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We are united in demanding leadership in the fight against HIV/AIDS and justice in prevention policies.
HIV prevention efforts in the United States have traditionally focused on individual behavior, ignoring the fact that two individuals from different communities can engage in the same activities but be at much different levels of risk for HIV. It is the paradox that we grapple with in trying to understand why certain communities bear such a disproportionate burden of HIV while others, even though they have the same levels of “individual risk activity,” do not.
Traditional interventions focus on identifying and changing the individual behaviors (unprotected sex, unsafe drug injection, childbirth and nursing) that contribute to the spread of the virus. These efforts include examining “risk factors” (other behaviors or traits that increase the odds of practicing risk behaviors)—populations that are most likely to engage in these behaviors and the level at which they lead to greater transmissions among individuals.
However, these efforts failed to achieve the CDC's goal of reducing HIV transmission by half. In fact, in some communities, HIV/AIDS rates may once again be on the rise. This does not mean that prevention efforts do not work – but it does mean that we must both scale up existing strategies and invest in innovative new approaches.
Appropriate prevention policies are vital for the health, rights and dignity of all people, including people living with HIV. In order to address HIV from a prevention justice standpoint to lower HIV risks, we must examine why certain groups are at such heightened risk for HIV and the social/structural conditions that drive that risk. Social and structural risk factors are sometimes acknowledged in programs, research and policies but only as a footnote or sidebar comment (e.g. noting the role of homophobia or poverty). What would our research, programs and policies look like if they centered around finding solutions to these very real structural issues? Currently, we have little in the way of assessment tools, prevention or intervention strategies that address the structural, social and systemic problems that increase the risks for certain groups of individuals more than others.
For example, unsafe sex between men is a risk-taking behavior. We know that environments that demonize any sex between men diminish their options to make healthier choices. But we do not know whether the opportunity to have unsafe sex is a better predictor of risk than the impact of homophobia. Furthermore, the fact that the prevalence of HIV is already so high in some communities (nearly 50% among African American men who have sex with men (MSM) in five cities studied by the CDC, for instance), means that the same level of individual risk behavior among such men exposes them to five or even ten times the risk as would the same behavior among other MSM.
Is a resource-poor Black or Latina woman with children more likely to contract HIV because she “chooses” to have unprotected sex, or because she chooses to do so in order to keep the man who pays her bills, feeds her kids and keeps the roof over their head? Which has a greater influence on her risk for contracting HIV?
These are just two examples of the scenarios putting individual risk alongside systemic vulnerability that play out in the lives of many people every day. A prevention justice approach calls for the evaluation of societal factors as well as the individual behaviors that heighten the risk for HIV transmission or acquisition. A prevention justice approach incorporates both individual and structural approaches for more effective HIV prevention strategies. And a prevention justice approach recognizes that the involvment, the rights and the dignity of people living with HIV are just as important and integral to the success of HIV prevention as efforts focused on people who are HIV negative.
The quest for a “magic bullet” solution, whether a single behavioral or biomedical intervention, is not likely to end the AIDS crisis. We urgently need theories, assessment tools and hybrid prevention strategies that address risk in the context of vulnerability and that directly address the root causes of vulnerability.
Principles
Here are 4 principles that must be reflected in a focused, justice-based HIV prevention strategy that can actually stop HIV/AIDS:
- HONESTY AND PROTECTION: UNIVERSAL ACCESS TO SEXUAL HEALTH EDUCATION, HARM REDUCTION AND HIV PREVENTION
- Prevention justice asserts the fundamental right of all people (including people living with HIV) to expect every effective and ethical approach to be employed to prevent HIV transmission. Everyone at risk of transmitting or acquiring HIV must have access to scientifically based, culturally and linguistically- appropriate sexual health, harm reduction and HIV prevention information, materials and tools.
- The federal government bears primary responsibility to fund these efforts at adequate levels (at least $2 billion per year across programs, as noted in the AIDS Budget and Appropriation Coalition's chart on FY 2008 Appropriations for Federal HIV/AIDS Programs), and must end bans on funding for effective programs such as syringe exchange. The next President of the U.S. should develop a results-oriented AIDS strategy that incorporates prevention justice principles and policies.
- If political and cultural barriers impede such access (such as bans restricting access to sterile needles/syringes, and condoms in prisons and jails; comprehensive, accurate sexual information and skills for school youth or detainees; or the gag rule on naming “harm reduction” in federally-funded research and programs), then funders and providers of prevention services must also invest in strategies to remove these barriers.
- Prevention justice asserts the fundamental right of all people (including people living with HIV) to expect every effective and ethical approach to be employed to prevent HIV transmission. Everyone at risk of transmitting or acquiring HIV must have access to scientifically based, culturally and linguistically- appropriate sexual health, harm reduction and HIV prevention information, materials and tools.
- IT'S NOT ONLY WHAT YOU DO, IT'S ALSO WHO YOU ARE: HIV/AIDS AS PROOF OF INJUSTICE
All prevention campaigns and strategies must include explicit goals to lessen and eventually eliminate structural risk factors that lead to community-level or population-level vulnerability, such as homelessness, high rates of incarceration, domestic and other gender-based violence, lack of adequate access to high-quality health care, and/or a living wage or income.
- They must include plans to eliminate any significant disparities among populations in HIV prevalence and risk, including those associated with race and ethnicity, immigration status and language, gender and gender identification, sexual orientation, nationality, age and area of residence. It must also address disparities in treatment, care and support for people living with HIV as a key component for HIV prevention. Resources must prioritize eliminating the greatest disparities in HIV prevalence and incidence.
- AIDS DOESN'T DISCRIMINATE… BUT SOCIETY DOES: END VULNERABILITY BY AFFIRMING THE DIGNITY AND RIGHTS OF ALL:
- All HIV prevention efforts must include an affirmation of the dignity and rights to equality of every individual (including those living with HIV/AIDS) and must actively confront social, cultural and legal norms and forces that prevent or impede realization of such rights and dignity, such as racism, sexism, and homophobia; HIV and drug-use stigma; or discriminatory legal status.
- Any programs that claim to prevent HIV by attacking the dignity and rights of individuals -- such as abstinence-only-until-marriage programs that encourage sexism, homophobia and AIDS stigma -- must be defunded and repudiated.
- Since rights are meaningless without the means to realize and use them, all HIV prevention must include or ally with efforts to provide every human with the economic and other material necessities of life, including adequate housing, employment or income, physical and mental care, food and nutrition, and drug treatment – the lack of which have each been shown to drive HIV spread.
- All HIV prevention efforts must include an affirmation of the dignity and rights to equality of every individual (including those living with HIV/AIDS) and must actively confront social, cultural and legal norms and forces that prevent or impede realization of such rights and dignity, such as racism, sexism, and homophobia; HIV and drug-use stigma; or discriminatory legal status.
- DON'T BLAME US OR SHAME US FOR WHAT YOU DON'T KNOW: RESOURCES, ETHICS, AND COMMUNITY INVOLVEMENT IN CRITICAL RESEARCH AND MONITORING
- Communities and programs lack the resources and tools to fill the gaps in our knowledge base on HIV prevention. HIV prevention research efforts must be funded in sufficient quantity and diversity as to quickly solve critical unanswered questions and provide essential tools and technologies we are currently missing.
- Research must focus on providing tools to assess community vulnerability and structural risk and to guide the design of efficient, comprehensive, multifactorial prevention strategies, as well as investigating new individual behavioral or biomedical interventions, and must include answers to relevant questions regarding prevention issues for people living with HIV.
- Further, government and private entities engaging in research and policies must provide timely, understandable and accurate information on their work and proposals, actively soliciting and integrating diverse community input into resource allocation and policy formulation.
- The basic elements of counting and describing people living with, or at risk for HIV infection (surveillance categories and systems, testing, case reporting, partner notification and counseling) must not blindly follow previous, narrow medical public health models, but must reflect the other principles described above. These systems and methods must be designed and implemented with awareness of their direct or indirect impact on individual dignity as well as community health and vulnerability.
- Communities and programs lack the resources and tools to fill the gaps in our knowledge base on HIV prevention. HIV prevention research efforts must be funded in sufficient quantity and diversity as to quickly solve critical unanswered questions and provide essential tools and technologies we are currently missing.
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