“We Are Just Supposed to Be Quiet”: The Production of Adherence to Antiretroviral Treatment in Urban Tanzania

Good, Bad Religious Leaders: Binary Talk in a Tanzanian Health Project

NGOs recruit religious leaders as health actors in Sub-Saharan Africa. Program designers both construct religious leaders as opponents of family planning interventions who discourage their congregants from using family planning and as proponents who persuade their congregants to use them. This article investigates a family planning project that recruited religious leaders in Morogoro, Tanzania. Research findings show that binary talk obfuscates the structural underpinning of high fertility rates. The construction of static binaries of good and bad religious leaders observed mismatches with peoples' own realities and it misses the lifelike nuances of actors' own ethical action.

Therapeutic citizens or therapeutic refugees? An examination of triage, refugeehood, and referral health care in Tanzania

Referral health care refers to the movement of populations between different levels of a health care system, often to seek specialized care at higher level centers. It requires mobility of populations. Critical questions on the shortcomings for accessing referral health care, especially for refugees in sub-Saharan Africa, remain unexplored. How do global guidelines on referral health care play out in the local context of a country like Tanzania, where refugees are not legally allowed to leave the refugee camp without permission? How do health care providers navigate this complex space, and how can we leverage anthropological theories of biopower and therapeutic citizenship to better understand this context? Based on six months of ethnographic fieldwork in Tanzania between 2011 and 2021, I trace how global refugee policy manifests itself locally. I argue that referral for refugees in Tanzania is as much a political and social process as it is medical. The bureaucratic process favors certain pathologies over others and creates significant delays in referral. Triage takes on nuanced forms whereby a certain aspect of a patient's case (i.e., prognosis, cost, age) is privileged in a context of strict refugee policy that restricts independent care-seeking. Most patients are approved for referral, but many are denied. A patient may not be sick enough to merit timely referral, or they may be deemed too sick to prevent referral altogether. Challenging other arguments of therapeutic citizenship where people living with certain health conditions acquire access to certain therapies and their right to health, I show how refugees with certain pathologies are actually excluded from care. These therapeutic exceptions produce consequences whereby bureaucracy and security have prevailed over the right to health and reinforced the power of state sovereignty in what may best be understood not as a therapeutic citizenship, but instead as a therapeutic refugeehood.

HIV Support Groups and the Chronicities of Everyday Life in eSwatini

Drawing on ethnographic research, I examine the evolution of HIV support groups and biosociality during the "treat-all era" in eSwatini. I show how support groups are shaped by local actors to cater to a need for social solidarity that transcends diagnostic status, and thereby move beyond donors' HIV-centric rationales to use the groups for HIV treatment scale-up. In this particular phase of the HIV epidemic, I suggest, support groups make up a particular kind of biosociality, which is shaped by shared experiences of structural vulnerability to chronic illness, and a desire to be prepared for future diseases and other misfortune.

Limits of neoliberalism: HIV, COVID-19, and the importance of healthcare systems in Malawi

Countries in sub-Saharan Africa have been seriously affected by HIV and now face a new pandemic - COVID-19. How have prior experiences with managing HIV prepared countries for COVID-19? To what extent has the structure of the global health field enabled or constrained countries' ability to respond? Drawing on qualitative methods, this article examines the impact of HIV interventions on the healthcare system in Malawi and its implications for addressing COVID-19. I argue that the historical and continued influence of neoliberalism in global health manifests in the structures and routines of clinical practice. In Malawi's health centres, a parallel NGO system of care has become grafted onto state healthcare, with NGOs managing HIV commodities and providing care to HIV patients. While HIV NGOs do support the work of government providers, it is limited to tasks that align with their programmatic goals. Outside of donor priorities, the conditions of public healthcare are left behind, and government providers struggle with shortages of staff, medical resources, and basic infrastructure. In the context of COVID-19, risks are compounded as public healthcare facilities not only struggle with resources to treat patients, but also become a site of risk itself for COVID-19 infection.

Tobacco use and cessation in the context of ART adherence: Insights from a qualitative study in HIV clinics in Uganda

Sub-Saharan Africa carries a disproportionate burden of human immunodeficiency virus (HIV). Tobacco use amongst people living with HIV is higher than in the general population even though it increases the risk of life-threatening opportunistic infections including tuberculosis (TB). Research on tobacco use and cessation amongst people living with HIV in Africa is sparse and it is not clear what interventions might achieve lasting cessation. We carried out qualitative interviews in Uganda in 2019 with 12 current and 13 former tobacco users (19 men and 6 women) receiving antiretroviral therapy (ART) in four contrasting locations. We also interviewed 13 HIV clinic staff. We found that tobacco use and cessation were tied into the wider moral framework of ART adherence, but that the therapeutic citizenship fashioned by ART regimes was experienced more as social control than empowerment. Patients were advised to stop using tobacco; those who did not concealed this from health workers, who associated both tobacco and alcohol use with ART adherence failure. Most of those who quit tobacco did so following the biographical disruption of serious TB rather than HIV diagnosis or ART treatment, but social support from family and friends was key to sustained cessation. We put forward a model of barriers and facilitators to smoking cessation and ART adherence based on engagement with either ‘reputation’ or ‘respectability’. Reputation involved pressure to enjoy tobacco with friends whereas family-oriented respectability demanded cessation, but those excluded by isolation or precarity escaped anxiety and depression by smoking and drinking with their peers.

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People living with HIV in Uganda hid their tobacco use from health workers.

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The experience of tuberculosis was the most common trigger to quit smoking.

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Engagement with ‘respectable’ masculinity promoted smoking cessation.

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Engagement with ‘reputational’ masculinity made it hard to quit.

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This model has wider applicability for antiretroviral therapy adherence.

'If I don't take care of myself, who will?' Self-caring subjects in Oaxaca's mutual-aid groups

Based on seven months of ethnographic fieldwork in two urban health centres in Oaxaca City, Mexico, this paper analyses the ways in which underprivileged middle-aged and older female patients experience and transform grupos de ayuda mutua (GAMs), or mutual-aid groups, a public health programme aimed at improving chronic patients' adherence to their biomedical treatments. GAMs work as 'technologies of the self' within the context of the Mexican neoliberal regime and patients are urged to be self-responsible. GAM members regard such urging favourably and act according to their broader understandings of life, which they see as a lucha (struggle) that requires cuidarse (a polysemic verb alluding to self-care for self-preservation) and hard work in a structurally unequal place characterised by precarity and social unrest. This seemingly rugged individualism is converted into microlevel collaboration through culturally distinctive Oaxacan practices of mutual help. By exploring the playful ways these women participate in GAMs, this paper shows how biomedical settings can be repurposed as spaces of socialisation and wellbeing for older women living in vulnerable conditions.

Dissonance of Choice: Biomedical and Lived Perspectives on HIV Treatment-Taking

Treat-all recommends prompt treatment initiation for those diagnosed HIV positive, requiring adaptations to individuals' behavior and practice. Drawing on data from a longitudinal qualitative study in Eswatini, we examine the choice to initiate treatment when asymptomatic, the dissonance between the biomedical logic surrounding Treat-all and individuals' conceptions of treatment necessity, and the navigation over time of ongoing engagement with care. We reflect on the perspectives of healthcare workers, responsible for implementing Treat-all and holding a duty of care for their patients. We explore how the potentially differing needs and priorities of individuals and the public health agenda are navigated and reconciled. Rationalities regarding treatment-taking extend beyond the biomedical realm, requiring adjustments to sense of self and identity, and decision-making that is situated and socially embedded. Sense of choice and ownership for this process is important for individuals' engagement with treatment and care.

Monitoring the body: grandmothers' ability to provide 'expert' care for grandchildren living with HIV in northwest Tanzania

Drawing on long-term ethnographic fieldwork on older caregivers and their shifting roles since the introduction of antiretroviral therapy in northwest Tanzania, this article explores grandmothers' roles in caring for grandchildren who are HIV positive and on treatment. While AIDS treatment programmes usually focus on cultivating expert patients who can perform self-care, this study focuses on older caregivers and how they become experts in caring for their grandchildren living with HIV. How is expert care enacted and what supports or limits its quality? Based on observations and in-depth interviews, this article argues that grandmothers become 'expert caregivers' by merging knowledge acquired in the clinic and support groups with intimate practices of grandparental care. However, the grandmother's gendered and generational position within kin networks affects her ability to provide expert care. The findings indicate that in analysing treatment outcomes among adolescents, it is important to understand the broader family dynamic that influences the actual possibility of expert caregivers to support children living with HIV.

Therapeutic citizens and clients: diverging healthcare practices in Malawi's prenatal clinics

This article examines how HIV policies and the funding priorities of global institutions affect practices in prenatal clinics and the quality of healthcare women receive. Data consist of observations at health centres in Lilongwe, Malawi and interviews with providers (N = 37). I argue that neoliberal ideology, which structures the global health field, produces a fragmented healthcare system on the ground. Findings show two kinds of healthcare practices within the same clinic: donor-funded NGOs took on HIV services while government providers focused on prenatal care. NGO practices were defined by surveillance, where providers targeted pregnant HIV-positive women and intensively monitored their adherence to drug treatment. In contrast, state-led practices were defined by rationing. Government providers worked with all pregnant women, but with staff and resource shortages, they limited time and services for each patient in order to serve everyone. This paper builds on concepts of therapeutic citizenship and clientship by exploring how global health priorities produce different conditions, practices and outcomes of NGO and state-led care.

Narrative Navigation: HIV and (Good) Care in Aceh, Indonesia

In this article, I elaborate the concept of narrative navigation to analyze the subjective and intersubjective ways in which people struggle through experiences of illness by constructing multiple, ambiguous and non-linear narratives that may continuously change, as they reposition themselves within changing circumstances. Drawing on ethnographic material on HIV care in Aceh, Indonesia, I show how subjunctivity and open-endedness are crucial narrative ways in which people living with HIV, their relatives, medical doctors and support group workers adjust to possibilities and limitations of care over time, thereby continuously negotiating what good care may be. Unfolding within a changing Indonesian healthcare system, their narrative navigations reveal caregiving to be a complex and contradictory process, thereby problematizing boundaries between good care and neglect.

The rebellious man: Next-of-kin accounts of the death of a male relative on antiretroviral therapy in sub-Saharan Africa

The HIV response is hampered by many obstacles to progression along the HIV care cascade, with men, in particular, experiencing different forms of disruption. One group of men, whose stories remain untold, are those who have succumbed to HIV-related illness. In this paper, we explore how next-of-kin account for the death of a male relative. We conducted 26 qualitative after-death interviews with family members of male PLHIV who had recently died from HIV in health and demographic surveillance sites in Malawi, Tanzania, Kenya, Uganda, Zimbabwe and South Africa. The next-of-kin expressed frustration about the defiance of their male relative to disclose his HIV status and ask for support, and attributed this to shame, fear and a lack of self-acceptance of HIV diagnosis. Next-of-kin painted a picture of their male relative as rebellious. Some claimed that their deceased relative deliberately ignored instructions received by the health worker. Others described their male relatives as unable to maintain caring relationships that would avail day-to-day treatment partners, and give purpose to their lives. Through these accounts, next-of-kin vocalised the perceived rebellious behaviour of these men, and in the process of doing so neutralised their responsibility for the premature death of their relative.

Freedom of choice, expressions of gratitude: Patient experiences of short-term surgical missions in Guatemala

Lack of surgical care has been highlighted as a critical global health problem, and short-term medical missions (STMMs) have become a de facto measure to address this shortfall. Participation in STMMs is an increasingly popular activity for foreign medical professionals to undertake in low- and middle-income countries (LMICs) where their clinical skills may be in short supply. While there is emerging literature on the STMM phenomenon, patient experiences of surgical missions are underrepresented. This research addresses this gap through thirty-seven in-depth interviews with patients or caregivers who received care from a short-term surgical mission within the three years prior to the four-week data collection period in July and August 2013. Interviews were conducted in Antigua, Guatemala and nearby communities, and participants came from 9 different departments of the country. These first-hand accounts of health-seeking through a surgical mission provide important insights into the benefits and challenges of STMMs that patients encounter, including waiting time, ancillary costs, and access to care. Patient agency in care-seeking is considered within the pluralistic, privatized health care context in Guatemala in which foreign participants deliver STMM care.

Redemption of the "spoiled identity:" the role of HIV-positive individuals in HIV care cascade interventions

Introduction

The concept of “therapeutic citizenship” has drawn attention to ways in which public testimony, the “story‐telling in the public sphere” undertaken by people living with HIV (PLHIV), has shaped the global response to the epidemic. This paper presents qualitative findings from two large studies in eastern Africa that reveal how the advent of population‐based HIV testing campaigns and efforts to accelerate antiretroviral “treatment for all” has precipitated a rapidly expanding therapeutic citizenship “project,” or social movement. The title of this paper refers to Goffman's original conceptualization of stigma as a social process through which a person's identity is rendered “spoiled.”

Methods

Data were derived from qualitative studies embedded within two clinical trials, Sustainable East African Research in Community Health (SEARCH) (NCT# 01864603) in Kenya and Uganda, and START‐ART (NCT# 01810289) in Uganda, which aimed to offer insights into the pathways through which outcomes across the HIV care continuum can be achieved by interventions deployed in the studies, any unanticipated consequences, and factors that influenced implementation. Qualitative in‐depth semi‐structured interviews were conducted among cohorts of adults in 2014 through 2015; across both studies and time periods, 217 interviews were conducted with 166 individuals. Theoretically informed, team‐based analytic approaches were used for the analyses.

Results

Narratives from PLHIV, who have not always been conceptualized as actors but rather usually as targets of HIV interventions, revealed strongly emergent themes related to these individuals' use of HIV biomedical resources and discourses to fashion a new, empowered subjecthood. Experiencing the benefits of antiretroviral therapy (ART) emboldens many individuals to transform their “spoiled” identities to attain new, valorized identities as “advocates for ART” in their communities. We propose that the personal revelation of what some refer to as the “gospel of ARVs,” the telling of personal stories about HIV in the public sphere and actions to accompany other PLHIV on their journey into care, is driven by its power to redeem the “spoiled identity:” it permits PLHIV to overcome self‐stigma and regain full personhood within their communities.

Conclusions

PLHIV are playing an unanticipated but vital role in the successful implementation of HIV care cascade interventions.

Fluid Drugs: Revisiting the Anthropology of Pharmaceuticals

This review discusses a growing body of scholarship at the intersection of anthropology and science and technology studies (STS) that examines how drugs are rendered efficacious in laboratories, therapeutic settings, and everyday lives. This literature foregrounds insights into how commercial interests and societal concerns shape the kinds of pharmaceutical effects that are actualized and how some efficacies are blocked in response to moral concerns. The work brought together here reveals how regulatory institutions and health policy makers seek to stabilize pharmaceutical actions while, on the front lines of care, pharmacists, health workers, and users tinker with dosages and indications to tailor pharmaceutical actions to specific circumstances. We show that there is no pure (pharmaceutical) object that precedes its socialization. Pharmaceuticals are not “discovered”; they are made and remade in relation to shifting contexts. This review outlines five key areas of ethnographic and STS research that examines such fluid drugs.

"A Body Like a Baby": Social Self-Care among Older People with Chronic HIV in Mombasa

As part of the chronic disease paradigm now widely used for HIV in sub-Saharan Africa, antiretroviral treatment programs emphasize self-care. In the informal settlements of Mombasa, Kenya, the management of stress-associated with economic precariousness-plays a significant role in self-care practices and ideologies. Based on ethnographic fieldwork, we examine how local narratives of stress and self-care intertwine with social responsibilities of older HIV-positive people. For older Mombassans, living with 'chronic' HIV means living with an unpredictable body, which affects how they are able to care for their kin. The physical reality of living with HIV thus shapes relational networks, making self-care a social practice. While, for some self-care entails managing the body so that its needs are hidden from loved ones, a kind of 'protective secrecy,' others enlist the support of their children and grandchildren in managing their body, and in that process subtly redefine generational expectations and responsibilities.

The Framing and Fashioning of Therapeutic Citizenship Among People Living With HIV Taking Antiretroviral Therapy in Uganda

In this article, we examine how people living with HIV (PLWH) were able to reconceptualize or "reframe" their understanding of HIV and enhance their capacity to self-manage the condition. Two in-depth interviews were held with 38 PLWH (20 women, 18 men) selected from three government and nongovernment antiretroviral therapy (ART) delivery sites in Wakiso District, and the narratives analyzed. ART providers played an important role in shaping participants' HIV self-management processes. Health workers helped PLWH realize that they could control their condition, provided useful concepts and language for emotional coping, and gave advice about practical self-management tasks, although this could not always be put into practice. ART providers in this setting were spaces for the development of a collective identity and a particular form of therapeutic citizenship that encouraged self-management, including adherence to ART. Positive framing institutions are important for many PLWH in resource-limited settings and the success of ART programs.

"They are looking just the same": Antiretroviral treatment as social danger in rural Malawi

Research on the social impact of ART pivots on questions of individual adherence and community acceptability of treatment programmes. In this paper we examine unexpected and unintended consequences of the scale-up of treatment in rural Malawi, using a unique dataset of more than 150 observational journals from three sites, spanning 2010 to 2013, focusing on men's everyday conversations. Through thematic content analysis, we explore the emerging perception that the widespread availability of ART constitutes a form of social danger, as treatment makes it difficult to tell who does or does not have AIDS. This ambiguity introduced through ART is interpreted as putting individuals at risk, because it is no longer possible to tell who might be infected - indeed, the sick now look healthier and "plumper" than the well. This ambivalence over the social impact of ART co-exists with individual demand for and appreciation of the benefits of treatment.

Redeeming Lost Mothers: Adolescent Antiretroviral Treatment and the Making of Home in South Africa

In this article, we explore how adolescent antiretroviral treatment (ART) might be signified to repair sociality in Eastern Cape homes that have been ruptured by HIV/AIDS and maternal loss. The post-apartheid period has exposed these families to new forms of social fragmentation, propelled by the disintegration of wage labor, declining marriage rates, and a rampant HIV/AIDS epidemic. Drawing on eight months of ethnographic fieldwork (August 2013-April 2014), we show that in the homes of some adolescents born with HIV, these present-day domestic ruptures were discursively connected to the past shortcomings of their dead and absent mothers. In some familial narratives lost mothers were accused of disobeying their elders, neglecting their children, and flouting custom; their social transgressions were made manifest in their child's inherited HIV. By signifying adolescent ART-taking as an enactment of the discipline and care purportedly absent in their mothers, these families might also attempt to imbue ART, beyond its biomedical function, as a means of social repair.

The Anthropology of Life After AIDS: Epistemological Continuities in the Age of Antiretroviral Treatment

Anthropologists working on HIV are increasingly reframing their research as taking place in “the age of treatment,” marking a shift from “the age of AIDS.” The age of treatment is characterized by the increasing biomedicalization of HIV, which has come about as a result of improved pharmaceutical and surveillance technologies and the presumption by international experts in global health that HIV could be eradicated in the near future through biomedical interventions. Despite this radical transformation, I argue that there are many important epistemological continuities for anthropologists researching HIV/AIDS in the twenty-first century. This review identifies such continuities between anthropological research conducted prior to and that conducted since the availability of life-saving treatment for HIV.

"Doing the Best We Can": Providing Care in a Malawian Antiretroviral Clinic

Following a national policy shift toward universal access to antiretroviral therapy (ART) in Malawi, hospitals and clinics around the country made major changes to enable the provision of ART. In this already resource-limited environment, the provision of ART brought new health care delivery challenges to bear on both patients and health care professionals. The substance and form of these local interventions are affected by a multilayered global context. Drawing on fieldwork in an antiretroviral clinic in rural Malawi, this article discusses the daily implications of providing and receiving care in the context of a massive global shift in health policy, and argues that in order to fully understand the process of service rollout in all its complexity, care should be explored not only from the patients' perspective but also from that of local and international health care professionals and policymakers.

HIV-serostatus disclosure in the context of free antiretroviral therapy and socio-economic dependency: experiences among women living with HIV in Tanzania

The worldwide implementation of free antiretroviral therapy (ART) raised great hopes among policy makers and health organisations about the positive changes it would bring about in attitudes and behaviours towards HIV and AIDS, as well as for infected people's lives. A change in illness perception was anticipated, leading to the hypothesis of a possible change in disclosure rates, patterns and the choice of significant others to inform. In the era of free treatment availability in the United Republic of Tanzania, we examined reasons for disclosure and non-disclosure among HIV-seropositive women enrolled on ART and their choice of significant others to inform. In so doing, we contribute to the necessary yet neglected debate about the social impact of ART on the lives of infected women. The study, for which an ethnographic cross-sectional pilot approach was chosen, was conducted at the Care and Treatment Center (CTC) at Bombo Regional Hospital (BRH) in Tanga city, Tanzania. Data presented here derive from participant observation, questionnaires and semi-structured interviews conducted with 59 HIV-seropositive women on ART. Interestingly, and despite treatment availability, the choice of significant others to inform, as well as reasons for disclosure and non-disclosure, mirror findings from previous studies conducted before the introduction of free ART. The main reason for non-disclosure was fear of discrimination. The hope for social, economic or health support was the main motivation for disclosure, followed by the need for a 'clinic companion' in order to receive ART, as requested by hospital staff. Nevertheless, healthcare staff were not unanimous in thinking that disclosure is always beneficial, thus the recommended extent of disclosure varied. ART and concomitant factors were raised as an entirely new and significant reason for disclosure by interviewees. Finally, findings confirm that despite ART, disclosure remains a highly stressful event for women.

Synergistic vulnerabilities: antiretroviral treatment among women in Uganda

Despite being an early success story in the reduction of HIV infection rates, Uganda faces myriad challenges in the recent era of accelerated antiretroviral treatment (ARV) scale-up. For those able to access treatment, ongoing vulnerabilities of poverty and violence compound treatment-related costs and concerns. This paper explores experiences of one particularly vulnerable population - women on ARVs who have also experienced intimate partner violence (IPV). Data were collected over 12 months in Uganda. They include ethnographic interviews (n = 40) drawn from a larger sample of women on ARV and semi-structured interviews with policy-makers and service providers (n = 42), examining the intersection of experiences and responses to treatment from multiple perspectives. Women's narratives show that due to treatment, immediate health concerns take on secondary importance, while other forms of vulnerability, including IPV and poverty, can continue to shape treatment experiences and the decision to stay in violent relationships. Providers likewise face difficulties in overburdened clinics, though they recognise women's concerns and the importance of considering other forms of vulnerability in treatment. This analysis makes the case for integrating treatment with other types of social services and demonstrates the importance of understanding the ways in which synergistic and compounding vulnerabilities confound treatment scale-up efforts.

Peer mentors, mobile phone and pills: collective monitoring and adherence in Kenyatta National Hospital's HIV treatment programme

In 2006, the Kenyan state joined the international commitment to make antiretroviral treatment free in public health institutions to people infected with HIV. Less than a decade later, treatment has reached over 60% of those who need it in Kenya. This paper, which is based on an in-depth ethnographic case study of the HIV treatment programme at Kenyatta National Hospital, conducted intermittently between 2008 and 2014, examines how HIV-positive peer mentors encourage and track adherence to treatment regimens within and beyond the clinic walls using mobile phones and computer technology. This research into the everyday practices of patient monitoring demonstrates that both surveillance and adherence are collective activities. Peer mentors provide counselling services, follow up people who stray from treatment regimens, and perform a range of other tasks related to patient management and treatment adherence. Despite peer mentors’ involvement in many tasks key to encouraging optimal adherence, their role is rarely acknowledged by co-workers, hospital administrators, or public health officials. Following a biomedical paradigm, adherence at Kenyatta and in Kenya is framed by programme administrators as something individual clients must do and for which they must be held accountable. This framing simultaneously conceals the sociality of adherence and undervalues the work of peer mentors in treatment programmes.

When families fail: shifting expectations of care among people living with HIV in Nairobi, Kenya

The availability of free antiretroviral treatment in public health facilities since 2004 has contributed to the increasing biomedicalization of AIDS care in Kenya. This has been accompanied by a reduction of funding for community-based care and support organizations since the 2008 global economic crisis and a consequent donor divestment from HIV projects in Africa. This paper explores the ways that HIV interventions, including support groups, home-based care and antiretroviral treatments have shaped expectations regarding relations of care in the low-income area of Kibera in Nairobi, Kenya, over the last decade. Findings are based on 20 months of ethnographic research conducted in Nairobi between January 2011 and August 2013. By focusing on three eras of HIV treatment – pre-treatment, treatment scale-up, and post-crisis – the authors illustrate how family and community-based care have changed with shifts in funding. Many support groups that previously provided HIV care in Kibera, where the state is largely absent and family networks are thin, have been forced to cut services. Large-scale HIV treatment programmes may allow the urban poor in Nairobi to survive, but they are unlikely to thrive. Many care needs continue to go unmet in the age of treatment, and many economically marginal people who had found work in care-oriented community-based organizations now find themselves jobless or engaged in work not related to HIV.

Medical technologies: flows, frictions and new socialities

While social scientists often highlight the way medical technologies mediate biomedical hegemony, this special issue focuses on the creative and often unexpected ways in which medical technologies are appropriated by diverse actors in homes, clinics and communities. The authors highlight key insights from twelve ethnographic case studies conducted in North and South America, Western Europe, Sub-Saharan Africa and Southeast Asia. The case studies focus on, among other issues, how sperm donors in Denmark, despite being subjugated to medical surveillance, experience the act of donating sperm as liberating; how sex workers in Indonesia turn to psychoactive painkillers to feel confident when approaching clients; why some anorexic patients in the United States resist prescribed antidepressant drugs; and how adolescent sex education workshops in Ecuador are appropriated by mothers to monitor their daughters and shame their 'lying husbands'. Hardon and Moyer conclude that studies of medical technology need to be sensitive to the micro-dynamics of power, the specificities of local markets in which medical technologies generate value, the social and intergenerational relations in which they are embedded, and their intersections with class hierarchies.

"Every drug goes to treat its own disease…" - a qualitative study of perceptions and experiences of taking anti-retrovirals concomitantly with anti-malarials among those affected by HIV and malaria in Tanzania

Background

Little is known about how people living with human immunodeficiency virus (HIV) experience malaria and the concomitant use of anti-malarial treatments with anti-retrovirals (ARVs). An understanding of how patients make sense of these experiences is important to consider in planning and supporting the clinical management and treatment for co-infected individuals.

Methods

A qualitative study was conducted in Tanzania alongside a clinical trial of concomitant treatment for HIV and malaria co-infection. Focus group discussions were held with people receiving treatment for HIV and/or malaria, and in-depth interviews with health workers responsible for HIV care and members of the clinical trial team. Data were analysed inductively to identify themes and develop theoretical narratives.

Results

Results suggest that people living with HIV perceived malaria to be more harmful to them due to their compromised immune status but saw the disease as unavoidable. For those enrolled in the clinical controlled study, taking anti-malarials together with ARVs was largely seen as unproblematic, with health workers’ advice and endorsement of concomitant drug taking influential in reported adherence. However, perceptions of drug strength appeared to compel some people not enrolled in the clinical study to take the drugs at separate times to avoid anticipated harm to the body.

Conclusions

Management of HIV and malaria concurrently often requires individuals to cross the domains of different disease programmes. In the context of a trial concerned with both diseases, patients experienced the support of clinicians in guiding and reassuring them about when and how to take drugs concomitantly. This points towards the need to continue to strive for integrated care for patients with HIV.

[Long-term impact of antiretroviral therapy in Africa: current knowledge]

By the end of 2013, 11 million PLHIV were taking ARVs in Africa; application of the WHO recommendation to initiate treatment earlier (at CD4 count of 500 cells/mm3 or less) should further increase this number. Currently, twothirds of patients in Africa have been on treatment for less than five years, and less than 10% have received treatment for eight years or more. Given the historical perspective is in its early stages, the long-term impact of ARV therapy is still unclear. This article reviews the knowledge gained over the period marking the first ten years of implementation of the universal access strategy (2003-2013) in Africa, through a review of the literature documenting the long-term consequence of ARV treatment, focusing on medical care for adults with an emphasis on the patient-centered approach. The goal is to understand the interrelationships between biological and social factors and individual and collective aspects that affect the lives of PLHIV and determine the impacts of ARV treatment over the long term. The biomedical and social factors are addressed successively, based on the most significant results. Key knowledge on the long-term outcomes for PLHIVon ARV treatment offers vital information on the necessary conditions and adaptations for care systems needed to ensure the benefits of treatment endure over time.

Stigma, disclosure, coping, and medication adherence among people living with HIV/AIDS in Northern Tanzania

This study examines a proposed theoretical model examining the interrelationships between stigma, disclosure, coping, and medication adherence among 158 HIV-infected patients on antiretroviral therapy (ART) in northern Tanzania. Perceived and self-stigma, voluntary and involuntary disclosure, positive and negative coping, and demographics were assessed by trained interviewers, and self-reported adherence was collected during 5 months follow-up. Data were examined using correlation and regression analyses. The analyses showed that perceived stigma is primarily related to involuntary disclosure, whereas self-stigma is related to voluntary disclosure. Religious coping positively relates to acceptance, whereas perceived stigma explains higher levels of denial of HIV status. Lastly, adherence was negatively affected by alcohol use, self-stigma, and denial. We conclude that adherence is predominantly predicted by negative rather than positive coping mechanisms. Therefore, substituting maladaptive coping mechanisms like denial and alcohol use with a more adaptive coping style may be an important strategy to improve long-term ART adherence and well-being of patients. Moreover, this study showed that it is useful to examine both involuntary and voluntary disclosure when studying its relation with stigma.

Counselling clients to follow 'the rules' of safe sex and ARV treatment

Ideas of 'responsible sexuality' are located at the centre of counselling in current antiretroviral treatment (ART) programmes. This paper analyses counselling practices in three HIV/AIDS clinics in Uganda on the basis of participant observation of counselling sessions and interviews with counsellors. The paper illustrates how counsellors concentrate on giving general behavioural instructions, while clients tend to demonstrate their compliance to these 'rules' rather than sharing their more intimate thoughts. This is especially the case in the contested terrain of sexual and reproductive behaviour. To explore this phenomenon, the paper analyses a number of dynamics characterising HIV counselling in Uganda, including the pressures of the global bio-political project to 'save lives' with ART, the counsellors' working conditions in resource-constrained clinics, the professional authority of counsellors and the clients' challenges to following the rules.

HIV and the moral economy of survival in an East African City

Based on fieldwork in the city of Kisumu, Kenya, the article examines the survival of HIV-positive people on antiretroviral (ARV) medicines and situates this within broader moral economies of their lives-in matters of food, hunger, social relationships, and networks of care, including NGOs. Through locating survival at the level of individual adherence to medication, ARV programs medicalize it. Yet their focus on the intimate relation between medicine and food also opens up spaces in which the material conditions of life can be articulated. The article follows these spaces, from the clinic to the economy of NGO interventions and community-based groups, paying attention to how hunger and material needs are visible in some spaces and invisible in others, and to how people have learned to articulate their "needs." In this economy, HIV identities accrue moral and economic value, as through them people become visible to the flow of funds and the distribution of goods organized by NGOs.

Local biologies and HIV/AIDS in highlands Papua, Indonesia

The province of Papua, Indonesia has one of the fastest growing rates of HIV infection in Asia. Within volatile political conditions, HIV has reached generalized epidemic status for indigenous Papuans. This article explores the merits of using the concept of local biologies as an analytic tool to assess the range of factors which affect a local pattern of untreated HIV and rapid onset of AIDS. A research team conducted 32 in-depth interviews with HIV-positive indigenous persons and 15 interviews with health care workers in urban and peri-urban sites in the central highlands region. The results show fear of gossip and stigmatization, regional political conditions and gaps in care interweave to create local biological conditions of evasion of care and rapid onset of AIDS. The normative emphasis in contemporary scholarship on stigma as shaping subjective responses to HIV needs to be complemented by a full assessment of the physiological impact of health services, and the ways political conditions trickle down and mediate local biological patterns. The concept of local biologies is highly effective for explaining the full scope of possible factors affecting the intersection of social and physical realms for HIV-positive persons.

Gender differences in enrolment in an HIV-treatment programme in rural Lesotho, 2006-2008: a brief report

The southern African nation of Lesotho has an HIV seroprevalence of approximately 25%. To address the need for HIV care in rural Lesotho, a project called the Rural Health Initative (RHI) was launched in seven clinics in 2006. Data on enrolment were collected retrospectively and analysed for trends in gender enrolment over time. Of 6001 enrolled, 3904 were women (65.1%) and 2097 (34.9%) were men. When analysed by month of enrolment, there was a higher percentage of men enrolled in December compared with the other months of the year (χ(2) = 15.98, P < 0.001). This may be due to the migratory work of the men in the mines of South Africa and suggests a need for targeted interventions to increase male enrolments over the entire calendar year.

Secrecy as embodied practice: beyond the confessional imperative

This introduction to this special issue of Culture, Health & Sexuality aims to intervene critically in debates in public health about sexual rights and ways of de-stigmatising HIV/AIDS, in which silence and secrets are seen to undermine well-being and perpetuate stigma. It presents key insights from collaborative studies on HIV/AIDS and youth sexual health, arguing that advocates of disclosure and sexual rights need to think more contextually and tactically in promoting truth-telling. The authors aim to enhance current thinking on secrecy, which examines it primarily as a social practice, by emphasising the centrality of the body and the experience of embodiment in the making and unmaking of secrets. To understand secrecy as embodied practice requires understanding how it simultaneously involves the body as subject - as the basis from which we experience the world - and the body as object - that can be actively manipulated, silenced and 'done'. The authors show how tensions emerge when bodies reveal reproductive mishaps and describe how the dissonances are resolved through a variety of silencing practices. The paper ends by discussing the implications of these insights for sexual-health programmes.

Concealment tactics among HIV-positive nurses in Uganda

This paper is based on two-and-a-half years of ethnographic fieldwork in two rural Ugandan health centres during a period of ART scale-up. Around one-third of the nurses in these two sites were themselves HIV-positive but most concealed their status. We describe how a group of HIV-positive nurses set up a secret circle to talk about their predicament as HIV-positive healthcare professionals and how they developed innovative care technologies to overcome the skin rashes caused by ART that threatened to give them away. Together with patients and a traditional healer, the nurses resisted hegemonic biomedical norms denouncing herbal medicines and then devised and advocated for a herbal skin cream treatment to be included in the ART programme.