Reassembling epidemiology: Mapping, monitoring and making-up people in the context of HIV prevention in India

Local Pathways of "Serodiscordant Couples": Unpacking a Global HIV Population Category in Papua New Guinea

HIV prevention programs focus on global "key populations" and more localized "priority populations" to ensure effective targeting of interventions. These HIV population categories have been subject to considerable scholarly scrutiny, particularly key populations, with less attention given to critically unpacking priority populations at local levels, for example "serodiscordant couples" (one partner has HIV, but not the other). We examine this population in the context of Papua New Guinea to consider how local configurations, relational pathways, and lived realities of serodiscordant relationships strain the boundaries of this population category and raise intriguing questions about its intersection with contemporary biomedical agendas.

Professionalisation experiences of a 'business-minded' HIV targeted intervention NGO in India: An organisational ethnography

This paper contributes to the literature on the professionalisation of NGOs in the context of the rise of 'business-minded' approaches whereby donors establish a market environment in which NGOs compete for funding by demonstrating their achievement of targets and implementing globally recognised management models. Theoretically, we use the distinction between 'economies of performance' and 'ecologies of practice' to explore how NGOs simultaneously 'perform' themselves publicly as meeting expected professional standards while simultaneously producing themselves practically through 'unprofessional' means. Limited global health and development literature addresses professionalisation as an empirical practice and experience. We report on an ethnography of a Bill and Melinda Gates Foundation-funded, HIV-targeted intervention NGO in western India, drawing on six months of participant observation and 17 interviews with NGO workers. The organisation meets 'business-minded' success criteria but does so through informal, personal, hierarchical arrangements at odds with the professionalisation model. Frontline workers are demotivated by their professionalisation experience, are suspicious of the performance of success, and find ways of achieving their vocation despite a system which they feel does not recognise the value of human relationships. Showing that 'business-minded' approaches do not necessarily rule out informal, potentially 'corrupt' ways of working, we argue against the 'professional-unprofessional' binary.

"Watering-Down" Strict HIV Testing Quotas on Chinese Men Who Have Sex with Men Community-Based Organizations

The Chinese Center for Disease Control employs Community-Based Organizations (CBO) to conduct mass testing on "hidden" Men who have Sex with Men (MSM). Testing MSMs is intended to make risky bodies legible to the state and discipline the CBOs around narrow health goals. However, detailed ethnographic fieldwork with MSM CBOs in southwest China demonstrates that pressures to achieve HIV testing quotas produce the need to "water-down" or manipulate data. This distorts the identities and practices of MSMs from state surveillance and builds collusive partnerships between CBOs and low-level government officials to mitigate the disciplinary impacts of strict audits.

Between pandemics: sex worker, sexual minority, and transgender activism from HIV to COVID-19

Public health crises alter political landscapes. This article investigates social movement strategies during and between the HIV and COVID-19 pandemics. We conducted a set of eighteen in-depth interviews with eleven leaders of organisations working with sex workers, sexual minorities, and transgender people around India, all of whom had been actively involved in HIV prevention programs, before and after the arrival of COVID-19 in India. First HIV, and then COVID-19, altered the political landscape for these groups in relation to three types of institutions: (1) donors (by creating dramatic increases and decreases in the amount, type, and conditions of global funding and deepening inequalities among organisations) (2) the state (by shifting the balance of advocacy and human rights work toward immediate relief); and (3) other social movements (by expanding solidarities across groups but also placing them in competition for limited resources). We argue that, to weather these dramatic shifts, organisations relied on internal alliances and resources built in and after periods of crisis. In this way, despite the differences between the two pandemics, the legacies of HIV shaped the response to COVID-19. Though responses to COVID-19 seem improvised and temporary, they build on a longer-term social movement infrastructure.

The Biomedical Closet? Undetectability among HIV-positive Gay Men in India

The discourse of Undetectability, referring to the effect of HIV viral suppression on forward sexual transmission, is at the heart of the current paradigm of Treatment-as-Prevention and is invested with hopes of eliminating stigma. But ethnographic examination of the way HIV-positive gay and bisexual men in four major Indian cities experience Undetectability reveals a more complicated picture. Rather than resolve the problem of HIV stigma, Undetectability enables new ways of managing it, including ethical non-disclosure in the face of social danger. This reveals three paradoxes inherent in the universalism of Treatment-as-Prevention and its reliance on biomedical solutions.

In Search of 'Success': The Politics of Care and Responsibility in a PrEP Demonstration Project

We illustrate the lively existence of the notion of success in the unfolding of a PrEP project led by a sex worker organization in India. In what we call the "search for success," particular attention is placed on the role that care plays among sex workers guiding the project. Drawing on our ethnographic work, we highlight how the search for success underlines particular affective dispositions that are underscored by overlapping temporal registers: in the early stages of fostering adherence; when project fatigue sets in; and as the project draws to a close, in the anticipation of what comes next for the organization.

Epidemiological Imaginaries of the Social: Epidemiologists and Pathologies of Modernization in Postcolonial Africa

There is a growing anthropological literature analyzing the place that epidemiological surveillance occupies in contemporary global health. In this article, I build on this literature and take it into new directions by exploring what I call the epidemiological imaginaries of the social. Drawing on science and technology studies, I suggest that epidemiologists help make up the world, articulating complex and normatively loaded visions of social life that both enable and constrain action. More specifically, I argue that epidemiologists tell stories about the type of societies and people that compose the world and that these stories often shape global health policies and programs in powerful ways. To substantiate this argument, I examine epidemiologists' efforts to map smoking in postcolonial Africa, documenting how they have imagined smokers and smoking through the lense of modernization theory and showing how these imaginaries have shaped tobacco control policies in the region up to this day.

Re-Assembling "Risky" Subjects: African Migrant Youth in Winnipeg, Canada

Drawing upon ethnographic research in Winnipeg, Manitoba, we complicate simplistic epidemiological and sexual health discourses that position African newcomer teen girls and young women as "at-risk" for HIV/AIDS and other consequences of being sexually active. By tracing the trajectories of sexual health messages and utilizing the concept of assemblage, we seek to account for the ways in which risk is actively made and negotiated in practice by African newcomer youth. By highlighting the perspectives and experiences of participants in relationship to Canadian literature on the subject of sexual risk, culture, and education, we work to counter essentializing, racializing, and pathologizing discourses.

Rites of Resistance: Sex Workers' Fight to Maintain Rights and Pleasure in the Centre of the Response to HIV in Brazil

Drawing on ethnographic research conducted from 2011 to 2015 and the authors' long-term engagement in diverse aspects of HIV and human rights advocacy in Brazil, this paper explores key elements of the Brazilian sex workers' movement response to HIV and the broader political factors that profoundly influenced its trajectory. We argue that the movement has constantly challenged representations of prostitution by affirming sex workers' roles as political actors, not just peer educators, in fighting the HIV epidemic and highlight their development of a sex positive and pleasure centred response that fought stigma on multiple fronts. Moments of tension such as the censorship of an HIV prevention campaign and implementation of 'test and treat' projects are analysed, as are the complex questions that Brazil's 2016 political and economic crisis evokes in terms of how to develop and sustain responses to HIV driven by communities but with material commitment from the State. We conclude with what we see to be the unique, central components of Brazilian sex workers' approach to HIV prevention and what lessons can be learned from it for broader collective health movements in Latin America and beyond.

The contributions and future direction of Program Science in HIV/STI prevention

Background

Program Science is an iterative, multi-phase research and program framework where programs drive the scientific inquiry, and both program and science are aligned towards a collective goal of improving population health.

Discussion

To achieve this, Program Science involves the systematic application of theoretical and empirical knowledge to optimize the scale, quality and impact of public health programs. Program Science tools and approaches developed for strategic planning, program implementation, and program management and evaluation have been incorporated into HIV and sexually transmitted infection prevention programs in Kenya, Nigeria, India, and the United States.

Conclusion

In this paper, we highlight key scientific contributions that emerged from the growing application of Program Science in the field of HIV and STI prevention, and conclude by proposing future directions for Program Science.

Achieving scale rapidly in public health: Applying business management principles to scale up an HIV prevention program in India

Numerous public-health interventions have demonstrated effectiveness in pilots or on a small scale, but have proven challenging to scale up for population-level impact. Avahan, the Bill & Melinda Gates Foundation's HIV prevention program in 6 states of India, confronted the challenge of rapidly scaling up services to reach 300,000 people most at risk of HIV. This meant working in diverse and complex environments with marginalized and largely hidden populations. This case report presents a number of business-management principles that the foundation drew upon to successfully scale up this public-health program: 1) strategy development through market segmentation and complexity analysis, 2) a dynamic and evolving strategy, 3) developing an implementation and management structure to match the strategy, 4) standardization with flexibility, 5) generating demand to balance supply, 6) a customer-centric approach, and 7) data-driven management. Lessons learned from this experience include the crucial role of data in guiding decision-making and strategic and programmatic change; the need for a central body to set strategy; a willingness to change course when experience and data demonstrate the need; and the importance of partnering with program beneficiaries at all stages of program design, operation, evaluation and sustainability. We believe these lessons are applicable to other development programs that seek to foster widespread and sustainable program benefits at scale.

Prioritizing Risk in Preparation for a Demonstration Project: A Mixed Methods Feasibility Study of Oral Pre-Exposure Prophylaxis (PREP) among Female Sex Workers in South India

BACKGROUND

HIV prevalence among female sex workers (FSWs) in India remains well above the national average. Pre-exposure prophylaxis (PrEP), a new HIV prevention technology, may help to reduce HIV incidence, but there is a dearth of research that can inform the potential scale-up of PrEP in India. In partnership with Ashodaya Samithi, a local sex worker collective, we conducted a feasibility study to assess acceptance of a planned PrEP demonstration project, willingness to use PrEP, and recommendations for project roll-out among FSWs in southern Karnataka.

METHODS

From January-April 2015, 6 focus group discussions, 47 in-depth interviews, and 427 interviewer-administered questionnaires were completed by female sex workers. All participants were 18 years of age or older and practiced sex work. Qualitative data were coded for key themes and emergent categories. Univariate descriptive analysis was employed to summarise the quantitative data.

RESULTS

Qualitative. PrEP was described as an exciting new prevention technology that places control in the hands of FSWs and provides a "double safety" in combination with condom use. Participants expressed agreement that women who may experience more HIV risk in their occupational environments should be prioritized for enrollment into a demonstration project. Quantitative. 406 participants (95%) expressed interest in PrEP. Participants prioritized the inclusion of FSWs under the age of 25 (79%), those who do not use condoms when clients offer more money (58%), who do not consistently use condoms with regular partners (57%), who drink alcohol regularly (49%), and who do not use condoms consistently with clients (48%).

DISCUSSION

This feasibility study indicated strong interest in PrEP and a desire to move forward with the demonstration project. Participants expressed their responses in terms of public health discourses surrounding risk, pointing to the importance of situating PrEP scale up within the trusted spaces of community-based organizations as a means of supporting PrEP uptake and adherence.

Confidentiality considerations for use of social-spatial data on the social determinants of health: Sexual and reproductive health case study

Understanding whether and how the places where people live, work, and play are associated with health behaviors and health is essential to understanding the social determinants of health. However, social-spatial data which link a person and their attributes to a geographic location (e.g., home address) create potential confidentiality risks. Despite the growing body of literature describing approaches to protect individual confidentiality when utilizing social-spatial data, peer-reviewed manuscripts displaying identifiable individual point data or quasi-identifiers (attributes associated with the individual or disease that narrow identification) in maps persist, suggesting that knowledge has not been effectively translated into public health research practices. Using sexual and reproductive health as a case study, we explore the extent to which maps appearing in recent peer-reviewed publications risk participant confidentiality. Our scoping review of sexual and reproductive health literature published and indexed in PubMed between January 1, 2013 and September 1, 2015 identified 45 manuscripts displaying participant data in maps as points or small-population geographic units, spanning 26 journals and representing studies conducted in 20 countries. Notably, 56% (13/23) of publications presenting point data on maps either did not describe approaches used to mask data or masked data inadequately. Furthermore, 18% (4/22) of publications displaying data using small-population geographic units included at least two quasi-identifiers. These findings highlight the need for heightened education for researchers, reviewers, and editorial teams. We aim to provide readers with a primer on key confidentiality considerations when utilizing linked social-spatial data for visualizing results. Given the widespread availability of place-based data and the ease of creating maps, it is critically important to raise awareness on when social-spatial data constitute protected health information, best practices for masking geographic identifiers, and methods of balancing disclosure risk and scientific utility. We conclude with recommendations to support the preservation of confidentiality when disseminating results.

Empty rituals? A qualitative study of users' experience of monitoring & evaluation systems in HIV interventions in western India

In global health initiatives, particularly in the context of private philanthropy and its 'business minded' approach, detailed programme data plays an increasing role in informing assessments, improvements, evaluations, and ultimately continuation or discontinuation of funds for individual programmes. The HIV/AIDS literature predominantly treats monitoring as unproblematic. However, the social science of audit and indicators emphasises the constitutive power of indicators, noting that their effects at a grassroots level are often at odds with the goals specified in policy. This paper investigates users' experiences of Monitoring and Evaluation (M&E) systems in the context of HIV interventions in western India. Six focus groups (totalling 51 participants) were held with employees of 6 different NGOs working for government or philanthropy-funded HIV interventions for sex workers in western India. Ten donor employees were interviewed. Thematic analysis was conducted. NGO employees described a major gap between what they considered their "real work" and the indicators used to monitor it. They could explain the official purposes of M&E systems in terms of programme improvement and financial accountability. More cynically, they valued M&E experience on their CVs and the rhetorical role of data in demonstrating their achievements. They believed that inappropriate and unethical means were being used to meet targets, including incentives and coercion, and criticised indicators for being misleading and inflexible. Donor employees valued the role of M&E in programme improvement, financial accountability, and professionalising NGO-donor relationships. However, they were suspicious that NGOs might be falsifying data, criticised the insensitivity of indicators, and complained that data were under-used. For its users, M& E appears an 'empty ritual', enacted because donors require it, but not put to local use. In this context, monitoring is constituted as an instrument of performance management rather than as a means of rational programme improvement.

The Loss of Boystown and Transition to Online Sex Work: Strategies and Barriers to Increase Safety Among Men Sex Workers and Clients of Men

Men sex workers in Vancouver have largely transitioned from street to online solicitation coinciding with losing "Boystown," the main outdoor sex work stroll for men. This article explores strategies and barriers to increase safety among men and trans sex workers and clients of men in Vancouver, Canada. Qualitative interviews were conducted (2012-2013) with 61 self-identifed men who currently buy and/or sell sex in a community-based research project known as CHAPS (Community Health Assessment of Men Who Purchase and Sell Sex). Drawing on a socioecological framework, thematic analysis of interview transcripts was conducted utilizing ATLAS.ti 7 software among men (39 workers; 8 buyers). Narratives indicate that gentrification and urban planning led to social isolation and loss of social support networks among men in the sex industry. Concurrently, the restructuring of sex work to online increased workers' safety and control. Narratives reveal how the Internet can provide greater opportunities to negotiate terms of sex work and enhanced screening using webcams, reducing risks of violence, stigma, and police harassment for both workers and clients compared with the street. This study highlights how losing Boystown led to a loss of community and solidarity: key protective measures for sex workers. Online solicitation increased workers' capacity to screen prospective clients and prevent violence. Recent legal reforms in Canada to further criminalize sex work raise significant concern for human rights and health of individuals in the sex industry, and point to the critical need to include voices of men and trans sex workers and buyers in policy discussions.

Towards 'reflexive epidemiology': Conflation of cisgender male and transgender women sex workers and implications for global understandings of HIV prevalence

The HIV epidemic has had a widespread impact on global scientific and cultural discourses related to gender, sexuality, and identity. 'Male sex workers' have been identified as a 'key population' in the global HIV epidemic; however, there are methodological and conceptual challenges for defining inclusion and exclusion of transgender women within this group. To assess these potential implications, this study employs self-critique and reflection to grapple with the empiric and conceptual implications of shifting understandings of sexuality and gender within the externally re-created etic category of 'MSM' and 'transgender women' in epidemiologic HIV research. We conducted a sensitivity analysis of our previously published meta-analysis which aimed to identify the scope of peer-reviewed articles assessing HIV prevalence among male sex workers globally between 2004 and 2013. The inclusion of four studies previously excluded due to non-differentiation of cisgender male from transgender women participants (studies from Spain, Thailand, India, and Brazil: 421 total participants) increased the overall estimate of global HIV prevalence among 'men' who engage in sex work from 10.5% (95% CI 9.4-11.5%) to 10.8% (95% CI 9.8-11.8%). The combination of social science critique with empiric epidemiologic analysis represents a first step in defining and operationalising 'reflexive epidemiology'. Grounded in the context of sex work and HIV prevention, this paper highlights the multiplicity of genders and sexualities across a range of social and cultural settings, limitations of existing categories (i.e. 'MSM', 'transgender'), and their global implications for epidemiologic estimates of HIV prevalence.

HIV vulnerability and the erasure of sexual and gender diversity in Abidjan, Côte d'Ivoire

In the fight against concentrated HIV epidemics, men who have sex with men (MSM) are often framed as a homogeneous population, with little attention paid to sexual and gender diversity and its impact on HIV vulnerability. This article draws on ethnographic research conducted in Abidjan, Côte d'Ivoire among les branchés - a local term encompassing several categories of same-sex desire and practice. In the context of increased HIV prevention programming targeting Ivoirian sexual and gender minorities, such diversity is effectively erased. This obfuscation of difference has particularly negative impacts for travestis, who may be at higher risk for HIV infection, though research and prevention efforts in which they are grouped with 'MSM' render them underrepresented and make their vulnerability difficult to quantify. Branchés whose class and/or ethnic backgrounds compound their stigmatised status as sexual and gender minorities also bear the burden of this exclusion. Furthermore, some branchés deploy 'MSM' as a form of self-identification, further complicating who such categories represent. By highlighting the ways in which constructions of gender and sexuality within HIV/AIDS programming obscure complex social realities, I aim to reorient thinking around the development of purposeful HIV programming that engages the complexity of sexual and gender minority experience.

Sex work in geographic perspective: a multi-disciplinary approach to mapping and understanding female sex work venues in Southwest China

This paper examines the findings from an extensive geographic mapping study of female sex work venues located in the south western Chinese city of Zigong, in Sichuan province. Drawing upon the findings from quantitative research, secondary historical sources and field notes, composed during participant observation, we provide a nuanced portrait of how the operation of sex work can be conceptualised in spatial terms, where 'space' is regarded as something socially constructed and historically contingent. The sex work geographies we analyse hold important implications for prevention work conducted in the region. When the sexual practices between sex workers and their clients are viewed against a wider geographic and historical backdrop, focus shifts from the properties and intentionalities of individuals towards the kinds of spaces where sex work operates, the organisation of which are underpinned by economic forces that have given rise to the rapid proliferation of small urban spaces in contemporary China.

Alternative accounting in maternal and infant global health

Efforts to augment accountability through the use of metrics, and especially randomised controlled trial or other statistical methods place an increased burden on small nongovernmental organisations (NGOs) doing global health. In this paper, we explore how one small NGO works to generate forms of accountability and evidence that may not conform to new metrics trends but nevertheless deserve attention and scrutiny for being effective, practical and reliable in the area of maternal and infant health. Through an analysis of one NGO and, in particular, its organisational and ethical principles for creating a network of safety for maternal and child health, we argue that alternative forms of (ac)counting like these might provide useful evidence of another kind of successful global health work.

Burden of Proof: Documentation of an HIV Prevention Program in Ghana

Globally, HIV programs face pressure to document their accountability and achievements using “evidence-based” criteria or “monitoring and evaluation” (“M&E”), yet little is known about how M&E occurs on the ground or its social and political effects. This paper explores how NGO actors in Ghana experienced routine documentation of a USAID-funded HIV program. Drawing upon 20 months of ethnographic fieldwork, I illustrate how M&E documentation reproduces hierarchical aid relations by engaging NGO actors to self-govern through unexpected strict adherence to documentation requirements. I explore institutional supervisors' frustration with their deference to documentation to further show how inequality is indirectly reproduced.