Prevention as hyperbole; culture as concupiscence

HIV Australia | Vol. 11 No. 1 | March 2013

Concupiscence: Libidinous desire, sexual appetite, lust (Oxford English Dictionary)

By GARY DOWSETT

This is the first in a series of articles drawn from presentations given at the 2012 Australasian HIV/AIDS Conference. Contributors discuss responses to HIV in the combination prevention era and themes connected with working to achieve targets set out in the United Nations 2011 Political Declaration on HIV/AIDS (UNPD).

For further discussion about implications of the UNPD in the Australian context, see www.unpdaction.org.au and the Melbourne declaration.

One of the powerful dynamics underpinning HIV and AIDS since its beginning is what Paula Treichler (1988)¹ memorably termed an ‘epidemic of signification’, an overabundance of meaning and meaning-making practices. In a sense, there has always been a constant struggle over ‘naming’ and ‘labelling’ in this pandemic. That struggle has occurred in the naming of the illness: what is now AIDS was early on GRID or ‘gay-related immune deficiency’ in medical terms; the ‘gay plague’ at the hands of the media and other commentators.

There was argument about naming the virus itself: LAV, HTLV III or eventually HIV, which signified more than just naming and acknowledgement of the science and the discovery, but also ownership of the technology and the considerable income that derived from its application in the HIV antibody test.

We all play the game. For 30 years social researchers in this country have named research projects with smart acronyms, some dull (like SAPA or the Social Aspects of the Prevention of AIDS, the first one I worked on 26 years ago), some wicked (like PASH, the Pleasure and Sexual Health study).

My best, or worst, go at it was CRAP, literally CRAP, the Cultural Representations of AIDS Project, which Michael Hurley and I dreamed up 20 years ago comparing gay community prevention imagery in Sydney and Darwin.

More can be at stake in the naming: the demands from those infected with HIV to be regarded and called ‘people living with HIV’ rather that ‘sufferers or victims dying’ from it was a powerful discursive shift in the framing the pandemic.

In contrast, the invention of men who have sex with men (MSM) as a term was a damaging move despite its attempt to shift the politics of AIDS from identity to practice. Unfortunately, it effectively erased and still erases the cultural work of the world’s gay communities in the history of the pandemic.

Recently, we’ve seen another Western acronym, TG (transgender), colonise the great varieties of cross/multigendered cultures in the word into one collapsed category as if these cultures are all the same and vulnerable to HIV in the same way.

Now, just as the 2012 ASHM conference happened, we have an even newer, nonsense acronym from amFAR – ‘GMT’, standing for gay men, other MSM, and transgender – further collapsing these complex and very different sexual and gender cultures, thereby eliding differences in vulnerability and erasing differential contributions to the global response even further. What a major step backwards!

The UN in leading the global response is equally canny in shifting the stakes and the focus when its needs to raise money, bring new partners into the game or even seem more successful at its job. Remember: universal access, a multi-sectoral response, enabling environments, structural interventions, prevention science, to name but a few.

In Washington DC at AIDS 2012, we heard an ‘AIDS-free generation’, ‘15 million by 2015’ (remember three by five), innovative financing mechanisms, implementation science – and so the list goes on. The discursive is a powerful tool, not just window dressing. These manoeuvres shift attention, refocus effort, redefine success or failure, prioritise certain policies and practices, and diffuse and sometimes even silence criticism.

Historically, in terms of gay men’s HIV prevention, we see effects in the original communitarian and cultural approach of sustaining safe sex for all losing momentum in the mid-1990s with the onset of HAART, in what I then termed the beginning of the ‘post-AIDS’ era as the commonality of gay men’s experience of the pandemic began to fracture and diversify.

This approach was tested even more during the last 15 years as a focus on community-based prevention itself was challenged by more psychosocial (or behavioural), individualistic models of prevention fostered by the notions of prevention science from the year 2000 onwards. More recently, the re-badging of prevention activity as the deployment of prevention technologies has removed the cultural and community focus from centre to periphery. Now the ascendency of biomedical prevention has rendered even that periphery largely irrelevant.

The biomedical shift

The shift to ‘biomedical technologies and interventions’ has come about as a result of research findings on treatments and their role in reducing vial load, as a response to cautious evidence on microbicide success, contested evidence on the efficacy of male circumcision in specific populations, encouraging effectiveness of treatment use by the uninfected, and the continuing vagaries of vaccines.

The hyperbolic discourse absorbing current HIV debate on ‘treatment as prevention’, and the ‘prevention revolution’ reveals yet again the longstanding tendency for HIV politics to swamp the world of practice and encourage us to lose sight of all we have learned in 30 years of pandemic.

The potential for effective treatment to lower viral load is not news – that was clear by 1996. Indeed, former President of ACON, Rolf Petherbridge, argued then, before the Vancouver conference announcement on HAART that year, that lowering viral load would eventually become a significant part of prevention; it was really a matter of time. So, it is nonsense to call this a prevention revolution. Evolution – yes; revolution – no.

The hyperbole surrounding biomedical prevention consistently fails to note that a technology has no effect until it is used; hence, the important conceptual and terminological difference between ‘experimental efficacy’ and ‘real-world effectiveness’.

Behavioural dynamics

Herein lies the rub: many studies of prevention technologies, and much of the hyperbole surrounding their almost always partially protective efficacy, fail to account for the behavioural dynamics of such technologies’ everyday use and the social and cultural contexts that structure that use, the users’ understandings of that use and its effects, and its effectiveness through the micro-politics of practice, and the structural factors underpinning social contexts.

It is neither novel nor simplistic to point out that no technology exists without or outside human behaviour, and that all human behaviour is socially determined and culturally comprehended. Yet, we see in the hyperbole on biomedical prevention not simply neglect of the behavioural underpinnings of prevention, but an enduring and conscious tendency in medical science to disregard the social and cultural when it suits its purposes.

That said, just when we least expect it, the social returns and transforms any technology into a practice. We only have to note the innovative sexual cultures of gay men the world over throughout the pandemic, evolving from the only really revolutionary moment we have had so far: gay men in so many countries taking up condoms so fast and so widely in the first few years of the pandemic. Now that was social revolution.

It will be at this level – the level of the social structuring of the micropolitics of daily practice – that new sex and pleasure cultures will arise to absorb, interpret and express the possibilities and constraints that biomedical technologies offer … just as the mechanical technology of condom use, once bedded in so to speak, was culturally reframed by gay men for nearly 30 years in inventive practices of safe sex.

We can now see a messy future upon us as PrEP (pre-exposure prophylaxis), PEP (post-exposure prophylaxis), microbicides, instant and/or home HIV testing, and viral load reduction, etc., will be used to think prevention possibilities. These biomedical prevention possibilities will produce their cultural forms and interpretations, the own adaptive practices, and their own successes and mistakes. All technologies ‘shape-shift’ in human hands and in daily practice.

So, more than ever we need to think about how we pursue our understandings of this pandemic and how we deploy our knowledge habits, our scientific utterances, and our prevention practices. We need to be more careful about our speech acts, our cultural reframing, if we are to manage this next step carefully. For we will see increases in HIV incidence directly related to the cultural reframing and enactment of each biomedical technology as it rolls out.

Margin of error

We will see mistakes made in understanding them (e.g. as Jonathan Stadler reported in the microbicide trials in South Africa.) We will see misinterpretation (e.g. the hotly contested debate on male circumcision as some advocate hyperbolically, despite the evidence, for its use in other populations and places). We will see technology misuse (e.g. one potential consequence of ‘home’ HIV testing). And we will see error at the individual level that will lead to infection.

Just what levels of error are we prepared to tolerate? This is particularly important as we soften our requirements for efficacy and accept lower levels of effectiveness in what seems at times renewed desperation as much as optimism to find an ‘end to AIDS’.

Depending on the setting, there will be inefficiency, irresponsibility and corruption at corporate, institutional and governmental levels in different places at different times (as Heather Worth and colleagues reported at the recent ASHM conference on the link between governance and ART and preventing mother-to-child transmission [PMTCT], when there are fewer controls on political corruption, there is less access to PMTCT programs). These too are vital behavioural constituents of effective prevention as much as sustained condom use after male circumcision and individual adherence to treatment regimes.

What has always struck me about the hyperbole, the sloganeering, the capturing of discursive fields, is how remarkably unknowing we are about human sexuality and pleasure-taking of all kinds.

I’ve been to many AIDS conferences in my time, and witnessed the sharing of orgasms that so many of them are for many who attend. In all that conferential concupiscence, it seems strange that the prevailing understanding of human desire is reduced to behavioural variables to be controlled for in our science.

Biomedical prevention will certainly be one of the next steps historically, but anyone who thinks it will be the silver bullet fails to understand history and culture. We need to be talking about and advocating for prevention interventions as practices, as linguistically and culturally framed, and profoundly social enactments within intersecting personal, interpersonal, communitarian, institutional and historical contexts. If we do not, then as George Santayana’s (1863–1952) famous maxim reminds us: ‘Those who cannot remember the past are condemned to repeat it’.

References

1 Treichler, P. (1988). AIDS, Homophobia, and the Biomedical Discourse: An Epidemic of Signification, in D. Crimp (ed.) AIDS: Cultural Analysis, Cultural Activism, MIT Press, Boston, 17–30.

Gary Dowsett, PhD, FASSA, is Professor and Deputy Director at the Australian Research Centre in Sex, Health and Society, La Trobe University.