November 14, 2012
It is widely held that social and economic marginalization drive the HIV epidemic around the world. Jonathan Mann, the founding director of World Health Organization Global Programme on AIDS, introduced this point in 1996 when he argued that those people who were marginalized before HIV arrived became those at the highest risk of HIV infection after the epidemic began.
Studies consistently show that low income, unemployment, food insecurity and lack of access to education and health care, among other factors, increase vulnerability to HIV. As an HIV professional, I often wonder: How can we take seriously the challenge of effecting the social and economic change necessary to alter the course of the HIV epidemic?
This question was at the center of my mind when I planned my schedule for the XIX International AIDS Conference in Washington, D.C., in July 2012. I was pleased to see that a number of sessions would directly address the "social and structural determinants of HIV" and that the profile of this issue had finally gained mainstream attention.
In "Connecting the Dots: HIV/AIDS in the Context of the Black Diaspora," panelist Kevin Fenton, M.D., M.P.H., director of the HIV/AIDS Program at the U.S. Centers for Disease Control and Prevention, gave a stirring presentation in which he described a complex array of behavioral, health system, social and structural determinants driving HIV within the Black Diaspora. I thanked Dr. Fenton personally after the session and asked, "What's next? How do we move from identifying the problem to developing effective solutions?" He answered that at this stage, just raising awareness of the problem was a key success.
In "Poverty Reduction and Risk Among Key Populations," interesting new evidence was presented tying low income to high HIV prevalence, and food insecurity to initiation of sex work and infection with HIV. During the discussion that followed the research presentations, I asked the panel how their research had informed policy and practice. James Hargreaves, Ph.D., senior lecturer at the London School of Hygiene and Tropical Medicine, said that it can be difficult to translate social epidemiology into practice.
In "Eliminating HIV Infections by Targeting Inequalities: Addressing Social Determinants of HIV Disparities," panelists discussed a range of key issues, including gender inequality and the impact of poverty, lack of education and income inequality on women's vulnerability to HIV; the spread of the HIV epidemic in contexts shaped by legacies of disenfranchisement and social upheaval; and the roles of stigma, discrimination and criminalization in increasing vulnerability to HIV. But solutions offered were vague, suggesting only that actions be focused on the structural level (what actions?) and that multi-sector, multidisciplinary approaches to prevention are needed (what approaches?).
In every case, I was disappointed to find that discussion focused more on describing the problem than identifying solutions.
The question of how we effect system-level change follows me as I consider how I want to move my career forward. In the past, I have worked on socioeconomic approaches to HIV programming, but in every case, these approaches are aimed at lessening the impact of socioeconomic disparity on people living with HIV rather than addressing those disparities at their root as a prevention strategy.
Whether I devote my time to expanding social protection frameworks, livelihood opportunities or social support programs for people living with HIV, the conditions that drive the HIV epidemic -- unequal access to income, education, health care, food and sanitation -- will continue to be reproduced within our societies. Now that we agree on the problem, let's move forward and develop concrete strategies for creating real social and economic change.