Skip to main content
Log in

Rethinking prevention: Shifting conceptualizations of evidence and intervention in South Africa’s AIDS epidemic

  • Original Article
  • Published:
BioSocieties Aims and scope Submit manuscript

Abstract

In recent years, statements about the ‘end of AIDS’ and an ‘AIDS-free world’ have dominated headlines about the epidemic. This contemporary moment of extraordinary optimism has been prompted in significant part by developments in the field of HIV prevention. New approaches to prevention include techniques that are markedly different from older strategies; new prevention techniques are targeted and relentlessly biomedical, and have increasingly displaced older behavior change programs and broad based social measures. HIV/AIDS, which was long called a ‘social epidemic’ marked by unprecedented human rights struggles and community action, has increasingly become dominated by a discourse and practice of discrete interventions and their calculable efficacy. This article aims to explain the shift in conceptualizations and practices of prevention, and the changed understanding of the epidemic. How did prevention become about access to drugs? How did the discourse around HIV/AIDS move from a concern with social determinants of disease and human rights to matters of efficiency, efficacy, and measurable impact? The article argues that a conjunction of new biomedical technologies, changing managerial logics of donors and governments, and emergent evidentiary practices have led to the ascent of new approaches to prevention. To support this argument, it traces prevention strategies over the last three decades in the context of South Africa’s HIV/AIDS epidemic. The South African story, while unique and historically situated, nonetheless serves as a lens through which to understand broad based transformations underway in HIV/AIDS and in global health writ large.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Similar content being viewed by others

Notes

  1. For a small sample of such statements, see Park (2014) and Havlir and Beyrer (2012).

  2. For other discussions of how New Prevention Techniques constitute a paradigm shift, see Cindy Patton (2012, pp. 295–310) and Nguyen et al (2011, p. 291).

  3. Indeed, “New Prevention Technique” has become a term of art in the HIV/AIDS field and goes by the acronym of NPT. The specific interventions that occupy the category of New Prevention Techniques also have acronyms: Pre-exposure Prophylaxis is PrEP; Treatment-as-Prevention is referred to as TASP; Voluntary Male Circumcision is VMMC; and Prevention of Mother to Child Transmission of HIV is PMTCT.

  4. There is a growing body of work which illustrates this orientation towards managerial accounting and accountability in global health. For instance, see Adams (2013, pp. 54–90); Adams (2016); Biruk (2012, pp. 347–366); Colvin (02, 2014, pp. 57–72); Erikson (2012, pp. 367–384); Timmermans and Mauck (2005, pp. 18–28); Prince and Marsland (2014).

  5. On changing norms of evidence-making, see Timmermans and Mauck (2005, pp. 18–28); Adams ( 2013, pp. 54–90).

  6. On accounts of South Africa’s response to the AIDS epidemic, see D. Fassin (2007); Thornton (2008); Hunter (2010); Robins (2006, pp. 312–323); Decoteau (2013).

  7. On this, see Mahajan (2008, pp. 585–596); Crane (2010, pp. 843–870); Crane 2013); Adams (2016).

  8. For histories of the early years of the AIDS epidemic in South Africa, see Barnett and Whiteside (2006); Epstein (2000, pp. 50–55); Vliet and Toms (1994, p. 107).

  9. In recent years, there has been dispute regarding whether Uganda was as big a success story as was initially made out in international health literature. Scholars such as Robert Thornton have argued that the drop-in prevalence was due to structures of sexual networks and changes therein rather than due to systematic alterations in individual behavior Thornton (2008). Others have argued that large number of deaths of AIDS patients contributed to the decline in prevalence numbers. Yet others have questioned the validity of the original data that indicated declining prevalence (Allen, 2006). There has also been questioning, albeit less widespread, of the success of the containing of the Thai epidemic, Fordham (2014, 2004).

  10. For a review of structural programs, see Coates (2008, pp. 669–684); Gupta et al (2008, pp. 764–775); Blankenship et al (2006, pp. 59–72).

  11. On challenges of evaluating structural programs, Gupta et al ( 2008, pp. 764–775); Ogden et al (2011, pp. S285–S292).

  12. Also see Benton (2012, pp. 310–328); Esser (02, 2014, pp. 43–56); Sangaramoorthy and Benton (2012, pp. 287–291).

  13. On TAC’s activism around nevirapine, see Heywood (2003, p. 278); Friedman and Mottiar (12, 2005, 511–565); Robins (2008).

  14. See Biehl et al (2012); Biehl and Petryna (2012, pp. 359–386); Van Hollen (2013); Gauri and Gloppen (2012, pp. 485–503).

  15. See Nguyen (2010); Kalofonos (2010, pp. 363–380); Benton (2015); Pfeiffer (2013).

  16. See Bothwell (2016, p. 2175).

  17. For instance, see Kenworthy (2014, pp. 1–6); Høg (02, 2014, pp. 210–223).

  18. For instance, see Merson et al (2008, pp. 475–488).

  19. For instance, see Aggleton (2007). and Westercamp and Bailey (2007, pp. 341–55).

  20. The questions about the applicability of efficacy trials to “real-life” situations have led in recent years to effectiveness trials which are also called pragmatic trials. Efficacy trials aim to define the performance of an intervention under highly controlled, ‘ideal’ circumstances. The choice of patients is selective and significant resources are expended in counseling them to ensure that they choose and adhere to the intervention. Interventions are delivered in extremely standardized ways in settings with high quality infrastructure and well-trained doctors. In general, the trials tend to be very expensive and demand intensive use of resources. The critique of efficacy trials has been that this ideal context and practice inevitably involves significant deviation from real-life clinical and social settings. It has been shown time and again that efficacy trials routinely overestimate the impact of a public health intervention.

    In contrast, effectiveness trials try to take into account some of the vagaries and unevenness inherent in patients, providers, and infrastructure. While they too standardize the administration of the intervention, fewer resources are dedicated to doctor training, infrastructure establishment, and patient adherence. The results of effectiveness trials are understood to offer greater validity for health care providers and policymakers.

    The pragmatic trials, however, are better understood as lying on a continuum with efficacy trials rather than as serving a radical break or dichotomy. Moreover, precisely because they try to take into account particular contexts, questions of whether their results can be replicated in other contexts become all the more pertinent. See Epstein (1995, pp. 408–437); Will and Moreira (2016).

References

  • Adams, V. (2013) Evidence-based global public health: Subjects, profits, erasures. In: Biehl, J. and Petryna A. (eds.) When People Come First: Critical Studies in Global Health. (pp. 54–90). Princeton: Princeton University Press.

    Google Scholar 

  • Adams, V. (2016) Metrics: What Counts in Global Health. Durham: Duke University Press.

    Book  Google Scholar 

  • Aggleton, P. (2007) Just a snip? A social history of male circumcision. Reproductive Health Matters 15(29): 15–21.

    Article  Google Scholar 

  • Allen, T. (2006) AIDS and evidence: interrogating some Ugandan myths. Journal of Biosocial Science 38(1): 7–28.

    Article  Google Scholar 

  • Barnett, T. and A. Whiteside. (2006) AIDS in the 21st Century: Disease and Globalization. Berlin: Springer.

  • Benton, A. (2012) Exceptional suffering? Enumeration and vernacular accounting in the HIV-positive experience. Medical Anthropology 31(4): 310-–328.

    Article  Google Scholar 

  • Benton, A. (2015) HIV Exceptionalism: Development Through Disease in Sierra Leone. Minneapolis: University of Minnesota Press.

    Book  Google Scholar 

  • Bertozzi, S.M., Laga, M., Bautista-Arredondo, S. and Coutinho, A. (2008) Making HIV Prevention Programmes Work. The Lancet 372(Sep 6–Sep 12): 831-844.

  • Biehl, J. et al. (2012) Between the court and the clinic: Lawsuits for medicines and the right to health in Brazil. Health and Human Rights 14(1): E36–E52.

    Google Scholar 

  • Biehl, J. and Petryna, A. (2012) Bodies of rights and therapeutic markets. Social Research 78(2): 359–386.

    Google Scholar 

  • Biruk, C. (2012) Seeing like a research project: Producing “high-Quality Data” in AIDS research in Malawi. Medical Anthropology 31(4): 347–366.

    Article  Google Scholar 

  • Blankenship, K.M., Friedman, S.R., Dworkin, S. and Mantell, J.E. (2006) Structural interventions: Concepts, challenges and opportunities for research. Journal of Urban Health: Bulletin of the New York Academy of Medicine 83(1): 59–72.

    Article  Google Scholar 

  • Bothwell, L.E., Green, J.A., Podolsky, S.H., Jones, D.S. (2016) Assessing the Gold standard–lessons from the history of RCTs. New England Journal of Medicine 374(22): 2175.

    Article  Google Scholar 

  • Brandt, A.M. (1986) AIDS: From social history to social policy. The Journal of Law, Medicine & Ethics 14(5–6): 231–242.

    Google Scholar 

  • Butler, A. (2005) South Africa’s HIV/AIDS policy, 1994–2004: How can it be explained? African Affairs 104(417): 591.

    Article  Google Scholar 

  • Chopra, M., Daviaud, E., Pattinson, R., Fonn, S. and Lawn, J.E. (2009) Health in South Africa 2: Saving the lives of South Africa’s mothers, babies, and children: Can the health system deliver? The Lancet 374(9692): 835–846.

    Article  Google Scholar 

  • Coates, T.J., Richter, L. and Caceres, C. (2008). Behavioural strategies to reduce HIV transmission: How to make them Work Better. The Lancet 372(Aug 23–Aug29): 669–684.

  • Cohen, J. (2011) HIV Treatment as Prevention. Science 334(6063): 1628.

    Article  Google Scholar 

  • Cohen, M.S., Holmes, C., Padian, N., Wolf, M., Hirnschall, G., Lo, YR. and Goosby, E. (2012) HIV treatment as prevention: How scientific discovery occurred and translated rapidly into policy for the global response. Health Affairs 31(7): 1439–1449.

    Article  Google Scholar 

  • Colvin, C.J. (2014) Evidence and AIDS activism: HIV scale-up and the contemporary politics of knowledge in global public health. Global Public Health 9(1): 57–72.

    Article  Google Scholar 

  • Connor, E.M., Sperling, R.S., Gelber, R., Kiselev, P., Scott, G., O’Sullivan, M.J., VanDyke, R. et al. (1994) Reduction of Maternal-Infant Transmission of Human Immunodeficiency Virus Type 1 with Zidovudine Treatment. N Engl J Med 331(18): 1173–1180.

    Article  Google Scholar 

  • Crane, J. (2010) Adverse events and placebo effects: African scientists, HIV, and ethics in the ‘global health sciences’. Social Studies of Science 40(6): 843–870.

    Article  Google Scholar 

  • Crane, J. (2013) Scrambling for Africa: AIDS, Expertise, and the Rise of American Global Health Science. Ithaca, NY: Cornell University Press.

    Google Scholar 

  • Crewe, M. (2000) How do we make sense of President Mbeki? AIDS Analysis Africa 11(1): 10–11.

    Google Scholar 

  • de Waal, A., Klot, J.F. and Mahajan, M. (2010) HIV/AIDS, security and conflict: New realities, new responses. Forced Migration Review: 6–8.

  • Decoteau, C. (2013) Ancestors and Antiretrovirals: The Biopolitics of HIV/AIDS in Post-Apartheid South Africa University of Chicago Press.

  • Epstein, H. (2000) The mystery of AIDS in South Africa. The New York Review of Books 47(12): 50–55.

    Google Scholar 

  • Epstein, S. (1995) The construction of lay expertise: AIDS activism and the forging of credibility in the reform of clinical trials. Science, Technology, and Human Values 20(4): 408–437.

    Article  Google Scholar 

  • Erikson, S.L. (2012) Global health business: The production and performativity of statistics in Sierra Leone and Germany. Medical Anthropology 31(4): 367–384.

    Article  Google Scholar 

  • Eshleman, S. (2004) Characterization of Nevirapine resistance mutations in women with subtype A Vs. D HIV-1 6-8 weeks after single-dose Nevirapine. Journal of Acquired Immune Deficiency Syndromes 35(2): 126.

    Article  Google Scholar 

  • Esser, D.E. (2014) Elusive Accountabilities in the HIV scale-up: ‘Ownership’ as a functional tautology. Global Public Health 9(1): 43–56.

    Article  Google Scholar 

  • Everatt, D. and Sisulu, E. (1992) Black Youth in Crisis: Facing the Future Ravan Pr of South Africa.

  • Fassin, D. (2007) When Bodies Remember: Experiences and Politics of AIDS in South Africa Univ of California Press.

  • Fordham, G. (2014). HIV/AIDS and the Social Consequences of Untamed Biomedicine: Anthropological Complicities. Vol. 18. New York and London: Routledge.

    Google Scholar 

  • Fordham, G. (2004) A New Look at Thai AIDS: Perspectives from the Margin. Vol. 4. Oxford, NY: Berghahn Books.

    Google Scholar 

  • Friedman, S. and Mottiar, S. (2005) A rewarding engagement? The treatment action campaign and the politics of HIV/AIDS. Politics & Society 33(4): 511–565.

    Article  Google Scholar 

  • Gauri, V. and Gloppen, S. (2012) Human rights-based approaches to development: Concepts, evidence, and policy. Polity 44(4, Deepening Democracy): 485–503.

  • Guay, L.A., Musoke, P., Fleming, T., Bagenda, D. et al. (1999) Intrapartum and neonatal single-dose nevirapine compared with zidovudine for prevention of mother-to-child transmission of HIV-1 in Kampala, Uganda: HIVNET 012 Randomised Trial. The Lancet 354(9181): 795–802.

    Article  Google Scholar 

  • Gupta, G.R., Parkhurst, J.O., Ogden, J.A., Aggleton, P. and Mahal, A. (2008) Structural approaches to HIV prevention. Lancet 372(9640): 764–775.

    Article  Google Scholar 

  • Halperin, D.T., Wamai, R.G., Weiss, H.A., Hankins, C., Agot, K., Abdool Karim, Q., Shisana, O., Otolorin, E.O., Kapiga, S., Serwadda, D.M., Sanchez, J., Pape, J.W., Mabuza, K., Bowa, K., Kebaabetswe, P., Wilson, D., Simelane, D., Morris, B., Sawires, Phiri, M., Setswe, G., Sewankambo, N., Heywood, M., Woelk, G., Ntaganira, I., Cates, W., Rees, H., Geffen, N., Ncala, J., Jackson, H., Dludlu, S., Diallo, M.O., Makhubele, M.B., Leclerc-Madlala, L., Kalambayi Kayembe, P., Nyamucherera, O.F., Bongaarts, J., Betukumesu, B., Kintaudi, L., Salang Seloilwe, Zungu, N.E., Ruiz, M., Venter, F., Micheni, K., de Moya, E.A., Cash, R. and Bailey, R.C. (2008) Male circumcision is an efficacious, lasting and cost-effective strategy for combating HIV in high-prevalence AIDS epidemics: Time to move beyond debating the science. Future HIV Therapy 2(5): 399–405.

  • Havlir, D. and Beyrer, C. (2012) The beginning of the end of AIDS? New England Journal of Medicine 367(8): 685–687.

    Article  Google Scholar 

  • Hendriksen, E. (2007) Predictors of condom use among young adults in South Africa: The reproductive health and HIV research unit national youth survey. American Journal of Public Health 97(7): 1241.

    Article  Google Scholar 

  • Heywood, M. (2003) Preventing mother-to-child HIV transmission in South Africa: Background strategies and outcomes of the treatment action campaign case against the Minister of Health. South African Journal on Human Rights. 19: 278.

  • Høg, E. (2014) HIV scale-up in Mozambique: Exceptionalism, normalisation and global health. Global Public Health 9(1): 210–223.

    Article  Google Scholar 

  • Hunter, M. (2010) Love in the Time of AIDS: Inequality, Gender, and Rights in South Africa. Bloomington: Indiana University Press.

    Google Scholar 

  • Kalofonos, I.A. (2010) “All I Eat is ARVs”: The paradox of AIDS treatment interventions in Central Mozambique. Medical Anthropology Quarterly 24(3): 363–380.

    Article  Google Scholar 

  • Kenworthy, N.J. and Parker. R (2014) HIV scale-up and the politics of global health. Global Public Health 9(1–2): 1–6.

    Article  Google Scholar 

  • Maggiolo, F., et al. (2010) Is HAART Modifying the HIV Epidemic? Lancet 376(9740): 492–493.

    Article  Google Scholar 

  • Mahajan, M. (2008) Designing epidemics: Models, policy-making, and global foreknowledge in India’s AIDS Epidemic. Science and Public Policy 35(8): 585–596.

    Article  Google Scholar 

  • Mahajan, M. (2012) The right to health as the right to treatment: Shifting conceptions of public health. Social Research 79(4): 819–836.

    Google Scholar 

  • Marais, H. (2000) To the Edge: AIDS Review 2000. Pretoria, ZA: University of Pretoria.

    Google Scholar 

  • McNeil, Donald. Jr. (2011) Clinton Aims for ‘AIDS-Free Generation’. New York Times, November 8, 2011.

  • Merson, M.H., O’Malley, J., Serwadda, D. and Apisuk, C. (2008) The history and challenge of HIV prevention. The Lancet 372(Aug 9–Aug15): 475–488.

  • Montaner, J.S., Lima, V.D., Barrios, R., Yip, B., Wood, E., Kerr, T., Shannon, K., Harrigan, P.R., Hogg, R.S., Daly, P. and Kendall, P. (2010) Association of highly active antiretroviral therapy coverage, population viral load, and yearly new HIV diagnoses in British Columbia, Canada: a population-based study. Lancet 376(9740):532–539.

    Article  Google Scholar 

  • Motsoaledi, A. (2011) Speech by Minister of Health on the Health Budget Policy.

  • Nattrass, N. (2004) The moral economy of AIDS in South Africa. Cambridge: Cambridge University Press.

  • Nguyen, V.K. (2010) The Republic of Therapy: Triage and Sovereignty in West Africa’s Time of AIDS. Durham, NC: Duke University Press.

    Book  Google Scholar 

  • Nguyen, V.K. (2015) Treating to prevent HIV: Population trials and experimental societies. In: Wenzel G. Para-States and Medical Science. (pp. 47–77) Durham: Duke University Press.

  • Nguyen, V.K., Bajos, N. et al. (2011) Remedicalizing an epidemic: From HIV treatment as prevention to HIV treatment is prevention. AIDS 25: 291.

    Article  Google Scholar 

  • Ogden, J., Gupta, G.R., Fisher, W.F. and A. Warner. (2011) Looking back, moving forward: Towards a game-changing response to AIDS. Global Public Health 6(S3): S285–S292.

    Article  Google Scholar 

  • Park, A. (2014) The End of AIDS, November 19, 2014, Time magazine.

  • Patton, C. (2012) The cost of science: Knowledge and ethics in the HIV pre-exposure prophylaxis trials. Bioethical Enquiry 9: 295–310.

    Article  Google Scholar 

  • Pettifor, A.E. (2007) Highly efficient HIV transmission to young women in South Africa. AIDS 21 (7): 861-865.

    Article  Google Scholar 

  • Pfeiffer, J. (2013) The struggle for a public sector – PEPFAR in Mozambique. In: Biehl, J. and Petryna, A. When People Come First: Critical Studies in Global Health. Princeton: Princeton University Press.

    Google Scholar 

  • Presidential AIDS Advisory Panel (PAAP). “A Synthesis Report of the Deliberations by the Panel of Experts Invited by the President of the Republic of South Africa, the Honourable Thabo Mbeki.”, http://www.info.gov.za/ptherdocs/2001/aidspanelpdf.pdf.

  • Prince, R.J. and Rebecca, M. (2014) Making and Unmaking Public Health in Africa: Ethnographic and Historical Perspectives. Athens: Ohio University Press.

    Google Scholar 

  • Rehle, T.M., Hallett, T.B., Shisana, O., Pillay-van Wyk, V., Zuma, K., Carrara, H. and Jooste, S. (2010) A decline in new HIV infections in South Africa: estimating HIV incidence from three national HIV surveys in 2002, 2005 and 2008. PLoS ONE 5 (6): n/a.

  • Robins, S. (2006) From rights to ‘ritual’: AIDS activism and treatment testimonies in South Africa. American Anthropologist 108(2): 312–323.

    Article  Google Scholar 

  • Robins, S.L. (2008). From Revolution to Rights in South Africa: Social Movements, NGOs & Popular Politics After Apartheid. Woodbridge. Suffolk: James Currey.

    Google Scholar 

  • Sangaramoorthy, T. and Benton, A. (2012) Enumeration, identity, and health. Medical Anthropology 31(4): 287–291.

    Article  Google Scholar 

  • Schneider, H. (2002) On the fault-line: The politics of AIDS policy in contemporary South Africa. African Studies 61(1): 145–167.

    Article  Google Scholar 

  • Schneider, H. and Stein. J. (2001) Implementing AIDS policy in post-apartheid South Africa. Social Science & Medicine 52(5): 723–731.

    Article  Google Scholar 

  • Shaffer, N., Chuachoowong, R., Mock, P.A., Bhadrakom, C. et al. (1999) Short-course Zidovudine for perinatal HIV-1 transmission in Bangkok, Thailand: A Randomised Controlled Trial. The Lancet 353(9155): 773–780.

    Article  Google Scholar 

  • Sidibe, M. (2011) Antiretrovirals for prevention: Realizing the potential. Closing commentary by the Executive Director of UNAIDS. Current HIV Research 9(6): 470.

    Article  Google Scholar 

  • Thornton, R. (2008) Unimagined Community: Sex, Networks, and AIDS in Uganda and South Africa. Vol. 20 Berkeley: University of California Press.

  • Timmermans, S. and Mauck, A. (2005) The Promises and Pitfalls of Evidence-Based Medicine. Health Affairs 24(1): 18–28.

    Article  Google Scholar 

  • UNAIDS. “Aids Epidemic.”, accessed July, 2008, http://unaids.org:80/en/KnowledgeCentre/HIVData/default.asp.

  • UNAIDS. (2006) “Report on the Global AIDS Epidemic.”: 4.

  • UNAIDS. (2011) Joint Strategic Action Framework to Accelerate the Scale-Up of Voluntary Medical Male Circumcision for HIV Prevention in Eastern and Southern Africa.

  • UNAIDS and WHO. (2001) AIDS Epidemic Update. December 2001.

  • Van der Vliet, V. (2001) AIDS: Losing “the New Struggle”? Daedalus 130(1): 151–184.

    Google Scholar 

  • Van der Vliet, V. and Toms. I. (1994) Apartheid and the politics of AIDS. Global AIDS Policy 3: 107.

    Google Scholar 

  • Van Hollen, C. (2013). Birth in the Age of AIDS: Women, Reproduction, and HIV/AIDS in India. Palo Alto: Stanford University Press.

    Google Scholar 

  • van der Vliet, V. (2001) AIDS: Losing “the New Struggle”? Daedalus 130 (1, Why South Africa Matters): 151–184.

  • Westercamp, N. and Bailey, R.C. (2007) Acceptability of male circumcision for prevention of HIV/AIDS in Sub-Saharan Africa: A review. AIDS and Behavior 11(3): 341–355.

    Article  Google Scholar 

  • Will, C. and Moreira, T. (eds.) (2016) Medical Proofs, Social Experiments: Clinical Trials in Shifting Contexts. Abingdon: Routledge.

  • Wilson (2012) HIV treatment as prevention: Natural experiments highlight limits of antiretroviral treatment as HIV prevention. PLoS.

  • World Health Organization. (2012) Progress in Scaling Up Voluntary Medical Male Circumcision for HIV Prevention in Eastern and Southern Africa. Brazaville: World Health Organization.

    Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Manjari Mahajan.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Mahajan, M. Rethinking prevention: Shifting conceptualizations of evidence and intervention in South Africa’s AIDS epidemic. BioSocieties 13, 148–169 (2018). https://doi.org/10.1057/s41292-017-0062-3

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1057/s41292-017-0062-3

Keywords

Navigation