members of groups, networks, and collectives, recognizing and relying on the fact that people interact together and indeed that people, viruses, information, and institutions of all sorts interact. Social relations and their transformation are the bread and butter of change. What these three countries developed was a “social vaccine” that produced social transformation.

CONCLUSIONS

Notwithstanding the recent attention to the social drivers of the epidemic and discussion of social impact,⁶⁹ we have argued that increasing biomedicalization is distorting prevention efforts. We go beyond describing the rise of biomedical prevention to offer an explanation of it in terms of what many believe is a failure in HIV prevention. HIV prevention has not failed—at least not everywhere. Where it has stalled it is possible that the linking of prevention to testing in the context of the roll-out of treatment in 1996 and the concomitant positioning of prevention as a private matter in the clinic may have played a role in that “failure”—by muting research and interventions into the social life of HIV, into the specificity of relations between people, viruses, and institutions that enable or prevent transmission. The more recent turn to treatment for prevention and treatment as prevention is likely to reinforce this positioning of HIV as an exclusively biomedical matter. Social transformation is difficult if not impossible to achieve in the clinic.

We are not trying to defend behavioral and structural approaches or to discount biomedical ones. Rather—whether prevention programs or interventions advocate delayed sexual initiation, the use of condoms, clean needles and syringes, microbicides, or PrEP or PEP—we argue that all prevention requires that people change their social practices, changes that cannot be effectively sustained unless they are supported by broader social transformation. The latest in technological innovation, “test and treat” or “treatment as prevention,” also requires changes in practice that can only be sustained if they are supported by widespread social change: annual HIV testing for those who test HIV-negative and, for those who test HIV-positive and accept treatment, a lifelong regimen of drugs, many of which have short- and long-term side effects. The challenges to the effectiveness of test and treat are the same as for any other prevention technology: they concern the kinds of relationships between people and things that are involved in the provision, acceptability, adoption, sustained use, and unintended consequences of any prevention technology or tool. How are countries, which at present cannot afford to treat those who are in need of treatment, going to find the extra funding (and at a time when there is broad anticipation that budgets for global health will shrink)?⁷⁰ Regarding acceptance and adoption: how do those advocating treatment as prevention propose encouraging people to test and to test regularly? Although in the context of provider-initiated testing the numbers of people being tested has increased, there continue to be very many who are not being tested and many with reason.⁷¹ The evidence that increased testing normalizes testing and reduces stigma associated with HIV is not clear: at least two studies, one in South Africa⁷² and one in the United States,⁷³ demonstrate that HIV-positive status continues to be associated with stigma and discrimination. And how do those advocating treatment as prevention propose encouraging all those who test positive to embark on a lifelong regimen of treatment?

Not only is it essential to ensure provision, acceptability, adoption, and sustained use of HIV-prevention strategies, but also an absence of unintended negative consequences is necessary for there to be an effective response. One possible unintended consequence of the promotion of test and treat is that it could make harm reduction measures such as the establishing of needle and syringe programs even more politically difficult to roll out in countries that have to date resisted them (some of which have rapidly growing epidemics at the moment). Governments may well use test and treat to justify their reluctance to provide needle and syringe programs. And what of the optimistic HIV-positive men and women on treatment who believe that they can engage in unprotected sexual intercourse with impunity? Or what of the relieved person who infers from his or her negative HIV test result that a degree of unsafe behavior is not that risky after all? Or of governments that fear that promoting anything that might challenge existing gender relations or that might involve them in being explicit in their dealings with sexuality is unlikely to get them re-elected? And, perhaps most important of all: how are those who advocate treatment as prevention going to convince governments and countries not to put all their HIV funding into treatment? Although treatment is essential for those in need of it as treatment, if it is going to play an effective role in preventing HIV transmission across a population, then social and political research on its effectiveness as a prevention strategy is needed.

We have framed our argument about HIV prevention in terms of a biomedical narrative that has shaped much of the field of HIV prevention in problematic ways, and a social narrative that has often been marginalized and muted despite its potential to yield insights about effective prevention. However, we see this opposition as one that has arisen historically and one that needs to be contested now as did Fee and Krieger in 1993.⁷⁴ Researching HIV prevention today demands that social scientists engage with HIV prevention without invoking a nature or culture distinction that supposedly describes how a virus is encountered by humans.⁷⁵ Social and biomedical scientists can best contribute to understanding prevention in the real world by engaging with HIV and efforts to prevent it as they are encountered in life—as biological and material, as information and technological, as emotional and affective, as social, collective, institutional.