Chronicity, crisis, and the 'end of AIDS'

Research, HIV/AIDS, and Turning Waria into a Key Population in Indonesia: An Ethnographic Oral History

The history of HIV/AIDS is often told from the Global North, a viewpoint that is naturalized in policies and programs that privilege biomedical models of treatment and prevention. This article explores how one Indonesian transgender population known as waria became the subject of various forms of research since the 1980s. Research was one way that waria came to be classified as part of the key population of "transgender people." Drawing on an oral history project conducted in 2021/2022, we show how - while necessarily hierarchical - ethnographic accounts of other HIV/AIDS histories can rethink fundamental global health concepts.

Achieving better engagement with care and support for young people living with HIV in Australia: a mixed-method enquiry

Young people aged 18-29 are considered "adult" within the Australian HIV health service context. However, evidence increasingly defines this age group as distinct from the broader adult population such that the needs of young people living with HIV may be overlooked in the context of HIV service design and delivery. This analysis draws on the Young + Positive study, a national study in Australia that documented the perspectives of young people (aged 18-29) living with HIV. Data were collected via survey (n = 60) and interview (n = 25) methods between 2018 and 2019. The data were analysed using descriptive statistics and thematic analysis, exploring the inner- and outer-world factors influencing participant engagement with HIV care and support. Using the multi-dimensional framework by Harms [2021. Understanding human development (3rd ed.). Oxford University Press], we found that both inner- and outer-world factors influenced participants' ability and motivations to engage with specialist HIV treatment and support. Inner-world factors included psychological outlook, and perceptions of HIV and HIV services. Outer-world factors included workforce competencies of service providers, physical space of the service and hours of service operation. These research findings confirm that opportunities exist to better meet the treatment and care needs of young people living with HIV.

A poetic inquiry: the role of the social sciences and humanities in revitalising AIDS

For the past four decades, biomedical science has transformed clinical outcomes for HIV and AIDS. However, the social, economic and gendered determinants of HIV remain largely intact. The social science and humanities offer concepts and methods for articulating why these remain intractable. I used poetic inquiry - an arts-based, qualitative approach - as I reviewed literature on the "end of AIDS, and post-AIDS". As I did so, I considered what contribution the social sciences and humanities could make in moving us closer to these ideals. Several themes and found poems emerged in this reading: (1) how language oversimplifies complex social realities; (2) the voices of people living with HIV and AIDS must be included; (3) HIV and AIDS intersects with social inequalities; (4) social and structural issues are no barrier to HIV prevention and (5) the need for radical interdisciplinarity. The paper concludes that the end of AIDS requires responses that are integrated, holistic and that radically challenge our silo'd disciplinary boundaries and frames. The social sciences and humanities are key to this charge.

Between delivering chronic care and answering patients' burdens: Understanding HIV specialist nurses' experiences in the age of treatment

AIM(S)

To understand the experiences of HIV nurses in the context of ambivalence between biomedical treatment advancements and the continuing burden for people living with HIV and negative representations of HIV.

DESIGN

An interpretative phenomenological study was conducted using in-depth interviews.

METHODS

Twenty-one interviews with nurses were conducted between November 2021 and March 2022. A thematic analysis was performed.

RESULTS

Six themes related to the nurses' experiences emerged. Despite effective treatment for most people with HIV, nurses identify patient populations that require additional care. Nurses are flexible in making extra appointments to accommodate complex issues in these patients. Nurses develop a unique relationship with their patients based on trust and empathy, linked to patient's experiences with stigma and discrimination for people with HIV. Nurses perceive their tasks as becoming increasingly complex. There is explicit awareness about the changes in HIV care from acute to chronic care and how this affects nurses' tasks. Nurses continue to differentiate HIV from other chronic conditions.

CONCLUSION

Biomedical advancements change the organization of HIV care while public health concerns remain and patient population has particular needs due to negative social representations of HIV. Nurses navigate these issues in their everyday care.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

A potential re-evaluation of the role of nurses in providing chronic HIV care.

IMPACT

Our study addresses the roles of HIV nurses as care is shifting towards chronic care models. The unique relationship between nurses and patients is key in understanding the importance of nurses in the care trajectory. These findings impact the institutional role of nurses in HIV treatment centres and the institutional organization of HIV care.

REPORT METHOD

The COREQ guideline was used.

PATIENT OR PUBLIC CONTRIBUTION

Amsterdam UMC (AMC) staff, the national organization of HIV Nurses and patient organizations contributed to the study design.

Cambios y continuidades de los significados del VIH entre la diversidad sexual chontal en Oaxaca

Aunque ciertos imaginarios en torno al VIH y al sida cambiaron con el transcurso del tiempo, otros han quedado instituidos, lo que ha favorecido la estigmatización de quienes socialmente son más susceptibles de contraer la infección, como es el caso de quienes representan a la diversidad sexual. En muchos casos esta estigmatización es más devastadora que el propio síndrome. A partir de un análisis cualitativo se observa que se están conformando nuevos imaginarios en torno a la cronicidad del VIH, sin embargo, estos significados no son compartidos por todos(as) los(as) participantes en esta investigación, pues la interseccionalidad de sus condiciones sociales, materiales y simbólicas les posibilita vivir diversas experiencias, adquirir conocimientos y sentir ciertos deseos.

It's about time: on the need of a temporal language for ecologically dimensioned medical humanities and public health scholarship

The COVID-19 pandemic has highlighted multiple system dependencies that urge us to rethink our relationship with other humans, non-humans and their various environments. Whereas a growing body of literature highlights the need for ecologically dimensioned medical humanities, focusing on where and how our healths unfold relationally through their ecologies, this paper argues that little attention has been paid to the when of health. In reply, this paper sets out to expand this understanding, first by grounding the ecological argument for medical humanities in a wider net of relational ontologies, and second by highlighting the need to think temporally, specifically multitemporally, about the relationalities of health. The paper advances the sociological concepts of 'time' and 'temporalities' to help us think about various tempi, rhythms, urgencies and legacies of how health unfolds unevenly into the future.

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.

Anachronic: Viral Socialities and Project Time among HIV Support Groups in Barbados

From 2005 to 2015, up to five support groups for people living with HIV (PLHIV) operated in Barbados. However, by early 2020, all but one had disappeared. What caused the demise of these groups and why? What does this demise tell us about the HIV response in Barbados, and more particularly, everyday life for PLHIV? More generally, what does it tell us about "viral socialities" (ties formed between groups of people as they confront the lived effects of infection and discrimination attributable to HIV) and the effects of "project time" (a time frame delimited through the priorities of global HIV/AIDS agencies) on these socialities? Through ethnographic and archival research methods, this article reveals how multiple, unstable project times create and transform viral socialities of Barbadian PLHIV with anachronic effects for some-i.e., a sense of alienation or being "out of time" in relation to the priorities of the global HIV response.

Remaking the Technosubject: Kenyan Men Contextualizing HIV Self-Testing Technologies

The Kenyan government offers free HIV self-testing kits to men who have sex with men. The value of self-testing is based on the imaginary of an autonomous technosubject empowered to independently control testing services, thereby "freed," through technology, from the social conditions that might inhibit health services utilization. Following a community-centered collaborative approach, community researchers interviewed their peers who examined and reacted to the technology. Participants reframed the technosubject as intertwined with the social world and the testing kit itself as an object that exerts agency and possesses affective potential. Attending to these socio-material relationalities offers insights into program planning.

Counting, Coping, and Navigating the Flux: A Focused Ethnographic Study of HIV and Diabetes Self-Management

Approximately 10-15% of people living with HIV are also diagnosed with diabetes. To manage their two chronic conditions, people must undertake certain activities and adopt behaviors. Due to overlapping symptoms, complex medication regimens, and heavy patient workloads, implementing these self-management practices can be difficult. In this focused ethnography, data were collected from semi-structured interviews and limited participant-observation with a selected subset of participants to gain insight into self-management challenges and facilitators. We conducted interviews and multiple observations with 22 participants with HIV+T2DM over the period of 9 months. Participants experienced numerous barriers to self-management in the areas of diet, medication adherence, and mental health. Social and familial support, as well as consistent access to care, were facilitators for optimal self-management. At the same time participants' lives were in a unique flux shaped by the dual diagnoses, and therefore, required constant mental and physical adjustments, thus illustrating challenges of managing chronicity.

The end of AIDS? HIV and the new landscape of illness in rural South Africa

The global HIV/AIDS scientific community has begun to hail the dawn of 'the End of AIDS' with widespread anti-retroviral therapy (ART) and dramatic declines in AIDS-related mortality. Drawing on community focus groups and in-depth individual interviews conducted in rural South Africa, we examine the complex unfolding of the end of AIDS in a hard-hit setting. We find that while widespread ART has led to declines in AIDS-related deaths, stigma persists and is now freshly motivated. We argue that the shifting landscape of illness in the community has produced a new interpretive lens through which to view living with HIV and dying from AIDS. Most adults have one or more chronic illnesses, and ART-managed HIV is now considered a preferred diagnosis because it is seen as easier to manage, more responsive to medication, and less dangerous compared to diseases like cancer, hypertension, and diabetes. Viewed through this comparative lens, dying from AIDS elicits stigmatising individual blame. We find that blame persists despite community acknowledgement of structural barriers to ART adherence. Setting the ending of AIDS within its wider health context sheds light on the complexities of the epidemiological and health transitions underway in much of the developing world.

PREVALENCE AND FACTORS ASSOCIATED WITH LATE DIAGNOSIS OF THE HIV INFECTION IN A MUNICIPALITY OF SÃO PAULO

ABSTRACT Objective: to identify the prevalence and factors associated with late diagnosis of the infection by the Human Immunodeficiency Virus (HIV), in a municipality of São Paulo. Method: an epidemiological, analytical and retrospective study that analyzed the HIV and AIDS cases notified by the health services in the period from 2015 to 2017 using data from the notifications of the Information System for Notifiable Diseases (SINAN Net) corresponding to the users recently diagnosed with HIV/AIDS infection in the municipality of Ribeirão Preto/SP, Brazil. Data collection was in May 2018. The chi-square test was performed, as well as binary logistic regression, where the dependent variable was the AIDS criterion at the moment of notifying infection by HIV. A p-value<0.05 was considered for the association between the variables studied in relation to late diagnosis. Results: of the 829 (100%) new HIV cases, 290 (35.0%) were diagnosed in the condition of AIDS. Most of the population was male and aged between 15 and 34 years old. Oral candidiasis and weight loss greater than 10% were the main symptoms associated with AIDS. It was observed that people with lower schooling levels and older were more prone to late diagnoses. Conclusion: it is necessary to devise strategies that favor timely diagnosis in the municipality under study, particularly among the individuals aged over 45 years old and with lower schooling levels.

Mortality, survival and prognostic factors of people with AIDS in intensive care unit

OBJECTIVE

To analyze mortality, survival and prognostic factors of patients with AIDS in Intensive Care Unit (ICU).

METHOD

Retrospective cohort study with a sample of 202 patients with AIDS in ICU, whose sociodemographic, epidemiological, and clinical characteristics were obtained from medical records and assessed.

RESULTS

Patients were mostly male (73.8%) and drug users (59.4%), with no regular health follow-up (61.4%) and no adherence to antiretrovirals (40.6%), presenting low CD4+ T lymphocyte count (94.0%) and high viral load (44.6%). The main causes of hospitalization were sepsis and respiratory and renal insufficiency. The mean duration of hospitalization was 11.9 days (p = 0.0001), with a 41.6% survival; 58.5% died in the ICU. Sepsis upon admission (p < 0.001), pressure injury (p = 0.038), sexual exposure (p = 0.002), high viral load (p = 0.00001) and prolonged hospitalization (p < 0.001) increased the risk of death.

CONCLUSION

Most patients had no regular health follow-up, were drug users and presented low CD4+ T lymphocyte count and high viral load. The high mortality indicated that antiretroviral adherence is essential to reduce viral resistance, opportunistic diseases, and mortality.

Community-Level Factors and HIV Health Among Older People Living With HIV (PLWH) in Alabama, United States: A Qualitative Analysis

ABSTRACT

As the number of older people living with HIV (PLWH) is increasing, there is an urgent need for research on community-level factors to better understand the health care needs of this population. In-depth interview transcripts of 20 older PLWH who participated in a community-based participatory research study conducted in Alabama, in the United States, were analyzed through a phenomenological research approach. Results suggest that crime, lack of resources, and social isolation experienced at the community levels were found to be associated with the wellbeing of older PLWH. Moreover, community characteristics may confound older PLWH's comorbid conditions and resultant polypharmacy. An increased understanding of the impact of contextual factors on HIV health can inform more holistic individual- and community-level interventions aimed at addressing barriers to retention or re-engagement in HIV medical care and viral suppression among older PLWH.

All the Other Stuff: Treatment as Prevention and the Embodiment of Undetectability

The "Treatment as Prevention (TasP)" campaign advocates extended undetectability-untransmissibility (U = U) as a means to "End the Epidemic" of HIV/AIDS. Drawing on ethnographic research in Buenos Aires (Argentina), I identify three issues that prevail in overly-optimistic discourses associated with TasP, which: overshadow the history of HIV and antiretrovirals; overlook the inherent dynamism of undetectability; and understand antiretrovirals as technical tools with predictable effects, regardless of context. I address how undetectability becomes embodied in the lives of pre-HAART survivors while underscoring the diversity of challenges faced in a Latin American country with universal and free-of-charge access to antiretroviral therapy.

Perceived Discrimination and Symptoms of Cognitive Dysfuntion Among Middle-Age and Older Persons Living With HIV in China: A Multicenter Cross-Sectional Study of the Mediating Role of Mental Health Symptoms and Social Isolation

ABSTRACT

Perceived discrimination is associated with symptoms of cognitive dysfunction (SOCD) among middle-age and older persons living with HIV (PLWH). We aimed to explore how the association between perceived discrimination and SOCD was mediated by mental health symptoms and social isolation. The sample included 321 PLWH, ages 45 years and older, for a multicenter cross-sectional study. Structural equation modeling showed an acceptable model fit and a significant total indirect effect between perceived discrimination and SOCD. All three indirect effect pathways were significant, suggesting that perceived discrimination could influence SOCD through mental health symptoms, through social isolation, or through mental health symptoms and then social isolation. Our study demonstrates that perceived discrimination is a concern for the management of cognitive function among middle-age and older PLWH. Both mental health symptoms and social isolation are critical elements in the design and evaluation of interventions for promoting cognitive health.

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.

The influence of antiretroviral therapy on HIV-related oral manifestations

PURPOSE

This review aims to provide primary medical and dental healthcare professionals with the current state of information on the oral manifestations of HIV infection in the era of antiretroviral therapy (ART) advancements.

RESULTS

Infection with the human immunodeficiency virus (HIV) is associated with an increased risk of infectious, neoplastic, and immune-mediated oral complications that are regarded as a major constituent of this global epidemic. HIV-related oral manifestations have been subject to changes in their prevalence with the employment of ART, particularly in this period of enhanced patient accessibility to ART. Available antiretroviral medications (ARVs), the clinical presentation of common HIV-related oral manifestations, and patients and healthcare providers' perceptions are also discussed.

CONCLUSIONS

Screening, diagnosing, and treating patients with HIV/Acquired immunodeficiency syndrome (AIDS) has improved drastically since the isolation and characterization of HIV. Oral manifestations have been acknowledged to correlate with treatment responses and disease progression. Healthcare providers should be familiar with HIV-related oral manifestations and comfortable in managing and referring patients with HIV/AIDS, they are also key stakeholders in facilitating the elimination of the stigma associated with the infection.

Intersectionality and syndemics: A commentary

This commentary addresses the possibilities and pitfalls of putting intersectionality and syndemics into conversation with each other. We engage with two studies published in this issue: the first on the health-related vulnerabilities among LGBTQ + Latinx men in Orlando after the Pulse nightclub shooting, and the other on syndemic health issues brought about by social and structural inequities among young Black gay, bisexual, and other men who have sex with men (GBM). Both manuscripts suggest that intersectionality and sydemics can be integrated or possibly merged to build effective health equity focused interventions for marginalized populations. We, however, argue that there are several methodological, ontological, and epistemological challenges in bringing together intersectionality and syndemics. Our argument coalesces around three key points. First, we contend that while it is feasible to think of their integration as useful to the study of health disparities, syndemics offers no added benefit to health scholarship grounded in intersectional analysis. Second, we argue that assumptions of common ground between intersectionality and syndemics rest on equating theories of interaction and additivity with critiques of mutual configurations of ideology, power structures, and social categories. Finally, we maintain that if intersectionality and syndemics are to be in conversation with each other, it must be done with the recognition and examination of where each framework situates itself relative to methodology, praxis, and power. Using our own work and those of intersectional feminist scholars, we demonstrate how the stakes of intersectionality diverge radically from those of syndemics, and how syndemics has the potential to undermine the significance of intersectionality for addressing issues of health equity.

Is the chronicity of HIV/AIDS fragile? Biomedicine, politics and sociability in an online social network

OBJECTIVE

to understand how the relationships between chronicity and politics shape sociability and mutual help among people living with HIV/AIDS.

METHOD

This is a virtual ethnography in a closed group on Facebook. To collect the information, on-lineparticipant observation and documental analysis were utilized. 37 posts were analyzed using the softwareNVivo 12 Pro and the thematic coding technique.

RESULTS

Two thematic categories emerged: Do the treatment and time will take care of the rest: Mutual help and HIV/AIDS as a chronic condition; and Yes, there is danger around the corner, my dear: Politics, conflicts and sociability in the group. The most relevant aspect of this study concerns the evidence of the fragility of the discourse on the chronicity of HIV/AIDS.

CONCLUSION

Through the analysis of sociability and mutual help produced among the members of the investigated group, it was possible to apprehend the ways in which, in their experiences on living with HIV/AIDS as a chronic condition, the relationships between health-disease, politics and time showed the dependence between chronicity and the State, and its impacts on daily life.

Factors related to quality of life of people living with HIV in Alicante, Spain

PURPOSE

To analyze the determinants that influence the health-related quality of life of people living with HIV in Alicante (Spain).

METHODS

A cross-sectional study was conducted, which recruited 214 Spanish-speaking participants over 18 years of age living with HIV from an outpatient consulting office of the infectious diseases in a hospital in Alicante between 2013 and 2014. A self-administration sociodemographic survey and the Short Form Health Survey (SF-36v2) was used to assess health-related quality of life. This questionnaire measures health on 8domains.

RESULTS

70% of the participants were male, 50% had CD4 cell count between 200-499 cells/mm³ and 20% were infected by the hepatitis C virus (HCV). For the 8SF-36v2 scales, the average scores were higher than 45. Men presented better scores than women; there were statistically significant differences in all the scales except for general health. Being co-infected with HCV and being unemployed or other situations other than having a job were significantly associated with a lower physical component summary, while being married or having a partner were significantly associated with a higher score in the mental component summary.

CONCLUSION

The socioeconomic level and the presence of clinical factors such as HCV influence the scales of quality of life of physical health among adults living with HIV.

Chronic patient as intermittent partner for policy-makers: the case of patient participation in the fight against diabetes and HIV/AIDS in Mali

Background

National and international strategies have increasingly promoted chronic patient participation at different levels of the health care system, building the image of an ‘active’ chronic patient engaged for example in his/her daily self-care and within associations dealing with service delivery and/or policy advocacy. Drawing upon examples of the fight against diabetes and HIV/AIDS in Mali, this article explores the factors that influence the engagement of patient associations at policy level. We focus on the openness of the institutionalised political system, and explore the role that public authorities, caregivers and donors give to diabetes and HIV/AIDS patients.

Methods

Data was collected between 2008 and 2014 in Bamako in the framework of a qualitative research. Thirty-eight actors fighting against diabetes were interviewed, as well as 17 representatives of donors. For HIV/AIDS, 27 actors were interviewed. In both cases, non-participant observation was carried out and documentary sources were collected. Based on theory of public and collective action, a historical and cognitive approach was adopted. Data analysis followed an inductive and iterative method.

Results

Partnerships between public authorities and diabetes patient associations have been intermittent over time and remained rather informal. In the case of people living with HIV/AIDS, the partnership between their associations and public authorities has steadily grown and was progressively institutionalised. Three political factors explain this difference: focus and extent of the commitment of public authorities, existing policy-making processes, and how the law frames patients’ roles. Moreover, opportunities for patient participation depend on the nature and extent of the support provided by international donors. Finally, the cognitive dimension is also at stake, notably in relation to the way the two diseases and patients have been perceived by public authorities, caregivers, and donors.

Conclusions

Chronic patients are intermittent partners for policy-makers. Despite the image of chronic active patients conveyed by national and international public health strategies, patient participation is not straightforward. Rather, political, economic, and cognitive factors underpin the presence of political opportunities that enable patient participation. Chronicity of the disease appears to play an ambiguous role in the shaping of these factors.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-7453-2) contains supplementary material, which is available to authorized users.

Towards ending the US HIV epidemic by 2030: Understanding social determinants of health and HIV in Mississippi

The disproportionate burden of HIV-related inequities borne by African Americans in the US South amplifies the role of social determinants of health (SDH) in shaping social patterning of illness. Despite some attention, SDH remain overlooked in a biomedically oriented, federal HIV policy. Mississippi is the poorest state with the worst HIV outcomes, nationally. Using qualitative methods, we investigated how primarily African American, HIV-positive Mississippians experienced SDH and health inequities in their daily lives. Employing grounded theory and in-depth interviews (n = 25) in an urban and rural site in 2015 yielded these findings: (1) absence of an enabling structural environment; (a) HIV-stigma constructed via social discourse; (b) lack of psycho-social support and HIV education; (c) insufficient economic and social support resources; and (2) presence of family support for coping. Due to stigma, being HIV-positive seemed to lead to further status loss; diminished social position; reduced life chances; and contractions in particular freedoms. Stigma further compounded existing inequalities - contributing to the moral, social experience of those living with HIV. Trump's plan to end HIV by 2030 creates the opportunity to rethink the biomedical-paradigm and fully engage SDH - using social science theory and methods that address multi-level social determinants in ways that are also policy-responsive.

"For us here, we remind ourselves": strategies and barriers to ART access and adherence among older Ugandans

BACKGROUND

Very little is known about the barriers and facilitators to antiretroviral therapy (ART) access and adherence among older Africans. Most studies on ART have focused on individuals who are 15-49 years of age.

METHODS

We used in-depth interviews with 40 persons living with HIV, aged 50 to 96 years, who had either initiated ART (n = 26) or were waiting to initiate ART (n = 14), to explore barriers and facilitators to ART access and adherence in rural Uganda.

RESULTS

Guided by the Andersen Behavior Model, thematic content analysis highlighted 21 primary factors related to environment, patient and health behavior. Nine of the factors were common to both access and adherence, the remaining 12 were evenly split between access and adherence. Transportation costs, food insecurity, and healthcare workers' knowledge, attitudes and behaviors were key barriers.

CONCLUSIONS

These barriers were similar to those outlined for younger populations in other studies, but were compounded by age. Despite barriers, either due to the exceptional nature of HIV care or overreporting, both ART access and self-reported adherence were better than expected. Older persons living with HIV highlighted health care needs for non-HIV-related illnesses, suggesting while HIV care is adequate, care for the ailments of "old age" is lagging.

Critical perspectives on the 'end of AIDS'

This special symposium critically examines optimistic promises about an imminent 'end of AIDS,' currently circulating in global health discourse and policy. We aim not simply to interrogate the discourse surrounding calls to end AIDS, but to also explore the broader practices, contexts, and policy landscapes that have transformed the global HIV response during the fourth decade of the epidemic and allowed this discourse to gain such political traction. In this introduction we preview the collection's five substantive papers, which delve beneath the 'end of AIDS' rhetoric, bringing greater realism as well as resolve together with empirical evidence about the state of efforts to end AIDS in diverse locations and populations. Taken together, these papers critique not the hope that one day AIDS may come to an end, but the means by which current policy expects to arrive at such ends, particularly in the absence of realistic, sustained commitments to extending treatment, prevention, and broader support in highly under-resourced places and populations.