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Barcelona devoted an entire session to women and reproductive health, titled Positively Pregnant within the social science track. Donna Barnes from the US spoke of mothering for HIV positive women in her study as a life affirming and valued role. Not unlike research conducted here in Australia (see McDonald et al, 2000; McDonald, in press) the women in her research spoke of their diagnosis as an unexpected interruption in their expected trajectory, which for many women includes motherhood as a very important part of their identity. R. Barbosa from Brazil presented a very interesting (albeit alarming) paper on the reproductive choices and the impact of the medical culture on sterilisation rates among HIV positive women in two sites, Porto Alegre and Sao Paulo. Postpartum sterilisation rates were 4.3 per cent in Porto Alegre compared to 50.6 per cent in Sao Paulo. Significant predictors of sterilisation include age, the number of living children, type of childbirth and prenatal care services. Even though the authors reported that a significant proportion of positive women desired sterilisation as a contraceptive method, they concluded that HIV positive women in their sample had higher rates of sterilisation than their uninfected counterparts. Furthermore, the local medical culture's views and practices regarding sterilisation appear more important than the women's reproductive choice. In other words, this research revealed that the types of care women receive are dependent on where they live. I presented on positive women’s use of and attitudes to antiretroviral therapy during pregnancy in Australia, which is the subject of my PhD research and involves interviews with 34 positive women from around Australia. I spoke of women’s concerns about antiretroviral therapy and that although most women agreed to commence treatment either before their pregnancy or by the second trimester, many women expressed concern about potential toxicity and/or harm to their unborn child. Some of the women also expressed grave concerns about giving antiretrovirals to their newborn baby, which resulted in a detrimental influence on the women's effective use of antiretroviral therapy. I concluded this paper by arguing that the interpretive and explanatory systems of mothers needs to be taken into account in exploring the benefits of antiretroviral therapy in order to provide effective and appropriate health care for women living with HIV/AIDS and their babies. Valeria Savasi from Italy presented their very successful research of intrauterine insemination (IUI) in HIV serodiscordant couples where the male partner is HIV positive. This method involves all sperm sample being HIV RNA tested by nucleic acid sequence-based amplification (NSBA). Insemination is performed only if the result if below the limit of detection (800 copies/ml). This method of sperm washing and IUI in HIV serodiscordant couples has been used in Europe where they have conducted over 4,000 cycles in more than 1,500 couples (approximately 10 per cent pregnancy rate) and to date no cases of HIV transmission have been reported. Although I have not covered all of the papers presented in the social science session it was clear that the papers provided the audience with a variety of issues concerning women and reproductive health from different sites around the world. The presentations also revealed the similarities of mothering as a universally important identity for many women. They also highlighted the cultural differences between countries and how women are really at the mercy of each country’s protocol or medical policies. I was also able to attend a few sessions within the prevention track. These presentations focused mostly on programs of peer support that were often run out of antenatal clinics. Mostly these presentations were descriptions of the program with little evaluation. However, the main take home message from the sessions I attended is that there is still a very important role for peer support in the care and well being of positive women, particularly in relation to pregnancy and mothering and newly diagnosed women. As always, most of the presentations on women and reproductive health were within the epidemiological track. These presentations were predominantly from high prevalence areas, particularly sub-Saharan Africa. There were numerous presentations on the results of randomised control/clinical trials concerning mother-to-child-transmission (MTCT). Several presentations focused on the effectiveness of the use of neviripine and zidovudine together (instead of monotherapy) to further reduce MTCT. It was pleasing to find that there was some discussion about the safety of protease inhibitors and virus resistance to treatments in repeat pregnancies. There are growing reports of non-nucleoside reverse transcriptase inhibitor (NNRTI) resistance among HIV positive people in the developed world. With the use of single dose treatment in many less developed countries (until maternal treatment becomes available) NNRTI mutations in a large proportion of women is probable. James McIntyre from South Africa talked about the possibility of treating the baby only to reduce the likelihood of treatment resistance in mothers. Obviously the best solution to this problem would be universal access to antiretroviral treatments. I was concerned to hear suggested on several occasions the potential for treating all women who present to antenatal clinic/hospitals in labour with single dose nevirapine to eliminate the need to know their HIV status and get around the voluntary testing and counselling (VTC) issues for example when women present late in labour or refused to be tested. Isabelle de Zoysa from the World Health Organisation spoke of the UNGASS Declaration of Commitment and the pledge to reduce the proportion of infants infected with HIV by 50 per cent by 2010. In order to achieve this it was recognised that 80 per cent of women would have to have access to antenatal care; that women would be offered VTC; that women will accept VTC; that treatments would be available to women and their babies and that women would accept treatments. While Isabelle de Zoysa and some presenters did acknowledge that there was issues with regard to toxicity and drug resistance, there were little or no meaningful discussion about these issues or the ethical implications of such an all-encompassing treatment program. Breastfeeding was referred to as “the remaining frontier” in reducing MTCT and research currently underway in this area includes examining the role of maternal viral load in breastfeeding. In Nairobi, research is looking at the immune systems of breastfed babies who are negative in their first year of life. The question that needs to be answered in relation to this research is whether maternal viral load or infant prophylaxis is most important in reducing HIV transmission in breastfed babies. Research from South Africa indicates that when breastfeeding is the chosen feeding method, it should be exclusive and not for a period longer than six months. It is believed that prolonged weaning and mixed feeding (breast milk and other milk alternatives) increases the risk of HIV transmission for breastfed babies. Heat treatment and/or pasteurisation and milk banks were very briefly mentioned in one session but it was concluded that more research and feasibility studies were required in this area. It was also frustrating to hear on a number of occasions speakers concluding their presentations with acknowledgements that behavioural or attitudinal data in relation to antiretroviral use during pregnancy is needed to further explain women’s attitudes towards treatments. Obviously few of these researchers attended sessions outside of their track! While the bridging sessions, if continued at future conferences, will begin to address this, researchers from all tracks and disciplines would benefit the affected communities they are serving by making greater efforts to attend sessions outside their particular disciplines. Women certainly had a stronger presence at this conference than the previous World AIDS Conference held in Durban, however, the focus still tends to be on women as vectors of disease in order to reduce or eliminate vertical transmission. There was little discussion or presentations either on, or by, positive women as women in society, not only as mothers but also as partners, sisters, and so on. It is unlikely we will progress to these kinds of discussions until universal access to antiretroviral treatment and care is achieved but at least women are now on the agenda in all tracks of the conference. We just need to find a more satisfactory way to bridge the information across all areas of research. References: McDonald, K., Grierson, J., de Visser, R., & Bartos, M. (2000). A complex uncertainty: Women on health, hope and HIV. Monograph 19,Australian Research Centre in Sex, Health and Society, La Trobe University, Melbourne. McDonald, K. (in press). I was devastated to think I couldn't have a child: The role of motherhood in the lives of HIV-positive women in Australia. In Kirkman, M., Maher, J-M. & Souter, K.S. (Eds), The fertile imagination: narratives of reproduction (special issue), Meridian. For more information on any of the papers mentioned in this article or for the power point presentations from the conference see the official website at www.aids2002.com Karalyn McDonald is a PhD candidate and a researcher on the Living with HIV program at the Australian Research Centre in Sex, Health & Society, La Trobe University, Melbourne. UNGASS - do you promise?Barcelona 2002 was the first global gathering of the AIDS community since the endorsement of the Declaration of Commitment in 2001 at the United Nations General Assembly Special Session on HIV/AIDS. Robin Gorna looks at the Declaration and asks if governments and civil society have kept the promises they made. In 2001, 180 governments signed a commitment to fight the spread of AIDS following a UN General Assembly Special Session on HIV/AIDS. That commitment, known as UNGASS, came after long hours of negotiation, heated debate and some subtle and overt pressure on country delegations. The resultant document, sub-titled Global Crisis - Global Action, is far reaching and embraces a broad agenda for action. It spans leadership, prevention, care, support and treatment, human rights, reducing vulnerability including the vulnerability of children and HIV/AIDS ‘orphans’, alleviating social and economic impact, research and development, conflict and disaster affected areas, resources and a plan for monitoring progress. It is specific, listing over 30 measurable targets to be met by 2003 and 2005. One of the strengths of UNGASS and a major frustration for activists seeking to influence the process, is that much of the negotiation was done by diplomats who were highly experienced at working the complexities of the UN system, but less experienced in working with information on sex and drugs. The benefit of UNGASS is that it forced a response from the whole of each government. AIDS could no longer be marginalised to the health portfolio, or left as the pet project of a couple of highly motivated bureaucrats. UNGASS demanded political commitment and activists suffered the watering down of some text as a consequence. “Maintaining the momentum and monitoring progress are essential,” said Rt Hon Clare Short MP, UK Secretary of State for International Development. Barcelona 2002 was an opportunity to ask if UNGASS participants have maintained momentum and kept the 2001 promise to monitor the implementation of the Declaration. “The time has come to put the pieces together,” said UNAIDS Executive Director Peter Piot. “Plans have been made. Needs are clear. Solutions are available. Leadership is gathering momentum.” But do we know if all – or any – of our countries are doing what they signed up to do? At Barcelona, only two sessions mentioned UNGASS in their title - both non-commercial satellites. The main conference had a scheduled a symposium, Making Global Commitment a Reality: Accountability and Funding, and you might have expected to find political leaders and advocates discussing how they are making the Declaration work. Instead, there was talk on the impact of UNGASS from UNAIDS followed by three presentations on funding opportunities. Digging deeper, it seems that focus and understanding has moved from the political commitments and targets enshrined in the UNGASS Declaration to intrigue at the latest apparent source of funds - the Global Fund on AIDS, Tuberculosis and Malaria. The Global Fund is only a tiny feature of the UNGASS Declaration squeezing into just two of the 14 paragraphs on resources in the 103 paragraph Declaration. The Declaration calls for “an overall target of annual expenditure on the epidemic of between seven and 10 billion US dollars in low and middle-income countries” by 2005. It was never envisaged that all of this would be dispersed by the Global Fund. In pre-conference satellite events, the Community Forum and Skills Building Sessions, the talk was on how to get money from the Global Fund - how to apply, what they’ll pay for and who received grants from the first round. There seemed to have been a movement away from the hard work of keeping government’s accountable to an ambitious plan of political commitment to the short-term goal of mobilising external resources now. While the short-term need is self-evident, there are dangers. In a pre-conference satellite Financing Care for PLWHA: The Country Perspective many speakers worried about the long-term sustainability for funding antiretroviral therapies in low and middle-income countries. Piot warned against the, “Easy, but fallacious, argument, ‘the Global Fund will fix it’”. He said, “It should not be an excuse for governments and companies to avoid funding. This is an additional funding scheme.” A representative of the Global Fund stated that in their first funding round, the Fund had financed antiretroviral treatment programs in 20 of the 28 countries given finances for HIV/AIDS projects. This would expand treatment coverage it was claimed, for example from 1,000 to 40,000 people in Malawi and from 3,000 to 70,000 people in Thailand. This seemed to be contradicted by Thailand’s Dr Taweesap Siraprapasiri, Director, Division of AIDS, Ministry of Public Health, who stated that currently 10,000 Thai adults and 1,900 children receive antiretrovirals and with the Global Fund money this coverage would double. Most importantly he focused on the difficulties of assuring a long-term supply of treatments. This point was underscored by Brazilian activist Ezio dos Santos-Filho who rejected the Global Fund as a permanent solution to treatment financing. “Activists and governments have got to think about local funds for sustainability,” he argued. “AIDS treatments are not something you give for six months or one year..…you need to have a permanent budget line.” Brazil’s treatment access programs are seen as one of the most impressive responses, showing that access to treatments in developing countries is not only possible but beneficial at every level, including the economic. World Bank Global AIDS Adviser Debrewok Zewdie, concluded the treatment satellite by stating “Brazil stands out because it dared. It said it’s not impossible.” In fact, all countries in the UN system have said that “it is not impossible” to respond to AIDS. They have declared their commitment to the pandemic and promised to meet ambitious targets and goals. But how are we checking if they keep their promises? This challenge is not simply the responsibility of governments and intergovernmental bodies. Unlike many countries, Australia is noted for taking seriously its obligations under the UNGASS Declaration and Strategies. So let’s start in our own backyard. What are Australian community groups doing to achieve the targets and promises made at UNGASS? New reporting called for Each participating country will need to report on a new set of indicators, designed to improve the evidence base and demonstrate that UNGASS is working. There was some debate about why new indicators are required on top of the UNGASS targets, but at least these should guide governments to develop concrete elements that can be assessed. At the country level, the new indicators will be used to track the epidemic among pregnant women and newborns. Countries will be asked to quantify the proportion of pregnant women with HIV who receive antiretroviral prophylaxis and the impact of the epidemic will be measured by tracking the level of HIV among young people and newborns. Government commitment will also be tracked by surveying national funds being spent on HIV/AIDS. Government’s will be given a report card on their progress. The National Composite Policy Index (NCPI) will integrate multiple planning and legislative gauges to provide a report on government policies related to human rights, prevention, care and support strategies. It will also monitor whether countries have a multi-sector HIV/AIDS co-ordination body. HIV/AIDS spending by donors will be tracked and the response to HIV/AIDS at an institutional level will be monitored to determine whether international agencies have workplace policies and staff training programs on HIV/AIDS in place. Information collected using the new indicators will be documented and published for broad dissemination and discussion. The new facts and figures are intended to make governments more accountable and to resolve doubts about effective HIV/AIDS responses. Repeatedly speakers at Barcelona stated that Governments would have to report before the global AIDS movement meets again in Thailand in 2004. The challenge now is to make sure that those reports are accurate and thorough and most importantly, that the targets in the Declaration are met and those fine promises kept. Robin Gorna is a past Executive Director of AFAO. She attended the World AIDS Conference in Barcelona as a Key Correspondent for the Health & Development Network.Missing the pointChris Puplick questions the relevance of the XIV World AIDS Conference and calls for a new forum for countries with a similar experience to Australia to come together and share their knowledge and experience. One of the things that most impressed me at Barcelona was the quality and impact of the Australian presentations. I attended a reasonable number of sessions in which Australians were presenting along with colleagues from elsewhere around the world. Almost uniformly I found the quality of these presentations superior to those from other sources, especially some of the American material in areas like social policy and education which I found embarrassingly awful. Presentations Australians such as David Cooper and Dennis Altman in particular stood out in my mind as exceptional, although there were many others and the large Australian contingent has every right to be very proud of their achievements and their impact. It was this fact that led me to reflect more seriously on a far deeper question - namely the use of such vast international conferences, especially from the Australian perspective. There were some 15,000 delegates and participants at Barcelona and the rather chaotic program was too large to be helpful. There was no real coherence around the conference theme of “Knowledge and Commitment for Action”. I have no doubt that for many people from less developed and developing countries that there was some use in listening to presentations from countries in similar situations and I am sure that the contacts they made through the satellite sessions, the Non Government Organisation briefings and the capacity building workshops were invaluable. On the other hand much, most of the material generated by first world researchers in areas of social policy, education and the like would have been either meaningless or irrelevant, or both. I appreciate fully that issues of gender politics, the lack of human rights protection, the disempowerment of women, cultural taboos mitigating against sex education, the impact of poverty, rurality and illiteracy and the lack of access to basic health services let alone expensive treatments are vital issues in most of the world. However, their relevance in the Australian context is highly questionable. It seems to me that there is a strong case for refocussing our international AIDS Conferences. At present we have a major worldwide conference each two years with regional conferences interspersed in the intervening year. Perhaps it is time that we sought to create a forum for “first world” nations to get together in a more coherent fashion to discuss public policy, research and health delivery issues in a forum where relevant experiences can be taken back home to be of benefit. I would like more time to meet with people from countries with political, economic and social systems more akin to our own in order to learn from their relevant experiences. I find presentations from India, South Africa, Vietnam, Indonesia, Barbados and Cuba both intellectually stimulating and often emotionally challenging. What I rarely get out of them are useful lessons for improving our Australian responses to the epidemic. I need to know more about what is happening in Paris, Prague, Toronto, Miami, Wellington and Wolverhampton because it is more likely that this information will be genuinely relevant to me as a potential public policy maker. Of course, if I was just a conference junkie with no other job in life I suppose I could attend the European and North American AIDS Conferences in the off years, but that is simply not practical. What I need is a larger “first world” forum on a more regular basis. Herein lies the great dilemma - the less developed world needs to have access to the resources (physical, intellectual, political) that we take for granted and we have a clear moral obligation to assist them and to transfer what knowledge and experience we can. Indeed, the obligation is not only moral, in many respects it is also infused with a great degree of long-term self-interest. I do not object therefore to putting more “into” these conferences than countries like Australia can ever hope to get “out” of them. Perhaps what is needed is to start to focus these conferences on the themes of transferability and to make that a key theme. What can be learned by who and from who? At the moment it is all too chaotic and haphazard. However, I thought that the last International Conference on AIDS in Asia and the Pacific (Melbourne, October 2001) started to approach this very positively. More needs to be done and perhaps with four years to go until the 2006 Conference in Canada, this is a subject which some of us should be giving a great deal more thought. Barcelona was in many ways a “reversion to type” after the quite different experience of the previous conference in Durban. It was originally planned that the conference after Barcelona would be held in Canada, but the reaction and the demands of the Durban delegates was such that the conference organisers (the International AIDS Society) determined that the 2004 conference would be held in another “non-first world” venue and so the next conference will be held in Bangkok in 2004 before heading to Canada in 2006. This decision illustrates one of the major problems now facing those concerned primarily with public policy development in the HIV/AIDS area - the significantly expanding discontinuity between policy issues and responses in developed countries such as Australia and less developed countries outside the first world. However my impressions of Barcelona were that the progress on many fronts since Durban had been far less than most of us would have hoped. Despite all the hype about vaccines and their development, I am still absolutely convinced that it will be a far longer process than any of us would like before a really useful vaccine is available. Commercially driven media hype about something “just a few months away” serves none of us well (apart perhaps from some pharmaceutical company stockholders) and in my view is a cruel hoax. There is real progress being made (and I am especially pleased to say that this includes significant advances being made by the Australian Vaccine Initiative) but a product available for widespread use seems to be to be still seven to 10 years in the future. What this indicates is a need for the preventive campaigns focusing on questions of behaviour and for risk minimisation to be reinvigorated, given that what we know about the rise in unprotected anal intercourse in Australia and elsewhere (not all of which, of course, can be characterised as “unsafe”) continues to be of the highest priority. Issues of stigma and discrimination continue, very properly, to be high on the agenda for AIDS policy makers. There has been far too little attention paid to the negative health consequences of persisting and even rising levels of stigmatisation and discrimination throughout the world and I am pleased to see that UNAIDS has decided to make this issue the focus of the World AIDS Day Campaign in 2002 - 2003 with the slogan “Live and Let Live”. From my point of view, I found some particularly interesting developments taking place around the world in relation to HIV and Hepatitis C control in prisons and custodial settings. In this respect Spain probably leads the world. Its programs based around harm minimisation and featuring the ready availability of bleach, condoms and clean needles supported by the prison authorities and underpinned by excellent peer education programs, have a great deal to teach us in our backward approaches to prison policy in Australia. Reports back in Australia reflected the continuing disaster of HIV/AIDS for sub-Saharan countries in Africa and one can only be profoundly pessimistic about the ability of any of those countries, or of the wider world community, to do very much about the future impact of the epidemic. However what the Australian press failed to highlight sufficiently was the alarming details of the spread of the epidemic in places such as Eastern Europe, Indonesia and China. The epicentre of the epidemic is moving and it is heading in our direction. New statistics from Indonesia and the possibility of Papua New Guinea descending into the chaos of a non-functioning state should be ringing alarm bells in every relevant quarter in Australia. Chris Puplick is the Chair of the Australian National Council on AIDS, Hepatitis C and Related Diseases. The concept of HIV optimism was the focus of at least six studies presented at the recent World AIDS Conference in Barcelona. Researchers from around the world presented results of studies at a session titled Effects of HIV Treatment (ART) on HIV Prevention. John Rule questions the research and asks who came up with the concept of HIV optimism in the first place. All of the researchers (excepting one) who presented on HIV optimism came to the same conclusion - that there was no causal link between the availability or expressed optimism around antiretroviral therapy and increases in unprotected or unsafe sex. Likewise, no evidence was presented that viral suppression leads to unsafe sex. These findings made me ask if the subject being investigated was wrong from the start. One presentation at Barcelona focussed on information from the Swiss HIV Cohort Study (SHCS) conducted in 2000, which saw over 5,000 individuals responding to a questionnaire. Presenting author Jim Young described the attempt to evaluate the sexual risk behavior of individuals in relation to antiretroviral therapy and concluded that there was "no evidence that viral suppression leads to unsafe sex among individuals of the SHCS." Another study of 3,000 gay men presented by Jonothan Elford examining whether HIV optimism could account for the recent increase in high-risk sexual behavior among gay men in London, came to a similar conclusion. Participants completed self-administered questionnaires between 1998 and 2001. Elford admitted that establishing the cause of sexual behaviour is doubtful territory (and some might say dangerous) and that a cross-sectional study such as this cannot describe cause and effect. The study found that optimism alone could not explain recent increases in high-risk sexual behavior. In the Elford study, the dimensions of optimism being explored related to the severity of living with HIV/AIDS and the susceptibility of becoming infected with, or transmitting, HIV. By this stage, I was beginning to wonder if anyone would find a link to anything and I pondered the costs of such research. I believe the answer is that there have been various and varying political agendas around “proving” or “disproving” a generalised belief that HIV optimism is linked to unprotected sex. Positions need to be taken or supported by a number of groups including positive people, policy makers, researchers and educators. Australian researcher Michael Hurley has described the way this operates in terms of the management of HIV surveillance where it has been suggested that, “Dramatisation precedes verification.” 1. While Hurley was not linking this description to any possible association between unprotected anal intercourse and optimism, it does seem feasible to ask in much the same way as he asked about surveillance, why are people invested in seeing gay men as Calamity Janes? The other two papers presented on HIV optimism at Barcelona also rejected any connection between sexual behaviours and the scaling up of or access to antiretrovirals. These papers, based on studies of around 800 participants in both Chile and in Cote d’Iviore, concluded that, "The enlargement of ARV (antiretroviral therapy) does not by itself increase at-risk behaviours among PLWHIV (people living with HIV/AIDS)." Also, "Fear that access to HAART (highly active antiretroviral therapy) may create incentives for 'irresponsible' behaviours toward transmission of HIV among African patients is not supported." The impetus for these research directions in Chile or Africa is obvious. As the presenter from the Cote d’Ivoire study said, “People on ART don’t become sexual maniacs” and research to overcome such fears was needed. What is the impetus though in other countries? It would be a fair guess to say that in some countries the focus on HIV optimism was partly a response to the perceptions or concerns of policy makers, health care professionals and educators that availability of antiretroviral therapy might be linked to a resurgence of risk behavior and researchers were following that track. Was it the right track? Ineke Stolte, from the Municipal Health Service in Amsterdam seemed to think so in presenting the paper Homosexual men switch to risky sex when perceiving decreased threat of HIV/AIDS due to HAART. The presentation began with the assumption that optimistic treatment beliefs due to the availability of HAART were known to be associated with increased sexual risk behaviour among homosexual men - a surprising starting point given the preceding presentations which did not demonstrate any such connection. In explaining the study details it was revealed 73 homosexual men participated and eight had ‘switched to risk’ over a period of two years. The definitions of risk explored were around behavioural patterns of ‘unprotected’ or ‘protected’ sex (with or without reference to the serostatus of their partners). The study seemed to leave no room for decisions based on what is known about viral load and transmission. I remained unconvinced that this study supported the hypothesis "of causality between treatment beliefs and a switch to HIV-related sexual risk behaviour". A qualitative study providing reflections on the concept of HIV treatment optimism by young gay men in the context of rising HIV incidence in Vancouver was presented by M. L. Miller. The study focused more on the social and cultural context of high-risk decision making. The author suggested that as a concept, HIV optimism had little relevance in young gay men’s sexual risk realities and decision-making. This analysis of 26 in depth interviews provided some focus on the sites and times of vulnerability rather than attempting to establish any ‘cause’. It was a relief to have attention redirected towards issues of intimacy, stigma and homophobia as contexts for understanding the whys and wherefores of risk-taking behaviour. After sitting through the six presentations, I wondered why I was even following this through. It’s because in Australia, I believe the notion of optimism was adopted in a certain way in various circles when the report Touch Wood, Everything Will be OK was published by the National Centre In HIV Social Research in 2000. The title was suggestive of optimism and some of the findings suggested practices were changing according to that optimism. One key findings was that, “Undetectable or low viral load may provide for a reduced sense of ‘infectivity’”. The report sat alongside the development of treatment optimism-skepticism scales that emerging from work within the National Centre in 1999 and 2000 and continued into 2002. There have been different readings of Touch Wood. It has been suggested that the title, along with some of the findings, “Suggested a lack of care, a lack of responsibility, a reliance on superstition in our (PLWHA) efforts to control the spread of our disease."1 In other words, a sense of optimism was being reworked as a sense of irresponsibility. There was some balance to this in the report as other key findings highlighted, “HIV positive gay men are employing individually tailored risk minimisation strategies when engaging in anal intercourse, including anal intercourse without a condom”. However, I still felt the notion of optimism was not being read or used in the same way by researchers and research subjects alike. Further, ‘Touch Wood’ was not a completed explanation of the understandings of clinical markers in sexual practice. The notion of HIV optimism has been employed differently in research literature. It is has been used in HIV Futures to describe attitudes to future health prospects and the efficacy and sustainability of treatments for PLWHA. Used this way, there has been no danger that people on antiretroviral therapy or HAART can be constructed as reckless and feckless in their sexual practices. The presentations on the concept of using HIV optimism to explain changes in sexual behavior demonstrated the way that language can be repeated until there is some belief it is a truth. How that ‘truth’ then becomes a ‘subject’ for investigation and the way that investigation reveals the language is hollow proved to me that years of research might be wasted because the wrong questions is asked! After the Barcelona presentations, it can be said that the concept of treatments optimism as the ‘cause’ or ‘explanation’ for increases in unprotected anal intercourse can be put to bed. In the context of providing therapies in resource poor settings, the fear around availability of treatments hindering prevention strategies can no longer be countenanced. In Australia, this means that hopefully now attention can be paid to looking more closely at the specific instances and socio-cultural contexts in which risk reduction and risk practices are occurring and placing these risk reduction and risk practices in the social, cultural and structural contexts in which they are apparent, rather than researchers seeking single ‘causes’. The reality and understanding of reduced viral load and how this works within sexual practices can be understood and approached as more that just a ‘feeling’ or ‘sense’ of optimism. Hopefully, the work of Australian researchers like Kane Race 2, Jon Willis 3, Michael Hurley 4 and any others now highlighting emergent ethical practices, care-of-others and cultures of care will continue to be given attention. These research directions are a useful shift beyond any scaling of behavior linked to being optimistic or pessimistic. After sitting through the HIV optimism presentations at Barcelona, I believe these research directions are realistic and urgent– but please, we do not need a ‘realism’ scale! John Rule is a HIV Living Policy Analyst with the National Association of People Living With HIV/AIDS. References
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