Sustaining safe practice: twenty years on

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Abstract

This paper examines the ways in which populations at risk of HIV in the developed world have enculturated the knowledges and technologies of both the medical and the social sciences. By revisiting a number of review papers and by reviewing findings from a range of studies, we argue that gay men have appropriated information that has enabled them to sustain safe practices while they have eschewed information that has made maintenance difficult.

The paper describes a range of risk reduction strategies and compares the responses of populations at risk of HIV in the years before the advent of highly active antiviral therapy (HAART) with their responses after the introduction of HAART in 1996. We concentrate our argument on the changing responses to HIV risk of gay men, although occasionally illustrate our argument with reference to the responses of injecting drug users. The responses of gay men to risk post-HAART—particularly those who reside in Australia—speak to the adoption of a range of considered strategies, not altogether safe, to reduce harm.

We argue that such strategies need to be understood and addressed within a ‘new’ social public health, that is, a public health that takes what social analysis has to say seriously. The paper examines the differences between the traditional, the ‘modern’ epidemiological/clinical and the ‘new’ social or socio-cultural public healths and describes the tensions between the medical and the social science disciplines in their efforts to inform public health. Key concepts provided by social science such as agency (including individual and collective agency), alongside its methodological reflexivity are key to effective public health. The risk avoidance strategies adopted by gay men suggest a way forward by turning our attention to the ways in which medicine is taken in(to) their practice.

Introduction

This paper concerns the manner in which the medico-scientific disciplines and the social science disciplines are implicated with one another and together inform HIV-prevention and health promotion. Sometimes the two disciplines work together, in both intended and unintended ways, and sometimes the relationship is antagonistic. This paper explores the relationships between them in terms of how HIV-prevention or risk avoidance is understood and enacted by populations at risk of HIV in the developed world, in particular, by gay men.

We are interested in HIV testing and antibody status, highly active antiretroviral treatments (HAART), viral load and categories of risk and how each is positioned in the narratives of both sets of disciplines, the medical and the social sciences. We argue that the history of HIV prevention and risk reduction can be viewed as a product of the tensions between the two sets of disciplines1 and the paradigms within which the research of these disciplines is framed. The relationship between the medical and the social sciences has changed over time—between pre-1996 when the social held sway, and post-1996 when we witnessed a switch to the dominance of medicine with the advent of relatively successful treatments and, more recently, the promise of vaccines. Although we have concerns about the impact of current medical dominance on prevention, we conclude that it is not only important to acknowledge the relevance of medicine as well as social science to prevention efforts, but that it is imperative that prevention takes medicine in(to) its practice.

The paper is divided into two sections: a review of the past–pre-1996; and of the recent past–post-1996 to 2001. In each of these time periods, we examine the impact of AIDS on the lives of people affected by HIV. In the main, we focus on gay men in the developed world and on the ways in which they have understood the risk of HIV transmission and responded to it. At each time period, we examine the role of medicine and the social sciences in their constructions of risk. We examine how gay men have enculturated medical and social scientific knowledges and technologies, that is, have appropriated and incorporated them into the structures of their everyday lives and made HIV-prevention and harm reduction work for them. Although a somewhat arbitrary division, because of the introduction of effective medical treatments, the post-HAART years are particularly challenging to populations at risk of HIV and, in turn, educators and prevention experts. As argued here, at one and the same time, treatments may pose a danger for prevention as well as offering some protection against HIV transmission.

Section snippets

The early years—pre-1996

The first phase of the response to HIV was a ‘prevention only’ phase, a phase which marks the recent past against which the introduction of treatments in 1996 can be foregrounded. Prevention has worked: in most northern European countries, in Australasia, and among certain populations in North America, both Canada and the United States, HIV rates declined (Anderson, 2000; Coates et al., 1996). In this period, in much of the developed world at least, there was a remarkable modification of sexual

Post-Vancouver—post crisis (1996–2001)

In 1996 at the 11th International AIDS Conference in Vancouver, Dowsett and McInnes (1996) presented new findings concerning gay communities in Australia, and coined the term ‘post-AIDS’, a term that has since been taken up in the United States of America (Rofes, 1998). Their term ‘post-AIDS’ referred to the sense that, in the developing world, the crisis had passed—prevention efforts were succeeding and people were learning to live with the epidemic. At the same conference, the success of new

Conclusions—a social public health

What was learnt in the early ‘prevention only’ days of the epidemic (up to 1996) was that successful strategies depend upon the following: partnerships between government, non-government organisations and affected communities, reflexive relationships between researchers, educators and communities, and the necessity of acknowledging the changing and disparate patterning of practice and its social and cultural production—what we have termed a social public health (Rosenbrock et al. (1999),

Acknowledgements

The National Centre in HIV Social Research is funded by the Commonwealth Department of Health and Aged Care.

We would also like to acknowledge the help of our colleagues at the National Centre in HIV Social Research in Australia.

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