The Political Economy of HIV in Africa

The Political Economy of HIV in Africa

Deborah Johnston, Kevin Deane, Matteo Rizzo

• Publisher: Taylor & Francis
• Year: 2018
• Print ISBN: 9781138741638
• eBook ISBN: 9781351725736
• Edition: 1
• Topic: Social Sciences
• Subtopic: Global Development Studies
• Index: Social Sciences

Biomedical revolutions seem to have radically altered the environment for HIV transmission: anti-retrovirals (ARVs) and drugs to reduce mother-to-child transmission promise to cut HIV transmission rates, as does male medical circumcision. However, the hopeful messages of UNAIDS are tempered with warning about expenditure shortfalls and calls for funding. Contributions to this book remind us that, along with the external financial constraints, there have been new fractures in state power and in the organisation of health systems. More than this, the book fundamentally calls into question whether biomedical interventions can change the social roots of this disease. As well as considering new policy approaches, the book reasserts a long-standing political economy approach to HIV and to adapt it to reflect new competing theoretical approaches. The chapters attempt to connect the debates about HIV/AIDS to larger discussions about globalisation, class differentiation, inequity and uneven development in African countries. This book was originally published as a special issue of Review of African Political Economy.

Trapped in the prison of the proximate: structural HIV/AIDS prevention in southern Africa

Bridget O’Laughlin

There is now agreement in HIV/AIDS prevention that biomedical and behavioural interventions do not sufficiently address the structural causes of the epidemic, but structural prevention is understood in different ways. The social drivers approach models pathways that link structural constraints to individuals at risk and then devises intervention to affect these pathways. An alternative political economy approach that begins with the bio-social whole provides a better basis for understanding the structural causes of HIV/AIDS. It demands that HIV/AIDS prevention in southern Africa should not be a set of discrete technical interventions but a sustained political as well as scientific project.

[Piégé dans la prison de l’approximatif : la prévention structurelle du VIH/SIDA en Afrique australe.] Il existe maintenant un consensus en matière de prévention du VIH : les interventions biomédicales et comportementales ne traitent pas assez les causes structurelles de l’épidémie, mais la prévention structurelle peut être comprise de différentes manières. L’approche des facteurs sociaux modélise des relations qui lient des contraintes structurelles aux individus à risque et conçoit des interventions qui influent sur ces relations. Une approche alternative de l’économie politique qui prend en compte l’ensemble biologique et social fournit une meilleure base pour la compréhension des causes structurelles du VIH/SIDA. Elle nécessite une prévention du VIH/SIDA en Afrique australe qui ne soit pas un ensemble d’interventions techniques discrètes mais un projet politique et scientifique durable.

Introduction

The HIV/AIDS pandemic has ravaged southern Africa for almost three decades. Given the relative wealth of many countries of the region, some were surprised by the rapidity of its spread and the resilience of the epidemic. Yet one can also ask, as Shula Marks (2002) did in relation to South Africa, if HIV/AIDS was not an epidemic waiting to happen in southern Africa, given its history of impoverishment, inequality, disenfranchisement, rapid urbanisation, labour migration, war and social disruption.

Initially, prevention followed established global approaches focused on the transformation of individual sexual behaviour: targeting high-risk groups, using social marketing techniques to provide information and to persuade people to use condoms, avoid concurrent sexual relations and, when testing became available, to know their status. Yet from the outset there were also critics who argued that prevention programmes focusing on changing individual sexual behaviour were failing to confront the structural causes of the epidemic. Some in South Africa particularly (but not only) even argued that the structural causes were the disease, thus compromising both the public health response and the legitimacy of their critique of prevention approaches focused exclusively on sexual behaviour (Fassin 2007).

South Africa’s treatment action campaign (TAC) around access to antiretroviral therapy (ART) drugs for all successfully challenged both government health policy and multinational pharmaceutical companies (Robins and Von Lieres 2004). Its success largely resolved the clinical debate on provisioning of ARTs across the region and underlined the importance and political possibility of addressing structural causes of the disease. Recognition of structural causes of HIV/AIDS has also acquired new legitimacy in global health policy. The Working Group on Social Drivers is one of nine set up by the AIDS2031 Consortium ‘to question conventional wisdom, stimulate new research, spark public debate and examine social and political trends regards AIDS’ (AIDS2031 Consortium 2011, xi). PEPFAR, the Global Fund and the World Bank now promote combined HIV-prevention packages that include structural, biomedical and behavioural interventions.

Reading through the literature on these new structural interventions, one encounters a bewildering array of different meanings and measures. Some are very specific, such as income-generating activities for adolescent girls or laws enforcing 100% condom use in brothels. Others are very general, such as improving public health and education systems. Some pursue the ‘gold standard’ of the randomised control trial (RCT) in pursuit of measures that have ‘demonstrated or promising efficacy’ (Kurth et al. 2011). Others emphasise that the social embedding, contextual specificity, political contingency and multiple outcomes of structural intervention make it difficult to sort out cause and effect statistically or to standardise interventions (Hankins and De Zalduondo 2010).

These differences in interpretation and practical approaches to structural intervention reflect the theoretical ambiguity of the field. This ambiguity goes beyond the inevitable conceptual blurring that emerges out of the negotiation process in the writing of institutional policy documents and funding proposals to fundamentally divergent ways of thinking about structural approaches to HIV/AIDS prevention. The same language is being used for different things. This essay argues that it is clarifying to distinguish two very different ways of conceptualising the structural causes of HIV/AIDS, each with different implications for strategies of prevention: the social drivers approach and an alternative bio-social political economy approach.

Social drivers: conceptualising the structural causes of HIV/AIDS

Global HIV/AIDS prevention has focused on controlling the sexual transmission of the disease. Yet many scholars of HIV/AIDS have long been convinced that its dynamics, like those of other epidemics before it, are grounded in structures of poverty and inequality (inter alia Farmer 1999; Barnett and Whiteside 2002). In their contribution to going ‘beyond condoms’, Klein, Easton, and Parker (2002) argued that HIV/AIDS prevention had to address the reasons for selective social vulnerability to infection. They identified different kinds of causes, all of which have relevance in southern Africa: poverty resulting from long-term patterns of economic development, gender inequality, migration and population displacement related to political instability. Stillwaggon (2009) has given particular attention to triggering co-factors and hence to the failures of public health systems in the wake of structural adjustment.

It has proven difficult, however, to confirm statistically a relation of causality between poverty and the incidence of HIV/AIDS. In a careful sifting through of available data, Johnston (2013, ch. 4) shows that there are no clear correlations between the various dimensions of poverty and being vulnerable to HIV/AIDS at either national or individual level. The relations are complex and variable over place and time. How then can the importance of social vulnerability for disease be captured empirically? Or must prevention retreat to what it has been able to measure – changes (or not) in sexual behaviour?

A thoughtful, detailed and accessible answer on how to integrate structure in HIV/AIDS prevention has been laid out by Justin Parkhurst (Parkhurst 2010, 2012, 2013, 2014), building on his earlier work with Rao Gupta (Gupta et al. 2008) and Auerbach, Parkhurst, and Cáceres (2011) on social drivers. Their approach now dominates the prevention policy literature; it uses social driver as a synonym for structural driver.

The social drivers approach models the processes that link social variables to sexual behaviour and hence to individual biological outcomes, in this case becoming HIV positive. Health outcomes are shaped directly by the immediate determinants of individual risk (the proximate determinants). In the case of HIV/AIDS these are exposure to, transmission of and infection by the HIV virus. But the proximate determinants are themselves structured by a multiplicity of social, cultural and environmental determinants (distal determinants) that make a particular group of people vulnerable to situations of immediate risk. ‘Pathways’ tie distal to proximate determinants and should thus be the focus of structural interventions. For example, poverty is a structural factor that gives rise to financial inability to meet daily food needs, which may lead to a parent engaging in transactional sex (Parkhurst 2014, 4). Identifying such links allows prevention to target the processes that aggregate individual risk into social vulnerability. Such causal pathways are contextually specific and often interdependent, i.e. health outcomes have multiple determinants and structural factors such as poverty have multiple, even countervailing, health outcomes (Parkhurst 2012, 4).

This approach thus begins with the decision-making, risk-calculating, health-seeking individual whose choices reflect social and cultural constraints as well as biological processes. Its methodological strategy is to begin with individuals whose choices have failed them; it identifies high-risk groups on the basis of HIV prevalence, and looks outwards for possible causes of vulnerability. Changes in individual behaviour or preferences are measures of successful intervention.

Analytical rigour is maintained in the identification of pathways by the insistence that the link to individual biological risk be statistically measurable. In looking, for example, at the ways in which migration might affect vulnerability to HIV/AIDS, Deane, Parkhurst, and Johnston (2010, 1459) emphasise:

Finally, and critically, to influence HIV risk, any distal factor must do so by changing one or more direct proximal factors – migration must affect a factor that is related to the number of potential exposures (number of partners, number of sex acts, partners from a higher prevalence community, etc.) or affect factors that mediate risk for any given sex act (condom use, presence of other infections, etc.) – all of which may change over the course of an HIV epidemic.

Parkhurst (2014, 3) argues that broad definitions of structure that include things such as human behaviour, health systems functioning or biomedical research are not operationally useful. He prefers to focus either on social factors that fundamentally shape or influence patterns of individual risk behaviour or on those that mediate how people can avoid HIV within a given context.

The proximate/distal approach is a familiar one to demographers and epidemiologists. Its language has long been used by the large international population non-governmental organisations (NGOs), such as Pathfinder, that initially dominated HIV/AIDS prevention in southern Africa. They used social marketing to promote change in sexual behaviour and emphasised gender relations in households as an important variable limiting women’s ability to choose for HIV testing or condom use. The analytical framework employed in the social drivers approach is also similar to that of contemporary micro-economics, the dominant framework in health economics, which assumes the utility-maximising individual operating within a universe of resources and constraints and thus construes population health as an aggregate of individual choices (Johnston 2013, ch. 3).

This paradigmatic congruence of theoretical approaches focused on individual choice orients the kinds of structural interventions deemed suitable in ‘combination approaches’ to prevention, the strategy favoured by UNAIDS, the AIDS2031 Consortium and many of the most prominent epidemiological experts on HIV/AIDS (e.g. Padian et al. 2011; Verboom, Melendez-Torres, and Bonell 2014). Structural interventions are designed to be part of prevention ‘packages’ that include existing biomedical and behavioural interventions. The new ‘structural interventions’ in HIV/AIDS prevention maintain a focus on changing the behaviour of individuals at risk but they add a social component intended to address the economic, social and cultural drivers that prevent individuals from exercising healthy choices.

To prove their efficacy rigorously, the social drivers approach prefers that interventions be tested by public health experts before being ‘scaled up’ to reach greater numbers of people at risk. Though Parkhurst (2014, 6) envisions the inclusion of qualitative evidence in designing and assessing interventions, others give almost exclusive priority to quantitative evidence, even demanding that packages be tested on the basis of the ‘gold standard’ of evidence-based medicine, RCTs (Kurth et al. 2011). Parkhurst emphasises the importance of contextually related variation in the drivers of HIV/AIDS and the limitations of a top-down approach, but translates this as searching for ‘generalisable strategies to provide what target groups need in “tailored” ways that respond to the specific set of multiple structural factors influencing the group’s risk and vulnerability’ (Parkhurst 2013, 2).

McMichael famously characterised modern epidemiology as a ‘prisoner of the proximate’, adept at determining which individuals are at increased risk, but not at understanding disease distribution within and between populations (McMichael 1999, 888–889). Certainly Auerbach, Parkhurst and the Social Drivers Working Group, all of whom recognise social inequality as a determinant of inequalities of health, have been concerned with finding ways to avoid the prison of the proximate. Yet existing examples of the combination approach in southern Africa suggest that their attempts fall short of an escape.

Experimental ‘structural interventions’ in southern Africa

As Hargreaves (2013, 3) has noted, the evidence base is thus far rather weak, but in an extended literature search I found a small number of well-documented studies on combined approaches to structural intervention in HIV/AIDS prevention in southern Africa. All are experimental in design, use RCTs and include various components. Interestingly, all focus on gender inequality as a pathway and identify women as subjects of intervention. I have chosen three that have been described in the literature as promising examples. They differ by location, by group of women targeted and by forms of intervention. They illustrate the kinds of theoretical and methodological conundrums that the social drivers approach confronts when it defines structure in terms of the determinants of individual choice.

Microfinance with gender training

The IMAGE project (Intervention with Microfinance for Aids and Gender Equity) is often cited as a successful or promising structural intervention in the policy, popular and scholarly literature (Epstein 2007; Gupta et al. 2008; Gibbs et al. 2012; AIDSTAR-ONE 2013). IMAGE was carried out in rural Limpopo Province in South Africa (Pronyk et al. 2005, 2006; Kim et al. 2008) as a joint project of prestigious institutions – the School of Public Health of Witwatersrand University and the London School of Hygiene and Tropical Medicine. It was intended to test whether a micro-credit programme could reduce intimate-partner violence, unprotected sexual intercourse and HIV incidence among poor rural women.

The study paired communities chosen for intervention with similar control communities elsewhere. The intervention included a group-lending scheme and gender training, both implemented by South African NGOs. The gender training featured HIV/AIDS education and political mobilisation, culminating in a political demonstration against violence against women. Women mainly used the loans as working capital for tailoring or for selling clothes, fruit and vegetables. Follow-up interviews with participants and their paired counterparts from similar communities were done about two years later.

The organisers of the study were initially quite modest about the significance of their findings (cf. Pronyk et al. 2006). Women in the intervention group were more likely than the control group to be economically better off, had more household assets, were more often members of rotating savings societies and spent more on food, but they did not achieve higher food security nor ...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Contents
• Citation Information
• Notes on Contributors
• Introduction: The political economy of HIV
• 1. Trapped in the prison of the proximate: structural HIV/AIDS prevention in southern Africa
• 2. The political economy of concurrent partners: toward a history of sex–love–gift connections in the time of AIDS
• 3. Wealthy and healthy? New evidence on the relationship between wealth and HIV vulnerability in Tanzania
• 4. Paying the price of HIV in Africa: cash transfers and the depoliticisation of HIV risk
• 5. Exploring the complexity of microfinance and HIV in fishing communities on the shores of Lake Malawi
• 6. Revisiting the economics of transactional sex: evidence from Tanzania
• 7. The key questions in the AIDS epidemic in 2015
• 8. 15 years of ‘War on AIDS’: what impact has the global HIV/AIDS response had on the political economy of Africa?
• 9. Breaking out of silos – the need for critical paradigm reflection in HIV prevention
• 10. Microfinance and HIV prevention
• Index