The social drivers of HIV: In conversation with Charles Stephens Part 3

Original content from our Mapping Pathways blog team

"I'd like to see us...reflecting on our successes. It has been proven that testing someone for HIV and, if positive, linking them to services and care as soon as possible has very positive health outcomes."

In the final part of this three-part series, Charles Stephens of AIDS United, a Mapping Pathways partner organisation, speaks about the successes in the HIV prevention landscape and some of the challenges faced by people in rural areas. Read part one here and part two here.

MP: What are the things being done well in the HIV prevention landscape?

CS: Models like the Mapping Pathways project excite me. The process of collecting data from a variety of different experts and stakeholders on the field and using that data to make a strong case is an excellent model. Other interesting models are AVAC’s HIV prevention research advocacy working group, which I’m a part of, and the community education and research advocacy work of the Black AIDS Institute. Most importantly, stakeholders and leaders within communities are trained and supported to go back to their communities with new biomedical HIV prevention information to disseminate it within their communities.

One of the things I’d like to see more of is reflecting on our successes and planning how to build on the victories we’ve seen over the last few years. It has been proven that testing someone for HIV and, if positive, linking them to services and care as soon as possible has very positive health outcomes. Also from the community perspective we have achieved certain successes like reducing stigma, mobilising communities and providing support networks and services. I’m extremely interested in finding out how we can build on these successes.

MP: What are some of the challenges individuals and communities face in rural areas?

CS: Capacity is one of the main challenges in rural areas. I find that the doctors on the ground are often very knowledgeable, passionate and committed, but the problem that is there just aren’t enough doctors and medical resources. 

Transportation is another huge barrier in rural areas. People have a hard time getting to their doctors, as the transportation infrastructure isn’t always in place. Some people have to travel three or four hours to get to their physicians.

Addressing these barriers has been a challenge, but there have been some innovations like telemedicine, where doctors can remotely provide medical information and check in with their clients from a different location.

MP:  Are there any trial results that came out recently that you have followed closely? Are there any upcoming trials you are interested in?

CS: The HPTN 061 study, which looked at 1553 black, American MSM, shared initial results at AIDS 2012 that reinforced what a lot of us had been seeing on the field. One of the most startling projections of the study was that unless improvements are seen, more than half of all young black gay men who are gay or bisexual will be infected by HIV within the next decade.

Other upcoming trials I will be following with interest are the HPTN 073 study which looks at ways to optimise PrEP adherence in black MSM and the HPTN 069 study, also called NEXT PrEP, which seeks to assess the efficacy of four ARV drug regimens used as PrEP to prevent transmission of HIV in a population of at-risk MSM.

[Content that is linked from other sources is for informational purposes and should not construe a Mapping Pathways position. Please look for us on Facebook here www.facebook.com/MappingPathways and you can follow us on Twitter @mappingpathways as well.]

The social drivers of HIV: In conversation with Charles Stephens Part 2

Original content from our Mapping Pathways blog team

"HIV has never been just a question of behavior. It forces us to look at science in a critical way and examine behavioral and social factors." 

In the second of this three-part series, Charles Stephens of AIDS United, a Mapping Pathways partner organisation, speaks about the social drivers of HIV and its impact on vulnerable communities. Click here for part one.

MP: According to the Centers for Disease Control and Prevention (CDC) figures, men who have sex with men (MSM) accounted for 61% of all new HIV infections in the U.S. 2009. There was also a 48% increase in HIV incidence figures among young black gay men (aged 13-29). Why has the HIV epidemic seemed to have disproportionately affected this demographic?

CS: I think there are a number of researchers right now investigating that question. I feel we are still at the stage of trying to figure out what questions we should be asking. For example, a number of researchers have done work that suggests that black gay men don’t necessarily engage in any higher sexual risks or drug-taking risks than white gay men. However, there is a higher incidence of HIV among black gay men – so why is that?

One argument is that there is a higher prevalence of HIV within existing black, gay male sexual networks, which leads to higher incidence numbers. There is also some thought about ways that poverty, stigma and other social factors can play a role in driving the HIV epidemic among black gay men.

HIV has never been just a question of behavior. It forces us to look at science in a critical way and examine behavioral and social factors. One of most exciting conversations I’ve witnessed in the research and advocacy realm is ‘What are the social drivers of HIV and how do those social drivers disproportionately impact some communities over others?’

I think researchers should be looking at lot of areas. But more importantly, considering the impact of HIV among young black gay men in particular, I think its important that researchers, policymakers and community members all come together in grappling with this really severe epidemic.

MP: Can you elaborate on some of the social drivers you talked about?

CS: Some of the questions we have to ask are: What is the role of housing or joblessness? What are the roles of social class, stigma and homophobia? These questions force us to think about HIV in a very intersectional way. By intersectional, I mean the challenge and issue of HIV is also connected to these other larger social issues.

An intersectional approach forces us not to operate in silos. It forces us to be very innovative in how we think about grappling with HIV. It’s impossible to think about HIV without some analyses of social issues because very often those social issues reinforce the impact of HIV, particularly in vulnerable communities.

Ultimately, it is important to look at communities that are most vulnerable. But what we seem to find is that communities vulnerable to HIV are also vulnerable to a number of other social issues, which means that we have to think very critically about the role that these other social drivers of HIV play – particularly in the lives of young black gay men.

MP: What are some of these challenges and issues that young black gay men seem to face in particular? What makes them so vulnerable?

CS: I think that, again, is a research question. There needs to be a research agenda around young black gay men, particularly in the context of HIV, that asks those very questions. Some of the questions to be asked are: How do we understand the vulnerability of this population? What are some of the forces that contribute to this vulnerability?

The research agenda should bring together researchers from multiple disciplines and approaches. This research agenda requires diverse methodologies, skillsets and worldviews. In effect, this would not just be a research agenda but a research and advocacy agenda, with the research helping drive the advocacy.

Current vulnerabilities include, but are not limited to, joblessness, poverty and stigma. We talk about stigma, in particular, as a barrier to someone accessing prevention or care services. Someone might be unwilling to get an HIV test because they don’t want to be seen going to an AIDS service organisation because of the stigma associated with HIV. Someone diagnosed with HIV might not tell people and thus fail to build a support system around them.

Lack of healthcare access is another vulnerability in this population. Communities that are marginalised because of race, class or gender sometimes don’t have access to the best healthcare resources, which contributes to negative health outcomes.

A number of steps have been taken to make HIV testing as accessible as possible. There are efforts to bring HIV testing to communities and one sees HIV testing events at community centers and mobile testing.

Stay tuned to the blog as we bring you part three of our conversation with Charles, where he speaks about some of the challenges faced by people living with HIV in rural areas and shares his thoughts on the good work being done in the HIV prevention landscape. 

[Content that is linked from other sources is for informational purposes and should not construe a Mapping Pathways position. Please look for us on Facebook here www.facebook.com/MappingPathways and you can follow us on Twitter @mappingpathways as well.]

Implications for social services in the time of PrEP and other new prevention technologies

via New America Media, by Zalined Mohammed

“The pendulum swing towards earlier treatment could come at the expense of other services,” said Lin. “Prevention efforts through education have been reduced and support to CBOs is significantly down. Many organizations have had to merge or close down.”

Major medical breakthroughs over the past year in the treatment of HIV/AIDS are setting off some surprising alarm bells.

While praised for their life-saving potential, they are causing a change in the dynamics of HIV/AIDS care – a shift that may squeeze out social services needed to support patients while they’re in treatment.
The focus in treatment is shifting increasingly towards HIV/AIDS medications and preventative strategies, such as Pre-Exposure Prophylaxis (PrEP) and HPTN 052.

At a recent forum in Oakland, attendees questioned how the new HIV medicines would directly affect their lives.

“It’s exciting, but will it help save lives in our communities?” asked Deborah Royal, a nurse practitioner at East Bay AIDS Center.

Providers and patients agree that advances in medication and a focus on prevention are positive steps towards treating the disease and slowing disease transmission, but also emphasize the importance of what they call “psychosocial” factors in determining whether a person starts and stays in treatment.

“The easy part is prescribing the medication, but how is the patient going to get the medications paid for?” asked Dr. Royce Lin, an HIV specialist who serves on the board of the Asian and Pacific Islander Wellness Center (APIWC). He noted, “if someone is monolingual, if someone is undocumented they may never even make it in the first place.”

Dr. Monica Gandhi, an HIV and primary care provider at Ward 86, one of the oldest and largest HIV/AIDS clinics in the country, pointed to several barriers that commonly prevent female patients from adhering to treatment protocols. “Gender based violence, poverty, social instability around taking care of children and not having social supports themselves prevent women from staying in treatment.”

Read the rest.


[Content that is linked from other sources is for informational purposes and should not construe a Mapping Pathways position.]

The Complexity of Changing Behaviors

via Newsworks, by Maiken Scott

So, what have we learned about prevention?

Inform, plead, scare them straight—HIV-prevention messages have covered it all.

Those working in prevention thought that if they gave people information about the disease, it would help protect them, according to Dr. Jennifer Lauby, a researcher at the Public Health Management Corporation.

"We found out that it's more complicated than that," she said.

Her colleague Lee Carson agreed. "Education alone doesn't equal behavior change," Carson said. "We see that in smoking and things like that."

Prevention has to be more comprehensive, Lauby said.

"There're really a lot of factors that go into making people at risk for HIV, including social factors, community factors, access to care," she said. "We have to look at all of those factors when we talk about HIV prevention."

Focusing on specific groups

To get a better sense of those factors, researchers such as Lauby and Carson started looking at specific groups with very high infection rates. One such group is African American men who have sex with men—and women.

Andrew Jackson, who helps out with a research project involving this group at the Public Health Management Corporation, said it is hard to reach this population because the men are very secretive about their lives and sexual activities.

Jackson is African American, gay, and HIV positive. Growing up in an Ohio steel-mill town, as a member of the Baptist church, secrecy became part of his life early on.

"You had to be all man, you couldn't divulge if you had a secret that you didn't want to give out," Jackson said.

Mum is the word not just when it comes to the behavior itself, but also when it comes to HIV, said Philadelphian Douglas Van Lue. And that puts men at risk.

"If nobody is talking about it, then nobody is asking about it, and then there's just the sexual behavior going on," he said

Both Van Lue and Jackson help spread the word about the research project.

Read the rest.


[Content that is linked from other sources is for informational purposes and should not construe a Mapping Pathways position.]

Addressing social drivers of HIV/AIDS: Q&A with Judith Auerbach

“It boggles me that I still have to make the case for understanding the relational and contextual nature of HIV transmission and the need to recognize that people and technologies are interactive and interdependent.”

Global Public Health recently published a paper titled “Addressing social drivers of HIV/AIDS for the long-term response: Conceptual and methodological considerations.” Written by Judith D. Auerbach, Justin O. Parkhurst, and Carlos F. Cáceres, this paper is generating a great deal of interest and discussion in the HIV/AIDS prevention arena.

The authors make a case for a shift in the public health community’s response to HIV/AIDS, “from an ‘emergency’ approach to a long-term response.” A key component of this shift is the need for HIV prevention efforts to adopt “a comprehensive strategy in which social/structural approaches are core elements.” The root causes, the actual drivers of HIV vulnerability, need to be addressed in order to enable individuals to protect themselves and others from HIV infection. Drivers of HIV vulnerability include factors such as poverty, gender inequality, and human rights violations. These phenomena are difficult to measure and define. More significantly perhaps, they do not operate in the same way across the world – the dynamics work differently in various countries, communities, and demographic groups.

Mapping Pathways caught up with Judith, who is not only one of the authors of this paper, but is Vice President of Research and Evaluation at the San Francisco AIDS Foundation as well. Judith, a “public sociologist,” has been working in the field of HIV prevention for 22 years. We spoke to Judith about her work, the challenges in her field, the paper, and the importance of understanding and tackling the social drivers of HIV in the context of ARV-based prevention strategies:

MP: Could you tell us a bit about your work as a public sociologist? What are some of the challenges you’ve faced?

Judith: I have a PhD in sociology, but have chosen to work outside of academia almost all of my career – in government, research, policy, advocacy, and community-based organizations – to bring the insights of sociology (and social science more broadly) to bear on medical research and health policy deliberations focused on HIV/AIDS, women’s health,and gender equity.

This has sometimes been a challenging role, as I am usually the lone social scientist in the biomedical conversation, particularly around so-called “biomedical technologies” for HIV prevention.Having to constantly educate and convince others about the existence and contributions of social science is exhausting and frustrating.It boggles me that I still have to make the case for understanding the relational and contextual nature of HIV transmission and the need to recognize that people and technologies are interactive and interdependent. But, I have seen progress in recent years, so I’m happy to keep playing the social science missionary through my publications, presentations, and inputs at meetings and conferences.

MP: Your paper talks about the need to understand and address social drivers of HIV – could you explain briefly why this is important?

Judith: We began working on the paper at the moment when there was a great deal of interest in what everyone was calling “structural interventions.” This grew out of a growing understanding that HIV epidemics would not and could not be ameliorated by individual-level behavior change or product use one-person-at-a-time, and that individual “choices” were frequently constrained by social and structural arrangements (cultural norms and institutions, laws and policies, health care infrastructures, economic systems, etc.).

The need to address these arrangements was clear but the methods for doing so were not – neither to the scientific community nor to program implementers – because, as our paper outlines, the desire to rush to interventions was not yet based on a good understanding of the fundamental social mechanisms influencing HIV epidemics in different contexts. (This is not that different from the early rush to develop HIV drugs and vaccines before understanding the basic virology and immunology of HIV.) Moreover, as our paper also notes, the standard methodology for intervention research – the randomized controlled trial – is generally not appropriate for social/structural approaches. So, our interest in writing this paper was in providing some guidance about how to move logically from conceptualizing social factors that influence HIV transmission and understanding their dynamics to designing and evaluating programs and interventions to address them.

MP: More specifically, how is this important in the context of ARV-based prevention strategies?

Judith: With the recent developments in ARV-based prevention strategies, much of the attention to social/structural approaches has vanished from the health research and policy discourse. But this is problematic, because far from obviating the need for social-level responses, these new technologies highlight it.So far, only the “efficacy” of ARV-based prevention technologies, such as PrEP and microbicides, has been established – that is, there is evidence that these products reduce HIV infections when delivered as part of a comprehensive HIV prevention package in the context of a controlled clinical trial. In order for any of them to be truly “effective” (that is, to demonstrate an impact on HIV incidence in a population when used under “real-world” circumstances), they will have to be taken up and used by people as intended.

But, as social scientists have pointed out, people are not passive recipients of technologies. They apply meanings to them, they incorporate them (or don’t) in the context of their intimate relationships – relationships that are fraught with dynamics of gender and transaction – and they modify them. Moreover, on a practical level, the new technologies have to be available and affordable for people to use. These are all social-level issues that require social science-driven understanding.My fear and my observation so far is that the excited discussions of the “treatment as prevention” strategies mostly are occurring without this understanding.

If you’d like to know more about this issue, you can read the complete paper here.

[Content that is linked from other sources is for informational purposes and should not construe a Mapping Pathways position.]