Evidence and AIDS activism: HIV scale-up and the contemporary politics of knowledge in global public health

Cultural discourses and HIV/AIDS activists' meanings about PrEP

Since the approval of pre-exposure prophylaxis (PrEP) for HIV prevention in 2012, research has increasingly considered how communities of men who have sex with men make sense of this prevention technology, often highlighting individual-level attitudes about PrEP. Drawing on interviews with 16 HIV activists, this study aimed to determine how activists make sense of advances in HIV prevention technology. Participants' sense-making about PrEP took the form of not merely the expression of individual attitudes, but rather reflections connected to their personal biographies and activist experience. Activists sustain seemingly contradictory discourses about PrEP, at once drawing on personal biographies and a discourse central to activist history to express scepticism about PrEP, but also other discourses to justify pharmaceutical intervention for prevention. Study findings provide evidence of the importance of attending to past and present cultural discourses when examining health advocacy groups' constructions of advances in science.

Health literacy, financial insecurity and health outcomes among people living with HIV in Australia

It is well documented that lower socio-economic status is associated with poorer health outcomes, while health literacy is considered important for improving health. What is less clear, is the extent to which greater health literacy can improve health outcomes among people for whom poverty or financial insecurity are important barriers to health. The paper presents findings from an Australian survey of people living with HIV (PLHIV) (N = 835) in which we explored the relationship between financial insecurity and health outcomes, looking at the extent to which health literacy mediates this relationship. The study drew on a comprehensive definition of health literacy, measuring participant’s confidence to communicate with healthcare providers, navigate the health system and take an active stance in relation to their health. Findings showed that financial insecurity was associated with lower health literacy and poorer self-reported physical and mental health. Health literacy mediated 16.2% of the effect of financial insecurity on physical health scores and 16.6% of the effect of financial insecurity on mental health scores. This suggests that programmes which seek to build health literacy among PLHIV may improve health outcomes among PLHIV who are struggling financially. Health literacy programmes are likely to be effective if they build confidence and resourcefulness among people to engage with health information, decision-making and care.

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.

Using health information for community activism: A case study of the movement for change and social justice in South Africa

The access to, use, and exchange of health information is crucial when strengthening public health services and improving access to care. However, many health system stakeholders, including community groups are perpetually excluded from accessing and using health information. This is problematic as community groups, themselves end-users of care, are well-positioned to keep the health system accountable, provide feedback on the quality of services, and identify emerging health concerns. Using qualitative, ethnographic methods, this paper investigates different strategies used by the Movement for Change and Social Justice (MCSJ)-a local health activism group-to collect, use and distribute health information to improve health care in Gugulethu, a low-income neighbourhood in Cape Town, South Africa. Through participant observation, shadowing, informal conversations and semi-structured interviews that were analysed using iterative thematic analysis, findings revealed that MCSJ effectively collected, used and exchanged health information to develop short-term health campaigns. To get access to the needed health information, they used innovative strategies, including cultivating allies in the health system, finding safe spaces, and using community brokers to effectively mobilise community members to keep the health system accountable. MCSJ's strategies highlight that stakeholders' engagement with health information is not only a technical exercise, but a complex social process that requires constant negotiation and relationship building. Therefore, to make meaningful improvements to health services and create adaptive and responsive health systems, we need to include community groups as active stakeholders in the health system, provide relevant, up-to-date and locally relevant health information, and facilitate opportunities to socially engage with health information and those who produce it.

'It has become everybody's business and nobody's business': Policy actor perspectives on the implementation of TB infection prevention and control (IPC) policies in South African public sector primary care health facilities

South Africa is increasingly offering screening, diagnosis and treatment of tuberculosis (TB), and especially drug-resistant TB, at the primary care level. Nosocomial transmission of TB within primary health facilities is a growing concern in South Africa, and globally. We explore here how TB infection prevention and control (IPC) policies, historically focused on hospitals, are being implemented within primary care facilities. We spoke to 15 policy actors using in-depth interviews about barriers to effective TB-IPC and opportunities for improving implementation. We identified four drivers of poor policy implementation: fragmentation of institutional responsibility and accountability for TB-IPC; struggles by TB-IPC advocates to frame TB-IPC as an urgent and addressable policy problem; barriers to policy innovation from both a lack of evidence as well as a policy environment dependent on 'new' evidence to justify new policy; and the impact of professional medical cultures on the accurate recognition of and response to TB risks. Participants also identified examples of TB-IPC innovation and described conditions necessary for these successes. TB-IPC is a long-standing, complex health systems challenge. As important as downstream practices like mask-wearing and ventilation are, sustained, effective TB-IPC ultimately requires that we better address the upstream barriers to TB-IPC policy formulation and implementation.

"Putting people in charge of their own health and care?" Using meta-narrative review and the example of online sexual health services to re-think relationships between e-health and agency

INTRODUCTION

Policy discussions reference ideas of informed and active users of e-health services who gain agency through self-management, choice and care delivered outside clinical settings. In this article, we aim to problematize this association by "thinking with" material from multiple disciplines to generate higher order insights to inform service development, research and policy.

METHODS

Drawing on meta-narrative review methods, we gathered perspectives from multiple disciplines using an iterative process of expert consultation to identify seminal papers citation mapping, synthesis and peer review.

RESULTS

We identify six relevant paradigms from sociology, philosophy, health services research, public health, the study of social movements and computer studies. Bringing these paradigms together illuminates the contrasting epistemological and ontological framings that co-exist in this area, including competing conceptualizations of e-health technologies as: neutral tools for service delivery, mediators within complex and unpredictable clinical interactions and as agents in their own right.

DISCUSSION

There is a need for e-health policy to recognize many human and non-human actors, the blurred boundaries between them and the unpredictable and evolving interactions that constitute engagement with e-health care. Established models for e-health service development and policy making are not designed for this landscape. There is nothing to be gained by asking whether e-health, in general, either "increases" or "decreases" agency. Rather specific types and aspects of e-health have diverse effects and can be simultaneously enabling and disempowering, and be differentially experienced by differently positioned and resourced actors.

Critical epidemiology in action: Research for and by indigenous peoples

Global social justice movements, including transnational activism for indigenous rights, are working to promote health equity by transforming public health research and policy. Yet little social scientific research has examined how professional epidemiologists are figuring within such efforts. Discussions are unfolding, however, in critical sectors of epidemiology about how to improve the profession's input into advocacy. Findings from a multi-sited ethnographic study of epidemiological research for and by indigenous peoples in three settings (Aotearoa/New Zealand, the continental U.S., and Hawai'i) demonstrate how researchers/practitioners connect epidemiology and advocacy by: (1) linking the better-known legitimacy of quantitative methods to a lesser-known causal framework that positions colonialism as a sociopolitical determinant of health, (2) producing technical critiques that aim to improve the accuracy and accessibility of indigenous population health statistics, and (3) adopting a pragmatic flexibility in response to the shifting political conditions that shape when, whether and how epidemiological findings support advocacy for indigenous health equity. Attending closely to the credibility tactics at hand in this work, and to the skills and sensibilities of its practitioners, charts new directions for future research about epidemiology's contributions to advocacy for health equity.

Incursions from the epicentre: Southern theory, social science, and the global HIV research domain

Research about HIV constitutes a global domain of academic knowledge. The patterns that structure this domain reflect inequalities in the production and dissemination of knowledge, as well as broader inequalities in geopolitics. Conventional metrics for assessing the value and impact of academic research reveal that "Northern" research remains dominant, while "Southern" research remains peripheral. Southern theory provides a framework for greater critical engagement with knowledge produced by researchers within the global South. With a focus on HIV social science, we show that investigators working in and from Africa have produced and disseminated knowledge fundamental to the global domain of HIV research, and argue that their epistemological contribution may be understood within the framework of Southern theory. Through repurposing a bibliometrical measure of citation count, we constitute a new archive of highly cited social science research. With a focus on South Africa, we situate this archive within changing historical contexts, connecting research findings to developments in medicine, health sciences and politics. We focus on two key themes in the evolution of HIV knowledge: (1) the significance of context and locality - the "setting" of HIV research; and (2) sex, race and risk - changing ideas about the social determinants of HIV transmission.

The 5th Annual One Mind Summit: Lessons Learned About "Science Informing Brain Health Policies and Practice"

Advances in science frequently precede changes in clinical care by several years or even decades. To better understand the path to translation, we invited experts to share their perspectives at the 5th Annual One Mind Summit: "Science Informing Brain Health Policies and Practice," which was held on May 24-25, 2016, in Crystal City, VA. While the translation of brain research throughout the pipeline-from basic science research to patient care-was discussed, the focus was on the implementation of "best evidence" into patient care. The Summit identified key steps, including the need for professional endorsement and clinical guidelines or policies, acceptance by regulators and payers, dissemination and training for clinicians, patient advocacy, and learning healthcare models. The path to implementation was discussed broadly, as well as in the context of a specific project to implement concussion screening in emergency and urgent care centers throughout the United States.

Mobilising a global response to hepatitis: Lessons learned from the HIV movement

Hepatitis caused by hepatitis B and C virus is increasingly becoming a significant global health threat, with widespread prevalence that may have severe disease and economic impacts in the future. Yet, preventative measures are not implemented universally and high costs of medicines limits treatment efforts. The global response to HIV/AIDS faced similar issues, but overcame them through a global movement that brought attention to the crisis and ultimately resulted in the creation and implementation of and access to better tools for HIV prevention and treatment. This also included effective policies and programmes behind and supporting the movement. Such could be done for hepatitis, specifically using lessons from the HIV response. Here, we will discuss the current and potentially severe future burden of hepatitis globally, the challenges in addressing this epidemic, and how principles applied from the global HIV response can facilitate a successful and similar hepatitis movement.

The Pivotal Role of the Social Sciences in Environmental Health Sciences Research

Environmental health sciences research seeks to elucidate environmental factors that put human health at risk. A primary aim is to develop strategies to prevent or reduce exposures and disease occurrence. Given this primary focus on prevention, environmental health sciences research focuses on the populations most at risk such as communities of color and/or low socioeconomic status. The National Institute of Environmental Health Sciences research programs incorporate the principles of Community-Based Participatory Research to study health disparities. These programs promote community engagement, culturally appropriate communications with a variety of stakeholders, and consideration of the social determinants of health that interact with environmental factors to increase risk. Multidisciplinary research teams that include social and behavioral scientists are essential to conduct this type of research. This article outlines the history of social and behavioral research funding at National Institute of Environmental Health Sciences and offers examples of National Institute of Environmental Health Sciences-funded projects that exemplify the value of social science to the environmental health sciences.

Narrative Methods and Sociocultural Linguistic Approaches in Facilitating In-depth Understanding of HIV Disclosure in a Cohort of Women and Men in Cape Town, South Africa

The South African National Department of Health has rapidly extended free public-sector antiretroviral treatment for people living with HIV from 2007. Approximately 6 million people are living with HIV in South Africa, with 3.1 million currently on treatment. HIV disclosure stigma has been reduced in high prevalence, generalized epidemic settings, but some remains, including in research interviews. This paper documents the unexpected reactions of people living with HIV to interviewers. It highlights shifts over time from discussing daily events with researchers to later expressing distress and then relief at having an uninvolved, sympathetic person with whom to discuss HIV disclosure. While there are commonalities, women and men had gendered responses to interviewers. These are apparent in men's uncharacteristic emotional responses and women's shyness in revealing gendered aspects of HIV acquisition. Both women and men expressed stress at not being allowed or able to fulfill dominant expected masculine or feminine roles. The findings underline the role of research interviewers in study participants confiding and fully expressing their feelings. This greater confidence occurred in follow-up interviews with researchers in busy health facilities, where time of health-care providers is limited. It underlines the methodological value of narrative inquiries with research cohorts. These allowed richer data than cross-sectional interviews. They shaped the questions asked and the process of interview. They revealed participants' increasing level of agency in expressing feelings that they find important. This research contributes to highlighting pivotal, relational aspects in research between empathetic, experienced researchers and study participants and how participant-researcher relationships progress over time. It highlights ethical dilemmas in roles of researchers as opposed to counselors, raising questions of possible blurring of lines between research and service roles. This requires further research exploration. It additionally underscores the importance of "care for the carer." Furthermore, it emphasizes that cultural sensitivity to language involves more than merely speaking the words in a language. Culture, humor, dialects, conceptual issues, wordplay, common sense, and respectful attitudes to other languages, resonates.

The politics of health mobilization in the United States: The promise and pitfalls of "disease constituencies"

A critical review of recent literature on U.S. social movements concerned with matters of health and illness prompts reconsideration of the prevailing conception of such movements as necessarily isolated and particularistic. With a focus on disease-constituency-based mobilization-presently the most potent model of efficacious activism to be found in the domain of health and illness in the United States-I argue that such activism may tend in two directions: a specific response to an imminent disease threat, and a bridging of collective action frames and identities that can lead to connections across differences and broader mobilization. Case studies have demonstrated how patient activism has affected the management of illness, attitudes and practices of health professionals, research practices, processes of innovation, state policies, and corporate behavior. Through close analysis of patient group mobilization and its distinctive orientation toward knowledge and expertise, I argue that patient groups in practice may connect with or influence one another or a range of other forms of mobilization in relation to health, and I examine the "linkage mechanisms"-spillover, coalition, and frame amplification-by which this can occur. Rather than imagine a stark opposition between particularistic, single-issue health politics, on the one hand, and universalistic efforts to transform the meaning and practice of health and health care in the United States, on the other, I propose closer attention to the potentially Janus-faced character of many health movement organizations and the ways in which they may look either inward or outward.

Reducing the overall HIV-burden in South Africa: is 'reviving ABC' an appropriate fit for a complex, adaptive epidemiological HIV landscape?

This article questions the recommendations to 'revive ABC (abstain, be faithful, condomise)' as a mechanism to 'educate' people in South Africa about HIV prevention as the South African National HIV Prevalence, Incidence and Behaviour Survey, 2012, suggests. We argue that ABC was designed as a response to a particular context which has now radically changed. In South Africa the contemporary context reflects the mass roll-out of antiretroviral treatment; significant bio-medical knowledge gains; a generalised population affected by HIV that has made sense of and embodied those diverse experiences; and a government committed to confronting the epidemic. We suggest that the situation can now be plausibly conceptualised as a complex, adaptive epidemiological landscape that could benefit from an expansion of the existing, 'descriptive' prevention paradigm towards strategies that focus on the dynamics of transmission. We argue for this shift by proposing a theoretical framework based on complexity theory and pattern management. We interrogate one educational prevention heuristic that emphasises the importance of risk-reduction through the lens of transmission, called A-3B-4C-T. We argue that this type of approach provides expansive opportunities for people to engage with the epidemic in contextualised, innovative ways that supersede the opportunities afforded by ABC. We then suggest that framing the prevention imperative through the lens of 'dynamic prevention' at scale opens more immediate opportunities, as well as developing a future-oriented mind-set, than the 'descriptive prevention' parameters can facilitate. The parameters of the 'descriptive prevention' paradigm, that maintain - and partially reinforce - the presence of ABC, do not have the flexibility required to develop the armamentarium of tools required to contribute to the management of a complex epidemiological landscape. Uncritically adhering to both the 'descriptive paradigm', and ABC, represents an historically dislocated form of prevention - with restrictive options for reducing the overall burden of HIV-related challenges in South Africa.

Engaging therapeutic citizenship and clientship: Untangling the reasons for therapeutic pacifism among people living with HIV in urban Zambia

This article explores the reasons for therapeutic pacifism among people living with HIV (PLHIVs) in urban Zambia. It contributes to a growing ethnography on global health, biosociality, and patient-provider dynamics. Therapeutic citizenship is a biopolitical citizenship that includes claims and ethical projects that emerge from techniques to control and manage bodies. In some contexts, therapeutic citizenship has included activism and claims-making against local, national, and international power brokers. This article investigates therapeutic citizenship in the specific context of impoverished urban Zambian compounds, sites of food insecurity, unemployment, and political exclusion, as well as targets for donor, NGO, and faith-based organisation projects and PLHIV support group proliferation. The article utilises data from participant observations at two Lusaka AIDS clinics, interviews, and focused discussions with support groups of PLHIVs. It argues that PLHIVs continuously negotiate subjectivities related to kinship, clientship, religious belief, and political citizenship in processes that complicate therapeutic citizenship. Rather than fostering participation in PLHIV support groups or challenging 'politics as usual' through activist claims-making to institutions of biopower, these processes lead to therapeutic pacifism.

What is needed for taking emergency obstetric and neonatal programmes to scale?

Scaling up an emergency obstetric and neonatal care (EmONC) programme entails reaching a larger number of people in a potentially broader geographical area. Multiple strategies requiring simultaneous attention should be deployed. This paper provides a framework for understanding the implementation, scale-up and sustainability of such programmes. We reviewed the existing literature and drew on our experience in scaling up the Essential Steps in the Management of Obstetric Emergencies (ESMOE) programme in South Africa. We explore the non-linear change process and conditions to be met for taking an existing EmONC programme to scale. Important concepts cutting across all components of a programme are equity, quality and leadership. Conditions to be met include appropriate awareness across the board and a policy environment that leads to the following: commitment, health systems-strengthening actions, allocation of resources (human, financial and capital/material), dissemination and training, supportive supervision and monitoring and evaluation.